HomeMy WebLinkAboutBuilding Permit #816-14 - 659 WAVERLY ROAD 5/12/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
H.
Permit N0: "' _ Date Received
Date Issued:12 14
IMPORTANT: Applicant must complete all items on this page
• ' e«�I �F,W&Wro,
PROPERTY OWNER 1 Y I ! C* IF -d] LC., L,E7
Print J 100 Year Old Structure yes no
MAP NO: 77 PARCEL 1. ZONING DISTRICT Historic District yes no
Machine Shop Village yes no
.TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non -Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
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CQ a off/" , a -
Identification Please Type or Print Clearly)
OWNER: Name:
r_�rrCC&"
CONTRACTOR Name: A Phone:
Address:Q c�V'N
Supervisor's Construction License: Exp. Date:
Home Improvement License:._ Exp. Date: -
ARCH ITECT/ENGINEER
ate:
ARCHITECT/ENGINEER
Phone:
� — 30 '� "meq ('0
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ ,- E00, (/p FEE: $
Check No.: I l-31 Receipt No.. Z-7 G- 0
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/OAne _ _ 0g afure of contractor Y 4 JPlans Submitted [1 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
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Plans -Submitted: Pians Waived 0: Certified Plot Plan ❑ . Stamped Plans F1
TYPE 0F,S) WERACEDISEOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑ ...
,Swimming Pools ❑
Well ❑
-Tobacco.Sales ❑
Food Packaging/Sales ❑
-Private:,(septic ta*, etc:_ ❑. -.- :.
permanent Dempster on -Site ❑
=THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING '& DEVELOPMENT
COMMENTS
-DATE REJECTED DATEAPPROVED
❑ ❑
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 ConnectioniSature & Date Driveway Permit
•
DPW To`aa: Engineer: Signature:
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Located 384 Osgood Street
FIRE DEPARTUENT - Ternp Dumpster on yes no
Located at 124,Mair, Street
Fire Departine►t signature/date---' 4
LC
011fiM.ENTS .
-Dimension-
Number
Dimension -
Number of Stories
_Total land area; .sq. ft.;
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter l.ocatio' n,`mast or service drop requires approval of
Electrical Inspector Yes No
DANGER..Z®NE LITERATURE: Yes No
MGL Cfi'apter166.Section 21A -F and G min.$100=$1000 fine
NOTES and DATA - (For de
El Notified for pickup - Date
Doe.Building Permit Revised 2010
ent use
Building Department
- The folEpwing is'a list of the required.forms to be filled out'-for:the appropriate. permit to' be obtained.
Roofivg. , Siding, Interior Rehabilitation Permits
❑-. BEailding Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.1.C. And/Or'C.S.L Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster: permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o 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
NOTE: 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the api)•?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
Location 60 060 Lj-e'e l e y
No. Slb —1 v Date 3-"17
Check #// �3
2265 8
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee so -h --
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
K
/ Building Inspector
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JACFR
of enrrh TOW OF iVORTHANDOVER,
- • ° OBFICE OF
BULMG -DBP.AR.T NT `
�� amyl 7600 Osgood S1reetB0din920,•Suite 2-36
7�s�acutis �• North Andover, Massachnsetts 01 845
Gerald A. Brawn
Inspector of Bi ldings Telephone (978) 688-95445
HOMEOWNER LICENSE EXEMPTION (978) 688-9542
32MRING PERI T APPLICATYOIel
Please�rint •• '
DATE: �• /,� / (-%
YOB LOCATION;_
Number S
oMMo P
- Name.
PRESENT MAILING ADDRESS
Address
Home
Map/Lot
Work Phone
Qty Tnt=n, State.
P Cade
The current exempfion for "homeowners" was extended to
to aI1ow sui;h ?�omeo},;mei to en ^ e an in
cividual.for litre whoLicoes �7�notosse7
p� a Tense, Prov ed thattthe ownean_d
acts as supervisor}. State Building (Code Section 108.3.5. i)
DEFINITION OF -HOMEOWNER
Person(s) who Qwns a parcel of land on which he/she resides or intends to reside, on
be, s idered a homeowner. one or two fwn structures. A persoxt who constructs mote which there is, or is intended to
ns
cothat one home in a two yearperiod shall not be
The undersigned " homeowner" assumes responsibi
Applicable codeslity for compliances
bylaws, rules and regulations
with the State Building Code and other
, .
c
The undersigned `homeowner" certes that he/she understands the Town of North Andover Building Department
inquire rn inspection procedures and requirements and that he/she will comply with,said procedures and
requirements,
HOMEOWNERS SIGNATURE f' .
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exdmption
•EOARD OF APPEAU 688-9541 C01\rSERVATTON 686-9530
HEALTH 688-9540 MANNING 689-9535
The Commonwealth of Massachusetts ,
Department ofIndustrialAccidents
Office of Invesfigations
600 Washington Street
Boston, )VIA 02111
www.mass gov1d1a
Workexs' Compensation Inssurance Affidavit: Builders/Cont°acfors/Electriclans/Pliimbers
Apulieant �n£ormation Please Print Led .!
Name (Business/Organi'zaiion/Tn(Uvidual):_�:
Address:
Are you an employer? Check the appropriate box:
Type of project (required):
.1111 am a employer with.
4. ❑ I am a general contractor and 1
6. [] New construction f
employees (full and/or part-time).*
2. El am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet
�� E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
worlting fox me in. any capacity.
workers' comp. insurance.9.
❑Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
required.]
3\0 1 am a homeowner doing all work
officers have exercised.their
right of exemption per MGL
I L ❑ Plumbing repairs or additions
myself. [Eo workers' comp.
c. 152, §1(4), and we have no
12.❑ Roofrepairs
insurancerequired.] t
employees. [No workers'
1311 Other
comp. insurance required.]
IAny applicant that checks box #I must also fill out the section below showingtheir workers' compensationpolicy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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' carnpensation insurance for my employees Below is the policy and job site
information.
Insurance Company
Policy /# or Self ins. Lie.. #: 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 required -under Section 25A ofMGL o. 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 fne
ofup 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.
X do hereby cert under the pains and penalties of perjury that the information provided above is true and correct.
r VmV o
Official use only. Do not write in this area, to be completer) by city or town official.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is de%ted as "...every person in the service of another under any contract: ofhire,-
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 or other legal entity, 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 shall not because of such employment be deemed to be an employes."
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
applicant who has not produced -acceptable evidence of compliance 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 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), address(es) and phone number(s) along with their certificate(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 an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for con&matlon of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department 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
thatznust submit multiple permitrlicense 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
towiz)." 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 homeowner 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 Office of Investigations would like to thank 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 aiid fax number:
`rho Corr_ M0.uwea1 ofM_assarhvsPtEs
De-paxtment of kaftftial Accidenta
Office offAvestigallona
600 Wubiagtoa Strut:
Boston,, MA 02111
TO, # 617-22.'x_4900 end 406 ox x-877,�MA.SS.AFE
Revised 5-26-05 FaX 0 617-727-7749
www.MEtss,g4 �dia