HomeMy WebLinkAboutBuilding Permit #200-11 - 638 CHICKERING ROAD 9/7/2010 BUILDING-PERMIT of µoRry q
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received `
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Date Issued: v
IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building L ne family 7b LA)N 1443 06 Cz
Addition Two or more•family Industrial
Alteration No. of units: Commercial .
Repair, re lacement Assessory Bldg Others:
Demolition Other
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DESCRIPTION OF WORK TO BE PREFORMED.,PREFORMED., (� r
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OWNER: Name: a Phone: - ea Q• 73 /9
Address: _ (e 3 g' C 4 I U i<•C-_e N Ck,
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$9000,00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ y�� '
,. n
Check No.:-q, tlj Receipt No.: a 3
NOTE: Persons contfaca, g with �egist red cor,Its�actol_ o not have access to the guaranty fund
-:t5.=:�',+' a :z_^•%-^-c ;- •r�k; - ;':.ix� � :ri:' '�i'•-:.`^�ns`T'.T�-•---: .:.'kr.,•,
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Location!�� i
No. Date
NORTh TOWN OF NORTH ANDOVER,
O L
6 w
9
Certificate of Occupancy $
CN�s<� Building/Frame Permit Fee $ -DY �
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # ' 0
234
Building Inspector
Plans Submitted Plans Waived Certified Plot Pian Stamped Pians
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/MassageBody 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
I�lJIV11VICNTS
HEALTH Reviewed on Signature
COMMENTS
a
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
-Conservation Decision: Comments
Water&c Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
:cS 1,y^
'i«".:�-+''-^�t,.:.:-a•�...i:e_-rr-;;._F_. 4,-'-1:i� ,-.: , _.tLocated•�.±:..m 384 O_vs.� c.oa:d:...Street
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ated:�t�'24.�ulat,
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.ice [:r ��;:•j:i` - - - - ..:.. - -:):a:.si?a.j<.,.�:.._:yi=';-
_ ,}. :•ham - - '.'f..
Y
(�^ `� %;rig 4...>.::• - ve z'�:
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter 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.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following 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
o 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
--:New ConstructionSingle and Two Family)
� 9 Y)
❑ Building Permit Application
r% -LIZ, r n nI_i n�
Q L-el uileU rrl'oposed I— WL roan.
❑ 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
NOTE: 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2008
ORTH
ToVM
o over
No. Mar
40A
LAK dover, Mass.,
T Q i
COC MIC ME WICK �
RATED
`s BOARD OF HEALTH
PERM IT T D Food/Kitchen
Septic System
000,Oft BUILDING INSPECTOR
THIS CERTIFIES THAT I11PIK....................................
....... .............. ......................................................
Foundation
has permission to ecArt..... ................ g I ,I;;........ci k. g
.............. buildings ..... ............................. ..................... Rough
to be occupied as Chimney
.. . . . . .........................................................................................
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRU ON ELECTRICAL INSPECTOR
Rough
................................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
The Comnionwe¢lth of Alassachuseiis
Dep¢rt►nent o f Indzastrial Accidents
Office Of£nvestigations
600 Washington Street
Boston, MA 02111
J
ompensation Insurance Affida ass°ov/din
Annlieant Information �t' Builders/Contractors/Electricians/Plumbers
Please Print Len-wV
Name (Business/Organization/Indivi dual):
------------
Address:4-sel- C
City/State/Zip:��
Phone#:_ �7,�� p
Are you an employer?Check the appropriate box: I
1.❑ I am a employer with 4- ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6- ❑New construction
12.7 I am a sole proprietor or partner- listed on
the attached sheet x 7• �qeemodeling
ship and have no employees These sub-contractors have
working for me in any capacity. workers' c g- ❑Demolition
[No workers' °mP•insurance.
comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition
3.[ re led] officers have exercised their 10•❑Electrical r
tam a homeowner doing all work right of exemption repairs or additions
myselL [No workers' comp. C. 152 1 � per MGL 11.❑Plumbing repairs or additions
insurance re aired. t �� C4);and we have no
q ] employees. [No workers' 12•❑Roof repairs
,,,,t r comp.insurance required] 13.0 Other
Y _- iron tmB ch-1-box-7 muni a3Cf BE,II f:^.e bei^t!'B.ROY..^.e.r
"Dmeowners who submit this affidavit indicating they are doing i b 'hsy him
-s'co�Y.s��+�u Y�i.2;.u�:..:..yy...
+Contractors that cbecl:th. *•in €aL`"on�¢t$en hire outside conttmato s i submit a new affidavit indicating such.
bo• �-�a'�-hed an addiiioaai sheet showing the name of the sub-c
I am an employer that is providing workers'compensation i►tsrtrance os ontracton and the,r workers'comp.policy information.
information, f my employees. Below,is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic-#:
Expiration Date:
Job Site Address:
Attach a copy of the workers, compensation policy declarationas City/State/Zip:
Failure to
p be(showing the policy number and expiration date).
secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of
fine up to$1,500.00 and/or one-year im risonmen criminal
� P as well penalties t as of a
- civil P
of vrl
up to $200.00 a day against the violator. Penalties in the form of a STOP WORK RK
Be advised that a c ORDER and a "
Investigations of the D FY°f statement may rine
IA for insurance coverage verification Y be forwarded to the Office of
I do hereby cera ,under gwairs and Penalties ofP .Ier
�thrrz the information.provided above is true and correct
ature.
Sim1<1557
Date
Phone#: _ d DJ -�
Official use only. Do not write in this area, to be completed by citi,or town official
City or Town:
Issuing Authority(circle one): Permitucense#
1. Board of Health Z.Building Department 3. CitY/Town Clerk 4.Eiectrieal Inspector. 5.plumbs.Insv
6. Other b , ector
Contact Person.
Phone#:
Information an- d Instructions
Massachusetts General Laws chapter 152 requires all employs to provide workers'compensation for their employees.
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 defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association og other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartnz ents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintemance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be cause of such employment be 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 it license or permit to operate a business or to C=onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coxnpliance with the insurance coverage required."
Additionally,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 un-t l 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-contractors)name(s), address(es) and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(I.L.C)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' comp ration insurance. If an LLC or LLP does have
employees,a policy is required.. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sore to sigh and date the affidavit:. The affidavit should
be i�.t.'urned to the city Or tkmm that the appliGa`uOn for the=r3nit'QT 1rCe�1Q�LS being r�glleStBd RQt F.'.^. ,��'en L";e rt Of
Industrial Accidents, Should you haveany questions regaTdi g the
compensation policy,please call the D
law, or if you airy re„K.i:;.;d to obtain a workers'
thepartment at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the 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
policy information(if necessary) 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 pests or licenses. A new 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 burn leaves etc.)said person is NOT required to complete this affidavit
The Ofnce of Investigations would Bice to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone and..fag.number._....
The Cammnwealth of M assar iusetts
Department of Industrial Accidents
Office of In,�,estications
600 Washington Street
Bastan,M A 02 111.
Tel. ff 617-72.7-4900 ert4O6 or 1-97-IVLA3SAFE
Revised 5-26-05
Fan:m 617-72.7-7 749
��frUi'.IIlaSs..�OV�t�Ia.
NaRTM TOWN OF NORTH ANDOVER
Of�t��n F6'�ti
- °L OFFICE OF
n BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover,Massachusetts 01845
SAGHUS�
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: oZ O v
JOB LOCATION:
/I PD
Number Street Address -Map/Lot
IiOMEOWNER /!�N ��'_,lro a-73/9 to-�f(77 X off.O
`O
e
j�er> Phone Work Phone
PRESENT MAILING ADDRESS G'`3 r t�•c,�v�, ��
City Town Qtwtw. Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
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 structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the 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 SIGNA
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 685-9530 HEALTH 688-9540 PLANNING 688-9535