HomeMy WebLinkAboutBuilding Permit #857-13 - 659 WAVERLY ROAD 6/10/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: fo J
IMPORTANT: Applicant must complete all items on this page
LOCATI
a]
PROPERTY OWNER,
Print 100 YearOld,:Structure yes no
MAPNO:off-_PARCEL: ZONING DISTRICT: Historic District- yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
C -I family
❑ Addition
❑ Two or more family
0 Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Welli
❑ Floodplain ❑ Wetlands
❑ Watershed District -
11 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
6(o t_0 s &-v 14 c,,,
Identification Please Type or Print Clear y)
OWNER: Name: Phone:
Address:
CONTRACTOR Name:
Address:
Supervisor's, Construction License;/
Home Improvement License:
Exp: Date:
. Date:
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON 125.00 PER S.F.
Total Project Cost: sy /� FEE: $
Check No.: Receipt No.: rIp- (10:7 i
NOTE: Persons contractinLr1with unr gistered contractors do not have access to the guaranty fund
Signatureof Agent/Owner Sg;lafure of contractor.
Plans Submitted ❑ Pla s Waiv d ❑ Certified Plot Plan ❑ Stamped Plans ❑
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 Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
.DATE REJECTED
El
DATE APPROVED
.❑
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:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow;d Engineer: Signature:
Located 384 Osqood Street
FIRE DEPA TM
Located at 124 Main
Fire Departmeri
COMMENTS
NT - Temp Dumpster on site yes
Street
t-signature/date
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 fol?wing 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
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o 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
o Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o 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 Construction (Single and Two Family)
o Building Permit Application
❑ Certified Proposed Plot Plan
o 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)
o Copy of Contract
o 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 appz. al 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: Doc.Buiiding Permit Revised 2012
la
Location,;ri
W -57a -Aa Date
a . TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
AITIO'l, TOTAL
Check #
26497 '-Kuilding Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
Ut www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/individual):_
Address: % ri I u)a lU Q r
Al er(mS
r
City/State/Zip: �lor�v� � n �jo d � meq' o�gySPhone #: gf- S -T g 6 y 15'
Are you an employer? Check the appropriate box:
Type of project (required):
L ❑ I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
have hired the sub -contractors
7 F1 Remodeling
2. El am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in an capacity.
g Y p tY•
workers' comp. insurance.
5. ElWe are a corporation and its
9. E] Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10.❑ Electrical repairs or additions
3. IT, am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, §1(4), and we have no
12.❑ Roof repairs
insurance required.] t
employees. [No workers'
1311Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors 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
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby 9&,#&undelpWains andpenalties ofperjury that the information provided above is true andcorrect
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
W13
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 #:
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 defined 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 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
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 may be submitted to the Department of Industrial
Accidents for confirmation 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 permittlicense 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 permits 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 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 and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
Tel, # 617-727-4900 oxt 406 or 1-$77,7MASSAFE
Revised 5-26-05 Fax 4 617-727-7749
w�.mass,go�/dia
TOMT OF i*iOR
�a�1L�P k6;�tid 'I'kI ANDOVER
. OFFICE OF
O ,� BUILDING DEPARTMENT `
Osgood Street Building 20, Suite 2-36
'�s`a�uusc�5 North Andover, Massachusett8 01845
Gerald A. Brown
Inspector of Buildings Telephone (978) 688-9545
HOMEOWN- ER'LICENSE EXE1V1pTION Fax (978) 688-9542
EWDING PERMIT AP -PLICATION
Please mrint
DATE: /� _ (p - ,
JOB LOCATION:
�Jv.tvMv WNEK '
Name.
PRESENT MAILING ADDRESS
Street Address
Home Phone
Map/Lot
Work Phone
�Ae./
A-1 TORM State -
Zip code
The current exemption for "homeowners- was extended to include owner -occupied dwellings to f�vo units or les
and
to allow such l,omeot=,vers 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 OFHOMEOWNER
Person(s) who Awns a parcel ofland on which he/she resides or intends to reside, on which there is, or is intende
be, a one or two family structures. A person who constructs more that one d to
home in atwo-yearperiod shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State $wilding Code and ocher
Applicable codes, by-laws, rules andregulations.
t
The undersigned "homeowner" certifies that he/she understands the Town of North ,Andover Building Department
minimum inspection procedures and requirements and that e -/She will comply with,said procedures and
requirements,
DOMEOWNERS SIGNATURE
APPROVAL OF BUILDING
Revised 7.2009
Fonn Homeowners Exemption
BOARD OFAPPEALS 688-9541 CONSERVATION 688-9530
HEALTH 688.9540 PLANNING 688-9535
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