HomeMy WebLinkAboutBuilding Permit #801-2017 - 674 SALEM STREET 2/27/2017I� , / " '` BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: d 6 G Date Received
Hata 15X1 iarl-
TYPE OF IMPROVEMENT
IPROPOSEDUSE
Resid tial
Non- Residential
❑ New Building
te6ne family
❑ AdOi#on
❑ Two or more family
❑ Industrial
s teration
No. of units:
❑ Commercial
❑ Repair, replacement
0 Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
tic El Well
❑Flood Iain 0 Wetlands
p
0 Watershed District .
Aater/Sewerr:
IZ- -Flocw
DESCRIPTION OF WORK TO BE PERFOKMtU_
Identification - Please Type or Print Clearly
OWNER: Name: [, ffans Phone: q78 - 08 -,7 7116
Address: GTI Sq Ltvn -9.
Contractor Name } l� Phone:. .
:..
Al
-i J":x+.��Z.,^P^`-. ,te...-P.ar+...-.. .�+ _ _. _. .,.... ... _-c.^�;-..••._ ., '�z-n.: mv.•"y`�,,^'a�"'tra Fdd.�'�!�,�A4: ,�v`cr'..' -_•
•4 . L .,
Supervsor;s>Con tfuctiongLlcense �.' _ �y' Exp: * Dafe,
rt .rr,.>....rs��r-z,tmt�`n`$Y .'6. 4 .. �4 ,_'r.a ". +45j •a�«*�ti *h".'r'.`�r
Holmprovenierit Licensed
Exp
me;
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULD/NG PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
'_,__,notal Project Cost: 600 FEE: $ V /Yu
$.4'"—
Check No.: gd- & Receipt No.; 3r 5-7 0
DOTE: Pe ns con aeti with unregistered contracto-rs do not have. access to the guaranty fund
5i "riatu e_o :�Agerit/O:wner Signature of contractor''
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/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
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
DOTE: 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
Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans ❑
TYPB'bF 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 Reviewed On
Signature_
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed o
Sianature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
a
i
lr Planning Board Decision:
r
CwDnservation Decision:
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Locatea jb4
yes no,
ooa Street
iimension
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
DANC=ER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Permit Revised 2014
Location &? J ,i t r �n
No. Yo I - 0O /'7 Date -9 7- Rot 7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ To
Foundation Permit Fee $ ,
Other Permit Fee $ z
TOTAL $ ,,
Check # q0I
6 1 � 7 0 Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 15'5,000.00
m
$ -
$
180.00
Plumbing Fee
$
22.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
22.50
Total fees collected
$
325.00
674 Salem Street
801-2017 on 2/27/2017
bathroom expansion second floor
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Donald Belanger
Inspector of Buildings
Please print
DATE:_9 L2712617
%
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
Telephone (978) 688-9545
Fax (978) 688-9542
JOB LOCATION: 7`� :Sx lem SYLr
Number Street Address Map/Lot
HOMEOWNER friL k" 178-196B-7-794
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 6 7-1 Sa lei.-, _
Akd-k Aydo f_ lVlAft b(BYS
City Town State Zip Code
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 110.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 understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
2'he Commonwealth of Massachusetts
Depa,,tment of �-nda�icalAccidents
- - F I congress Street, Suite 100
Sosion, MA 02114-2017
www mass.govIdia
ensation7nsuranc8 A•£fidavit: Buildens/Cont actors/Electricians/1'ltzmbers.
Wq kers' Comp
TO BE FILED-WU`RTBE I'M G AU7CJ3CORI1 Y.
1r1P�eaPrint ]
t� aall071%Indlv3dRa1): j Qh
Namo (Business/Orgiiix
Address:
/1 .�•IM i. .. c A A a /
City/State/Zip:
Axe yon an employer?
eck6e appropriate box:
I)hono #:
1.❑ I am a employer with employees (fun and/or Pari i5me)•
2.[] I am a sole proprietor or parCnerssbip andhave no employees Working forme in
required]
any capacr<y, [Noworkers' comp. insurance
3, ahomeownerdoingall workmyself W -'workers comp. ins
a'
Q ❑7 am ahomeowner andwill. be hiring contractors to conductaU work onmy property. twill
ensurethat all Bout etms eitherhave workers' compensation instuance or are sole
proprietors with no employees.
5.❑1 am a general conuactpr and I have h red.the sub -contractors listed ontbe attached sheet
These sub -contractors have employees mdhaveworkers' comp. insurance?
6.❑ We are a corPora$.on. and its officers have e:rercisedtheirrigbt of'exemPtion perMGL c.
no employdes_ [No workers' comp. insmance_regnired.]
Type of project (Seciuix8cl);
7. ❑ Ne'do`nsfauction
g. j;K'.modeak
9. ❑ Demolition
10 [] Building addition
11.❑ Elecical repairs or additions
12. [] P11 mbing repairs or additions
11 [ Ko6frepaits
14.[] Other
152, §1(4), andwe ave ,�
i Homaepopwlincearrs�twthhaotcshubecmkist bthbiXs #affi1 mduaysitt ailnsdoificaltilnoug Ethheey saercetdooninbgelaoiwl whorokwainngdtheirwors'compensai—
"
,n
thenhire outside ooniactols-ustsabimtanowafidavitindica5ng such
?Contractors that checkthis boxnmvst attached'an additional sheetshowing thename ofthecub-contractors and state -whether ornotthose, enfities have
rovidetheir workers' comp. poIicynumber. .. .._ _ .. - _
employees. Ifth� sub -contractors have employees, theymust p - .
X am an employes that isp�'ovidingt-vo1*keNs' compensation ix�.sr��ancefo�° my errzployees, Below is tFiepolicy aradjob •site
information.
Insurance Company
Policy # or Self -Ins. Lir-.
ExpirationDate,
I City/State/Zip: ..
rob Site Address: sltov�g the p olicy number anal expiratzoxa date).
Attach a copy of the -workers' coanpensation p obey declaration page (
500.00
Failure to SOr-ure coverage as required underM nalttesZm�fh2e f � of� STOP wO� punishable
1and a fmof4 to $250.00 a
and/or one-year imprisonment, as well as P
day against the violator. A copy oftbis statement may be forwarded to the Office of Investigations of the DIA fox ins tante
coverage verification.
X do Jiere�y ceYtify zznder the -pains andpenalties of brat the information pi oviderX move is true a2? corpec
Official rase only. Do notwrite in t1,18 area, to be co�r�pletecl vy city o town off tial.
• Permit/License #
City or Town--
Dsuiug Authority (circle one): iactor
X. Board ofIfealth 2- BuildingDepartnzent 3. City/Town Clerk 4. Electricalfuspector 5. Plumbing Xnsp
6. other
Phone
Contact Person•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eaAployees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
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 enferprise, and including the legal representatives of a deceased employer, or the
receiver'oz trustee 6f 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."
MGI, chapter 152,,§25C(6) also states that "every state or Io cal 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
applicantwlid 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 su-b=contractors) n-ame(s), address(es) and phone numbers) along with their certificates) 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 conftmlation ofinsurance 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
I-adustrial,Accidenis. should you have any questions regarding the law or if you are required to obtain a -�rorkers'
compematioA 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. Ofracials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space atthe 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 fillin the permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple parmiVlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) -and under "lob 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 fide for future permits or licenses. Anew affidavit must be .filed out each
year. Where ahome owner or citizen is obtaining alicense or permit not related to any business or commercial venture
(ie. 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
Department of Industrial A-ccid-ents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877 MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia