HomeMy WebLinkAboutBuilding Permit #1080-15 - 66 BRIGHTWOOD AVENUE 6/22/2015 -7} i \>
BUILDING PERMIT o�No Dr"
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
9 ye"Permit No#: ° Areoa
OH
/01
(9
SSgCHUS
Date Issued:
/
IMPORTANT: Applicant'must complete all items on this page
LOCATION 1 n C9 ' ( �L-�- GJ add AUaw V .N.
Print
PROPERTY OWNER 0aTE -%CAL- I N
Print 100 Year Structure yes n
MAP PARCEL: ZONING DISTRICT: Historic District yes n
Machine Shop Village yes o
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building [$IOne 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
El Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: TtL.�c �_( `� Phone: ?cf- 9�f3�-o(2a
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone: t
f
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: $ �.�,(, 0 FEE: $
Check No.: 2, Receipt No.:
NOTE: Persons contracting •h unregistered contractors do not have access to the guaranty fund
Location
No. Date
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy '$
Building/Frame Permit_Fee $�
Foundation Permit Fee "$
Other Permit Fee $ �,
TOTAL $
Check# �23
? Building Inspector
S
Locationf
U
No. �� Date �3
17
• - TOWN OF NORTH ANDOVER
Q •
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL (/ C' /Z� k $`50 ...
Check#
j `� 'Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL r
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swurnning 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 Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEA;:.TH Reviewed on Signature
x
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
P
Conservation Decision: Comments
t
Wafter& Sewer Connection/Signature& Date Driveway Permit
]DPW Town Engineer: Signature:
Located 384 Osgood Street
hkFIREDEzPARTMENT ' T;emDumpsteronisitea
#iL0 ated a"t,1k24Main¢Street �F ;� t
� • ;.r �� , :gnatur�e/dated_m�. _ �_a�v_�� ...._..._...,_._. _- - - �-_
'C.®MMENI S'_
- - - -
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: lyes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
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
4, 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4 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/Cross Section/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
• 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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 2014
NORTH
own of
0 ."
ItiNo.
h ver, Mass, �!
CDC ICKlw1CK �1•
�ds RATE1)
U BOARD OF HEALTH
I ' T L D
Food/Kitchen
PER Septic System
THIS CERTIFIES THAT MI!. BUILDING INSPECTOR
has permission to erect .......................... buildings on�ta... ... Foundation
Rough
4
to be occupied as ........ . . `!!r...... ....�... ................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Col- ruction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
-PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIOT TS Rough
Service
....................... . ....r
..... ............................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
C�Gt,h11Q
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
24,000.00 m
$ - $ 288.00
Plumbing Fee $ 36.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 36.00
Total fees collected $ 460.00
66 Brightwood Avenue
1080-15 on 6/22/15
Kitchen and Bath remodel
NORTh
Town of � n
� "t
No. 140 A6 n
h ti ver, Mass,
COCHICHIWIC
A04AT E D
s U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD/nn Septic System
THIS CERTIFIES THAT Offs ,, y,` — I v. , BUILDING INSPECTOR
.................... .................e...............................................................
//"_ //��
has permission to erect .......................... buildings on ...v 4C,.........06.Ci.V1 w.tv.
xaC.=............. Foundation
-/ Q _ Rough
to be occupied as ...... 1. ......�..... .�i.'1 .....r .eve✓vq ....................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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
2F1� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ST TS Rough
Service
............... ... ................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy.Buildin 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 byte Building Inspector. Burner
Street No.
Smoke Det.
TOS'
• ��"'�v 6^}''I~J.�'.•¢Ra''ey' . OF NORM AND OVER
O�ICE OF
!KUMJNG DEPARTMENT
. k60nDBkooaStrootBuffdiu 20,-Silite—
3-
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Me.,
•-N-oithAridovox7-Massachusetts 01845
Gerald A.Brown TelepI.one(979)699-954-5
l'uspectorofJ311dings _Fax (978)689-9542
IOC)W I�7EK LICENSE EMPTION . .
13MING PRPMT PPL IC.AT10N
please rin-t '
LATE:1� - 22- I C
,
�oB LOCATION., k
Number StzeetAddress Map)Zot .
�10NMovMER ,j . -lf-, g y
Name. home l'Izone 'SN01k7?>sone
'RESENT MAA NG.ADDRES �� a
1`Jv ,i`01 AWde)Ve% AA - elf l
• -F Co_s
The currentexempfionfor"homeowners"was extendedto?ncludeowner-ocgtipieddtvelingstot-V unitsor?Ogg
and
to a71ow su�T, omeo�aners to engsge an.in' dividual•for lire who does not possess a license,provided that fhe owner
acts assuperYisoz). ,S ate3ulding (coda Secfion.1o8.3,5j)
DFMIT`ION OFHOMEOWNER.
P01-Sons)who awns aparcel of land on wb%cll helshe resides or iHtends to reside,on wbicll there is,or is intended to
b"e,aOne ortvofamilysfMGtares- ApersottwILoconstractsmoretri
atone bomezn•atFvayearperzodshall zotbe
considered ab.omeowner.
Tho undersigned"lioxneowner"'assttmesxesponsz�biIVfozcompliauces v,,Ith the StateBuildiug Codeand otber
.Applicable codes,by-law;rules and-iegr�.Zations.
The andersigned`fomeoWnee'cerl�&s tbat.bels'La understands ffie TOW-a oflgorih An.doverDWIding De�arEza(-nt
Mfidmum iuspeofiou procedures and requireanents and thathelsho wM comply with said procedures and
requirernents, .
HOMEOWNERS SIGNATURE '
APPROVAL OF PU. I)WO OFFICUL .
Reyised 7.2009 y
1~'orm xiommwners Exemption ,
3DA.RD OF'APPEA.TSS 688-9541 CONTSERVAUON 698-9534
1'3EAL'IH6$8-9540 pLAN�VTtJr qua a;a;
The Commonwealth of Massachusetts
. 0 Department of IndustrialAccidents
M r 1 Congress Street,Suite 100
- Boston,MA 02114-2017
°gym 5v�
www mass.gov/dia
Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plum ers.
TO BE FTLED'WITH THE pERM[TTIlVG AUTHORITY. Please Print Le 'bl
Ali formation 110 r
Name(Business/Oiganization/Individual):
Address: 7 7 1� *AJ 513 �eJ• �4a ""��i
City/State/Zip:(J• Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
em to ees full and/or part-time).* 7. 0 New'donstW6tion
1.MI am a employer with P y ( P
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. yfRemo delifig
any capacity.[No workers'comp.insurance required.] 9, El Demolition
3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole
11.0 Electrical repairs or additions
proprietors with no employees. 12.[�Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•, Rb6f reliairs
These sub-contractors have employees and have workers'comp.insurance? 14.0 Other
6.Q We are a corporation and its•officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.(No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached'an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name'
Expiration Date:.
Policy#or Self-ins.LIG.#:
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 MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Date: '
Simafore:
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):
LI.Board of Health 2.Building Department 3.City/`I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
er
ct 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 of hii" ,
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
receiv6fdr 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 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
applicant who has not produced-acceptable evidence of compliance with the insurance coverage r'equi'red."
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 certifcate(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 of 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts l
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax#617-727-7749
Revised 02-23-15 wwwmass.gov/dia