HomeMy WebLinkAboutBuilding Permit #689-14 - 62 ELM STREET 4/8/2014TOWN OF NORTH ANDOVER
APORTANT:
APPLICATION FOR PLAN EXAMINATIO2fPermit NO.• Date Received J' "Date IssuedA licant must complete all items on this page
LOCATION7�
� Pri t.
PROPERTY OWNER ���r F-j� `✓ Y`. 'J
Print 100 Year Old Structure yes o
MAP NOS PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village
y6 -no
TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
COne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
.Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic 0 Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
0 Water/Sewer
D SCRIPTION OF WORK TO BE PERFOKMtU:
C la ep�04,_c✓ V_, �iGl6 SJS"Q e 7L S c✓ ivYr,,%
l�Ce- lel
OWNER: Name:��o.✓ i
Address: & a e ( S
XoPlfAce. ,v e -CA s.
Type or Print Clearly)
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License:
Home Improvement License:
Exp. Date:
Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
c
R s- .i c exec✓
78/-S 7.2 - ;Z 3_N --JC
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ Cr-> ^
Check No.: Receipt No.: 2-o
NOTE: Persons contracting wi h unregistered contractors do not have acces the guaranty fund
Signature of Agent/Owner a44,1- Sigpature of contractor
Plans Submitted L.J Plans Waived ❑ Certified Plot Plan 0 Stamped Plans 0
Plans Submitted ❑ Plans Waived ❑ _ :.-Certified Plot Plan ❑ Stamped Plans ❑
.,TYPE OF-SEWERAGE_DiSPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
Swimming Pools ❑
Well ❑
_Tobacco.Sales
Food Packaging/Sales ❑
Private (septic tank, etc._ ❑ -- _ .
permanent ]Duinpster on Site ❑
THE. FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE;APPROVED
PLANNING & DEVELOPMENT` ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision: Comments
Water & Sewer Connection/ Signature Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTW-Nt =Temp Dumpster on site yes_
Located�at 124 Mair. Street -
Fire Departine►it signature/date`'
COMMENTS
Wcaiea jo4 us ooa Street
no
Location f�L�'1'1 �S j
No. a -- Date CG tr
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
J/
Building Inspector
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The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
kvi 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): %7Ct'/j rt% /f // s -
Address: 6,;'- e /vim 5
City/State/Zip: A), A (1e i Y 2 VJ// /9,'/ Phone S_ 7,2 -a 3 f -C
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet t
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. [a I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert under the pains and penalties of perjury that the information provided above is true and correct.
- 5- -2.2 - a 3
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
3 -/�-/
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person:
Phone
�O£IAeaMk aYd TO" OF NORTHANDOVER
- TAONCE OF
BUILDING DEPARTMENT
ENT `
C
°" I600 �Jsgood Street Building 20, -Suite 2-36
y�Ssgcuus��y North Andover, Massachusetts 01845
Gerald A. Brown - Telephone (978) 68$-9$45
InspecforofBuiTdings -Fax (978) 689-9542
.. HOMEOWNER LICENSE EXENLPTTON
BM)NG P MIT APPLICATION
Pleasetrmt •
DATE:—/�%`j`� -
JOB LOCATION:
ry umner Street Address
Map/Lot .
• S�'OMEOWNER • - /1Gir0. �P2 �/�'•.
Name. . Home Phone %Cz/ ' - ` 7`'Z , a 3S'
Work Phone
-PRESENT MAILING ADDRESS
a e /�_M S
C'i y To,tn,
Sfafw • ?,p Code
The current exemption for "homeowners" was extended to include owner-occu ied
to allow su;h homeo; ers to engage anin
divid,_W.for hire w.ho doesdve""gs to UVO units -or loss notposse a JicsGns provided That the owner
acts as supervisor). Statei3uilding (Code Section 708.3.5.1)
DEFINITION OFHOMEOWNER
Persons) who Awns aparcel ofIand on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two family structures. A person who consirocts more that.one home in a iwo yearperiod shall not be
considered ahomeowner.
The undersigned "homeowner" assumes responsibility forcompliances with the State Building Code and other
Applicable codes, by-Iaws, rules andregulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Dearfinant
equneminimum inspection procedures and requirements and that helshe. will comply with,sa!d procedures and
requirements, '
730MEOWNERS SIGNATURE .
APPROVAL OF 33MUNG OFFICIAL
Revised 7.2009
Porro Homeovmers Exemption
'BOARb OF APPEALS 68&-9541CONSERVATION
688-9530 HEALTH 688-9540
PLANNING 688-9535
O igen °• �O
Town of North .Andover
Machine Shop VillageNeighborhood Conseration District Commission
1600 Osgood Street North Andovcr, MA 01$45
SACHUS�
Application For EXCLUSION From Certificate to Alter
For Items 9,10 or 11, provide the following documentation:
Photos/drawings of existing doors, windows or siding, as applicable
VA Description/Catalog Cuts of proposed materials to be used for doors, windows or siding
Plan and elevation of reconstruction for Item 11
Determination:
This project is determined to be
xempt
❑ of exempt
from review by the Machine Shop Village Neighborhood Conservation District Commission. Projects
that are not exempt must complete the Application for Certificate to Alter, available from the Building
Department and be reviewed by the Commission.
Determination made by.
Signature
bZ g S
Neighborhood Conservation District 60mmission
3 19 1 // t -/
Date
MSV NCDC Page 2 Current Chair: Liz Fennessy, 77 Elm Street, lizettafe_ nnessv�a),yahoo.com, 978-688-2915
,&ORTI{
'e,ti0
ti== °A Town of North Andover
Machine Shop Village Neighborhood Conservation District Commission
1600 Osgood Street North Andover, MA 01845
SS4CHUSE
Application For EXCLUSION From Certificate to Alter
Certain alterations are excluded from review by the Machine Shop Village Neighborhood
Conservation District Commission in accordance with the Bylaw. Applicants for exempt projects
must,ill out theform below and submit to the Commission Chairperson (contact info below).
Date: 3 /! q/1
Contact Name & Address:
AQr'oq i�, bus
Z E-( rvt S t -
N AAA o J•�
Project Address: (p ZliY�
Project Description (attach additional pages, if needed):
gcealr dapbOCAA w View wood ( IQ4Dboar61
Rf.oa I r l.)or c)/1 vJ wood r)( v o d Fr A" I OQ Se -( Q t� � ✓t�
Exclusion From Review Requested For (U (U VVl r) S k1Gi yl J V cucf S bA I U S �C, S
❑ 1. Interior Alterations
❑ 2. Storm windows and doors, screen
windows and doors.
❑ 3. Removal, replacement or installation of
gutters and downspouts.
❑ 4. Removal, replacement or installation of
window and door shutters.
❑ 5. Accessory buildings of less than 100
square feet of floor area.
❑ 6. Removal of substitute siding.
❑ 7. Alterations not visible from a public
way.
kv8. Ordinary maintenance and repair of
architectural features that match the
existing conditions including materials,
design and dimensions.
❑ 9. Replacement of existing substitute
doors, substitute siding or substitute
windows with new materials that are
substantially similar to the existing
condition.
❑ 10. Replacement of original fabric
windows or doors with substitute
windows or doors that maintain the
architectural integrity with respect to
form, fit and function of the original
,windows or doors.
❑ 11. Reconstruction, substantially similar in
exterior design, of a building, damaged or
destroyed by fire, storm or other disaster,
provided such reconstruction is begun
within one year thereafter.
MSV NCDC Page 1 Current Chair: Liz Fennessv, 77 Elm Street,lizettafennessy(irwahoo.com, 978-688-2915