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HomeMy WebLinkAboutBuilding Permit #829-16 - 66 HERRICK ROAD 1/21/2016gily Permit No#: Date Issued: LOCATION. BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page PROPERTY OWNER_ MAP PARCE eick qnu--A et G-1 K eel() Print 1100 Year Structure ZONING DISTRICT: Historic District Machine Shop Village yes yes (Fio� yes Z5 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial �4 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District Water/Sewer Go -i 1 d Dar - OWNER: Name: DESCRIPTION OF WORK TO BE PERFORMED: w C f I mvid n J dart— to d, v Ae - Please Type or Print Clearly I r-0. G-9 I` -Lo.e&,i Address: H� �/' �.� �%,�►r Contractor Name: Phone: Email: Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Date: bed rao 0A, 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: $U U FEE: $ Check No.:, /7 Receipt No.: --q 4 NOTE: Persons contracting withai yg�s'K Xd contractors do not have access to the guarantyfund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming ❑ g 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 o U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION C0,1MMENTS, HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Signature o� ?aning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: I - -r Comments Copservation Decision: Comments. Water & Sewer Connection/Signature Date Driveway Permit DPW Town Engineer: Signature: 7 Located 384 Osgpgd 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, Electrical Inspector Yes mast or service drop requires approval of No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10o-$1o00 fine 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 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 Building Permit Application 4. 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 4, 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 Location No. Date Check # -9?*. *. TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fees Foundation Permit Fee Other Permit Fee $ TOTAL Building Inspector < C7 0 •a rt � �_ O O C:5 O a � C p• CD n '� (' • p ;mu Z p S S� N -1 p O tp CD N �7 C o � CL "' CO) O CD W CD .a O N 0 2 — 7 O > OrL rt N U3 N_ CD 00 CD Z N C S. M-0 CD O 0 7r Z CL m cr N.� CL —• i Cl)c zN IDw n cQ O Opp � �n— p CD o$ - O �m U 0)C C t/) _2 CD CL Cr — Z CD `< O 0 Q)'O t p0 Oo M n O o CD Z a:; y, y a —•FL"CVS• —1 p _ Ntr� rt 1 r CO CD CD E • lb C as Z� C: �� s, CD� 0 O. p 0, O c): nCD C CD 0 � Oc O C CL rA O (D (D + N (D (D r* O WT C 3 rD m m D m m z j O) A O C, S N LA 0 O T j 0) (n O C n �p O C cmO) S m m AZ � m m T j A O C orqd S V C W m m 0 T j n S 7 A O C S T O C O_ p :3(D C c G1 Z 0 to (D 'a n 3 T O O \ n S m ' po v m O m D = Gerald A. Brown Inspector of Buildings Please print TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION DATE: 1 /2', / JOB LOCATION: (06 14 e r,, .,k � C1 - Number Street Address HOMEOWNER Kj b,,+ K8e4,1 97 Name Home Phone PRESENT MAILING ADDRESS Telephone (978) 688-9545 Fax (978)688-9542 Map/Lot -66 y I 92g q79 -Sova Work Phone I ;z _F', w -ev--- 5- - �jA-Ade\he.J ►M r -- City Town State Zip The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. 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 dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned "homeowner" assumes responsibility for compliance with State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she unde tands t own of North Andover Building Department minimum inspection procedures and requireme nd t he/s e ill comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth ofMassoOusetts Department of IndustrialAecidents 1 Congress Street, Suite 100 ^ ? Boston, MA 02114-2017 www.massgov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING .A.UTHORXT'Y. - Name (Business/Organiaationlindivid:zal): [!1 i k .f• J I *Any applicant that checks b0x#1 must also flu out the section below showing their workers' compensation policy information. T Homeowners who subM—X this affidavit indicating they are doing all work andthen 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 sub -contractors have employees, � iey must proxide their workers' comp. policy number. d am an employe that is povidir�g workers' compensation insurance for my employees ' gelow is the policy and job site information. Insurance Company Name:. Policy # or Self -ins, Lic. Expiration Date: fob 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 o. 152, §25A is a criminal violation punishable by a fuse 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 u c2e tlzepal s and . nalties ofpeajury that the information pr ovided above is tr a and correct. A1 / / �AFVNMRM enone 7F: Official use only. Do not write in this area, to be completed by city or toren official _ City or Town: P'ermit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Phone #: Contact Person: ACyvUr X11 � 5 Phone #: 970— (13 —66..q l City/State/Zip: Are yon an employer? Checktlie appropriate box: Type of project (fecluired): 1.[] 1 am a employerwith . employees (full and/or part-time).* 7. Now constmOtion 2. El I am'a sole proprietor or partnership and have no employees Working for me in 8. [ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3.M 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 n Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will have workers' compensation insurance or are sole 11. E] Electrical repairs or additions ensure that all contractors either proopries withno eir<ployees. prjd tobrr ---12-E] Plumbing repairs.or-addxiions„ 5. ❑ I am a general contractor and 1 have hired the sub-coivtracfors listed on the attached sheet. 'rade employees and have workers' comp. insurance.t 13. E] Roof repairs These sub -contractors 14. E] OtheT 6.❑ We are a corporation and ifs of6gers have exercised their right o£ exemption per MGL c. 152, §1(4), andwe have nq employees. [No workers' comp. insurance required.] *Any applicant that checks b0x#1 must also flu out the section below showing their workers' compensation policy information. T Homeowners who subM—X this affidavit indicating they are doing all work andthen 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 sub -contractors have employees, � iey must proxide their workers' comp. policy number. d am an employe that is povidir�g workers' compensation insurance for my employees ' gelow is the policy and job site information. Insurance Company Name:. Policy # or Self -ins, Lic. Expiration Date: fob 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 o. 152, §25A is a criminal violation punishable by a fuse 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 u c2e tlzepal s and . nalties ofpeajury that the information pr ovided above is tr a and correct. A1 / / �AFVNMRM enone 7F: Official use only. Do not write in this area, to be completed by city or toren official _ City or Town: P'ermit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Phone #: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires ag evaployers to provide workers' compensation for their e pployeeg. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contractoR'Aire, expres� or implied, oral or written." I An employer is defined as "an indMdu partnersWp, association, corpoTation, or other legal entity, ' .41 or any two or more of the foregoing engaged in ajoint 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 ofthe dwelling house of anotherwho 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." MOL 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 ofpublic 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 1ho'boxes that apply to your situation and, if necessary, supply sub 'coirtractoi(s) name(s), address(es) aud-phone number(s) along with their certificate(s) of ----insur-auce;--L-imited-L-iability-C-ompanies-(L-L-Gyor-L-imitud-L-iability-Potaut,.5Wg-(ELP�w—itffn—oempl-oyddso er an 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 Depatiment. of Idustrial Accide-utsfo�confLtmationofinsurance coverage. Also be sure to sign and date the aifidavit. The 'affidavit should be returned to the city or town that the application for the permit or license is bein'g requi-asted, noi the Department of Industrial Accideir�s. kould you have any questions regarding the law 0'r ifyou'are r�q�re� to obtain a workers' compensatioA �oliqy, please call the Department. at the number listed below. Self-iii�ur6d companies should'entortheir self-insu.ranc'e 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 youregarding 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 my given year, need only submit one affidavit indicating current I?oli6y 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 matIced by the city or town way be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be filled out each year. Where a home owner or citizen is obtab-iing 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, AdA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia