HomeMy WebLinkAboutBuilding Permit #878-13 - 659 WAVERLY ROAD 6/17/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
v
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Others:
❑ Repair, replacement
❑ Assessory Bldg
❑ Demolition
❑ Other
O'Sept c; 51�y1111ellOiWetland's
'r
j®i UVatersl ed I]istnct "
r/Sewer
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UtbUKIIJ i 1UN vi- WORK TO SE PERFORMED:
OWNER: Name. OMA k4elrW Phone: �- / ' -5 K",
Address: U U
4A
.,
CONT�RAtCTr®R� Name r
S`upervisorr's?Const�uct(ph icense .
Homrrprovemen.tLticense._.:: �..1
ARCHITECT/ENGINEER Phone:
Address: Reg. No
1:,51 f S+ kt♦.
FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
'Total Project Cost: $3.50. FEE: $__00
Check No Receipt No.: (�,
NOTE: Persons contrac ng with unregist ed contractors do not have access to the guaranty fund
Signatuce'of:Agent/.Owne: : Siat,u_re'U''ntrac
g _ _- - -..
Plans Submitted ❑ Pla Waived Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived-❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGEDISPOSAL
Public Sewer❑
Tanning/Massage/BodyArt F]..
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
COMMENTS
HEALTH
COMMENTS
Reviewed
�jb uj-jk(:�l
'%
Reviewed on Signature
Zoning Board of Apl,61s: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Commen
Conservation Decision: Com
Water & Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384
FIRE -DEPAIoTM-ENT - Temp Dumpster on site yes
Located at'124 Maim Street
Fire ®eparibiep t,sigiiature/elate
COMMENTS
d Street
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
'VIGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
oc.Building Permit Revised 2010
Building Department
The fol owing is a -list of the required forms to be filled out for the appropriate.permit to be obtained.
R.00firg, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L.- Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
10TE: 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
o 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
Q 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
OME: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
fn 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
rniist be subm--tted with the building application
Doc: Doc.Bui?ding permit Revised 2012
Locationa-�-- zuw�A
No. Date
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupappy $
Building/Frame Permit Fee
Foundation Permit Feq
Other Permit Fee $-
TOTAL $
"'Building InIspector
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.� The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Uf www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
City/State/Zip:,
Phone #:
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. #
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. ❑ 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 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' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
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 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 certto under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed 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. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact
Phone
Information and Instruction's
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 -contractors) 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 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 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 bum 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
604 Washington Street
Boston., MA 02111
TO, # 617-727-4900 eyt 406 or 1-877,MASSAFB
Revised 5-26-05 Fax # 617-727-7749
__WWW-Mass.govfdia
�� EA°R7k aya TO • W O.L} NORTH ,( N
Q teo .c'i�.L�IDO,VTi+7'l
°Td OFFICE OF a rl�
BUILDING DEPARTMENT
,.°" :. '1600 Osgood Street Building 20, -State 2-36
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
InspectorofBuiidings .
Fax (978) 688-9542
HOMEOWNgR-LICENSE EXEMPTION
BMI)ING PERMIT .APPLICATION
Pleaseyrint • , •
DATE:
JOB LOCATION:
Number Street Address
Map/Lot
HOMEOWNER
Name . Home Phone
' Work Phone
PRESENT MAILING .ADDRESS
Cifv To v=m
lip Code
The current exemption for "homeowners" was extended to include owner-occdpied dwellings to i�vo units or less and
to allow sub1, i�omPos.,,ners to engage an ldividual•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
Persons) who awns a parcel of land on which he/she resides or intends to reside, on which there is, oris in to
be, a one or two family structures. A person who constructs more that one home in a two-year period shalt not e
considered a homeowner.
The undersigned "homeowner" as 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 th
minie Town of NoAndover ndoverBuilding Department
requirements,mum inspection procedures and requirements and that he/she will comply o with,said procedures and p
HOMEOWINIBRS SIGNATURE
APPROVAL OF BUILDING
Revised 7.2009
Form Homeowners Exemption
EGARD OF APPEALS 688-9547 CONSERVATION 688-9530
HEALTH 688-9540
PL.ANNII.ZG 688-9531