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Home My WebLink AboutBuilding Permit #370 - 67 RALEIGH TAVERN LANE 11/12/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �---�6_— Date Received Date Issued: &Z2 IMPORTANT: Applicant must complete all items on this page LOCATION—,/,7 ring - PROPERTY OWNERr/il 1 ? Print MAP NO: 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: Identificatip Please T e or Print Clearly) OWNER: Name: ��y✓ G Phone: l -- �✓� Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Horne Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: 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: $ L2.bo C, FEE: $ �� Check No.: �a S Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Age �--- ignature of contrac r 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature ;OMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 1`24 Main Street Fire Department signature/date COMMENTS 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 2008 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 NOTE: 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 ❑ 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 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 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: Doc.Building Permit Revised 2008 x.10 R T11 Town of t 4Andover . 0 to No. 3 '0 - �`y z~ - dover' 'Mass. �/1a• • O� T () COCKICI WICK ORATED I"? �y `S BOARD OF HEALTH PERMIT T D • Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT...........� ......... .^^. .'! !^' .............................................................. Foundation has permission to erect94Ar.0.4004,- .............. .............. buildings on .40.1.......... ... . .... Rough own% to be occupied as....... .......... .................... ........�.�..........8A4 Chimney . ................................... provided that the person accepting this permit shat in every respect conform to the terms of the application on file in Final 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR 00< UNLESS CONSTR C STARTS Rough ......... ..... ..................:................................................. ervice BUILDING INSP Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location//4- � 6 m 7/1 vw�-- No. Date �ORTh TOWN OF NORTH ANDOVER O:i .•o :•'�1y0 MPIWMW D i • ; Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ S cHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # V` / 2262 Building Inspector c10RTH Town ofAndover : 0% No. 3 70 dover, Mass.,i/ la• • D� , T 0 - LAKE � COCMICHEWICK V ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT .............................................................. w�.rvw•�� ............................. Foundation has permission to erect ...................................... buildings on ..�7...... .... ... . ' i.....� Rough trm to be occupied as........ ............... .. ..........................rin��every Chimney . .. . . . .... . . . ................ . . . .. . . . �r.. . ... ..... . . . . . . y provided that the person accepting this permit sharespect conform to the terms of the application on file in Final 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 «� % PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR STARTS Rough ......... ..... .................................................................... Service BUILDING INSP Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov. 1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zi ✓. Phone#: Are you an employer? Check_the appropriate bog: Type of project(required): 1.❑ 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 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for 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.] officers have exercised their ❑ 3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions I\ myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *.:n.applicant,flint checks box#1 miist also Ell 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. :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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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 in urance coverage verification. I do hereby certify under he ins and penalties of perjury that the information provided above ' true and correct Si afar Date: �/.2- /11 Phone#: �2 7,11 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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 the'. Pursuant to this statute,an employee is defined as "...every person in the service workers, it employees. express or implied, oral or written." another under any contract of hire, An employer is defined as"an individual,partnership,association, corporation or other legal entity, or an tw of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, ty y o or more receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However or the owner of a dwelling house having not more than three a the dwelling house of another who employs persons to do maintenance,aconstruction eor repair�wo k ons sor the uch el the or on the grounds or building appurtenant thereto shall not because of such employment h dwelling house p yment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance renewal of a license or permit to operate a business or to construct buildings in the commonwealth for anyor 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 enter into any contract for the performance of public work until acceptable evidence of compliance with the nsuran requirements of this chapter have been presented to the contracting authority.,, ce Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply necessary, supply sub-contractors)name(s), address(es)and phone number(s)along with thein-certificate(s)of situation and, if insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does other than the e 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 sh be reg p int of ed to the city or town that the application for the permit or license is being requested, not the Depa ould 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 self-insurance license number on the appropriate line. enter their City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at of the affidavit for you to fill out in the event the Office of Investigations has to contact you regardingthe a p the bottom Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant applicant. that must submit multiple permit/license applications in anPp ant Policy information(if necessary) Y given year,need only submit one affidavit indicating current and under"Job Site Address"the applicant should write"all locations in town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be -(cityprovided to thor applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial ven ur (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. tore The Office of Investigations would like to thank you in advance for your cooperaon and should you have any please do not hesitate to give us a call. y questions, s, The Department's address,telephone and fax number: The COMMOnwealth of Massachusetts Department of Industrial Accidents Office of bvestigations 600 Washington Street Boston, MA,02111 Tel. # 617-727-4400 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-72.7-7749 wvw.mass.gov/dia AORTH TOWN OF NORTH ANDOVER a ��oet;`■D�`'a�°� OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20 Suite 2-36 ADAATID SPP` North Andover,Massachusetts 01845 �SSACHUSE� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE:—,)///) JOB LOCATION: Number Street Ad ress Map/Lot HOMEOWNER ��il vr7 Name Home Phone Work Phone PRESENT MAILING ADDRESS /��?�� /�✓ C�� xu, �T�oyl✓. O� City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners 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 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 fancily structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies tha she understands the Town of North Andover Building Department minimum inspection procedures and re . eme and that he/she will comply with said procedures and requirements. r� HOMEOWNERS SIGNAT APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535