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Home My WebLink AboutBuilding Permit #783-2017 - 629 WAVERLY ROAD 5/1/2018 t4AW TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: g 'a0l Date Received Date Issued: IlVIPORTANT Applicant must complete all items on this page .y..,_ *'-__.ate^t:�:r Yf•i�'."' '®n'f�•`-'t al ,�+�,, .•' ,� ..a., _ �,, w . .�,,, may,' ...;. - ..3 LOCATIONt Print PR_®PERTY+OVI/NER GGNNpy "�' Pnnt) 10Q,pYe&J ld Structure_ yes, no .FHistoric ®Istrctp K I MAPS NOcPARCEC{: ZON_INGtD1STRI;CT _• -'�� , Y ". ;�. _ . ;� x.�" _ ;a,. � ,. Machme;ShoptVlllage�# yes o _ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building A One family ❑Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial K Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Septic- ; .Well =❑ Floodplain. ,Wetlands .UVatershed Digtrict� , ❑Water/Sewer: - - - -- - - DESCRIPTION OF WORK TO BE PERFORMED: 1Le� at i l en-)-tie roa-f on houea Identification Please Type or Print Clearly) OWNER: Name: 6aV06tJ MRX N Phone: F Address: vjo"10e u64 P- !CONTRACTOR Name - _._ Phone= Address: - -- `Supervisor's`Consfruction;Licerise _ Exp - •Home Improvement License ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 00 FEE: $ ► C315-3'? Check No.: n ,S Receipt No.: - -- — , NOTE: Persons contracting with unregistered contractors do not have access to .fund : . .: ;: .Si iatu:e:of:.contractor , �Signature of•Agent/..Qwner::l:.;.. : .::...;. . . ..g �W�_ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - r Plans Submitted ❑ Plans Waived F1 Certified Plot Plan El Stamped Plans F1z TYPE-OF-SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster 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 Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature ®ate Driveway Permit _ DPW Tovv Engineer: Signature: Located 384 Osgood Street FIRE.DEPARTMENT) .-Temp Dumpster on site yes no Located at 124 fila.frbet Fire Deparfinerit signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL: Movement of Deter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A--F and G min.$10041000 fine NOTES and DATA= (For department use E i i B Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department T the fol owing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the; app,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be- subm:tted with the building application Doe: Doc.Bui.ding permit Revised 2012 own of North Andover layment Date Thursday,February 16,2017 )eposit Number 1702161 )perator Counter pc 1 ICR(BUILDING INSPECTION) $120.00 C� otal Paid $120.00 ;ash $120.00 ;hange $0.00 teceipt Number gov00005364 '/16/2017 1:08:23 PM W Jame 783-2017 ;ashier Id. treascoll-17 The Commonwealth of Massachusetts Department ofTndustrial.Accidents m r I C011gress sj reet,,5 &u 100 ~" d Boston,-VA 02114--2017 www mass.gov7dia �/Var 'ers'Compensation Tnsux anee Affidavit:Builders/CO A OR�'. czansll'lmmbers. TO BE FILED'ng' H PE� R `�I Please Print L 'bI A •-ii:cant Tnformation GHS N Name(Business/Oigaidation/Individual): 6 EN Address: (o Zq W k�G'R�� /LD NDRi'H q.1J'op�Ee,SAA 6 V u S Phone#: q7T ` q 7 y ?369 Gty/State/Zip: ecktIieappropriate riafebox: Type 0project(mmirecl); Axe you an employer.Ch 1.[]Tam a employer with employees(full and/or parE time). 7. []N&Wd6nstrdction 2-❑Tamasoleproprietor orparfnershipandhavenoemployees�torldngozmem 8. �Relnode7liig auy caparity.[Noworl�comp.insurance ragaired-] 9. El DeAlolttion 3.%1 am ahomeowner doing all workmyseli;:[No-workers'comp.iasorancerequired.l 10 ElBuilding addition q_❑Tamahomeowneraudwp]hehidngcoufzactorstoconduciaUwork onmypropety. TwiI1 11.❑Electrical repairs o additions ensurethat all contractors eitherhave workers'compensation insmance or are sole 12. Plumbing repairs or additions proprietors with no en3pioyees. 5.[-]T am a general contractor and TJlage hiredthe snb-contactors listed onthe attached sheet. '.�Roofzepairs l3 These sub-contractors have employees andhave workers'comp.insurance 14. Other (•❑We are a corporation and its,officers have axercisedtbeir right of exempfion per MGL e. 152,§1(4),and'we kava no empldyees-[No workers'comp.insurance required-] - campansation *Any applicant that checl�bbX#1 must also fill out the sertion doinglall work andihmbire outside contractors pnust sabmit a new affidavit indicating such. i Homeowners who submibtbis affidavit indicatmgthey _ �Coniractors that check this box m�eattacbi yan�s,��progide thein workers'comp.policy nnmb��state whether or nottliose.entities aqe - employees. Tfthe sub-oontr�.etsrs ? ,.. . X can arz employer tliczt is providing-rvorker�s'corrzpen�ation irzsurarzce for°rrzy employees ,8e1ow istXie policy orad job site information. Insurance Company Natnu- Expiration Wa' Policy#or Self-ins.Lic.#:. City/State/Zip: Job Site Address: Attach a copy of the•4voxkers' compensation policy declaxation page(shovvhig the policy number and expiration date). Failure to secuze coverage as required under MGL a-152,§25A is a cximinal violation punishable by a fin e up to$�.,5 00.00 UP and/or one imprisonment,as-well as civil p enalties in the foam of to a OP ce O�ORDER of td a he DIA foe of x ins°rrran 0 a day against the violator.A copy ofthis statement may be forwarded coverage vexifxcation. urzcler the sins arz�penalfies ofpedury that the irzfor�matiora ptoviderl above true cor�ec Idoraereliy certify�L P ' o�� O Z /61?W7 Date: Si afore: Phone#: 7 g_ 7 official use only. Do rzot-Write in this area,to be completed by city or totvrz of • Permit/Liceuse# City or Town: Issuing Authority(circle one): ' I.Board of Pfealth 2.Building pepartment 3.Cityffovn Clerk d-.Electrical Laspector 5.Plumbing Jfnspeetor 6.Other Phone#- Contact Person- Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their eAppyees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is d'efiired as"an individual;partnership,also dation,corporation or other legal entity,or any two or more Of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the xeceiver"or trustee Qfan individual,partnership,association or other legal enttty,employing employees..However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shallnot-because of such employment b6 deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicaAtwhd has not produced-acceptable evidence of compliance with the insurance coverage rued." Additioually,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),addresses)and phone number(s)along with their certiftcate(s)of insurance. Limited(Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If au LLC or LLP does have employees,a policy is required_ Be advised thatthis affidavit may be submitted to the Department of Industrial Accidents fox confmration ofiusurance coverage. Also be sure to sign and date the affidavit The affidavit should b e returned to the city or town that the application for the permit or license is being requested,not the Department of Iudustria1Accidents. Should you have any questions regarding the law or if you are required to obtain a w' orkers' compensation policy,please call tlieDepartment atthe number listed below. Self-insured companies sboWdenter their self insurance license number on the appropriate Had. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space atthe bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current PORGY information(ifnecessary)'and under"Job site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bunt leaves etc)said person is NOT requited to complete this aff davit. The Department's address,telephone and fax number: The, Commonwealth of Massachusetts De argent of p Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-I5 wwwmags.gov/dia of t►ORTil TOWN OF NORTH ANDOVER ,,? �•t _4''• °oma OFFICE OF A BUILDING DEPARTMENT } * 120 Main Street �44VED��'cy North Andover,Massachusetts 01845 SSACHUS� Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Building Permit Application Please print DATE: 2 1( 1 )l JOB LOCATION: r;2� W* �LL�y Number Street Address Map/Lot HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS �20) W P(yEaL," WRI'R AA\Soov&W_ MJF Olg4 City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as su ep rvisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 9/16 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535