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Home My WebLink AboutBuilding Permit #413-16 - 674 SALEM STREET 10/1/2015 L BUILDING PERMIT ° NORTF� w. �qt LEU 16 q-r� TOWN OF NORTH ANDOVER 02.h~''- APPLICATION FOR PLAN EXAMINATION w/- !`9 � n4A oCM C„ y1� M Permit No#: 6/ /7/ Date Received gSSACHU`�� Date Issued:-/-Z-) - / -/�/ IMPORTANT: Applicant must complete all items on this page LOCATIONPt _ Print PROPERTY OWNER —Fr1 c_ �ALt.4an- _.__ �l Print 100 Year Structure yes no MAP PARCEL:u7 ZONING DISTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial MAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District d Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: goLgw LA 8 x to 4ct'rt++rl ca bCq- Q U G>/ 48 b f und-L r nactnA a ;Ja o,4- e(APe 111rJc did -Crsp -Rcor h)-06^g -6x�"r-s aj UPs6,v5. - -3 Iden i ication- Please Type or IkAnt Clearly brle . OWNER: Name: Phone: Address: Contractor Name: t Phone: _ Email:,— - Address: _ w_ 6. Supervisor's Construction License: Exp Date: Home Improvement License..__ _ _ -.r ,_ ._ Exp. Date: 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: $ 2- Q FEE: $ Check No.: Receipt No.: NOTE: Persons contractink with unregistered contractors do not have access to the guaranty fund ignature ofAgent/Owner_ _ 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract u Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks u Building Permit Application L3 Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) u 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) o Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) u Copy of Contract o Mass check Energy Compliance Report u 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:Building Permit Revised 2014 I � I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL i 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_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS f 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 Y DPW Town Engineer: Signature: oca a sgood Street �- � Fire Departmen"t signature/date' . a '^COMMENTS;__- --i--- -- - - ---- - - ---- __ ■ 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 i 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 Call Email [DateTime Contact Name Doc.Building Pennit Revised 2014 Location No. L fffo Date //)/, . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� -� Foundation Permit Fee $ r'Rr� Other Permit Fee $ TOTAL $ h C ec k# 2944 Building Inspector t%ORTH Town of 1 E ndover O - 0 No. * = �=- C, h ver, Mass, COC"Ic„ewICU �1' A°RATED BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT �' .........................................................nBUILDING INSPECTOR ........................ ..�.�!................ .. . ........ .. Foundation 411 has permission to erect .......................... buildings on ...zj .......... -...... ,. Rough to be occupied as ......).. or.F.. ...... ...... ............. .................... .. ..RTs 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. eot&q.p PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI011,911 AR Rough Service .................... . ... ...... ... I ................................ 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. The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): I l q(}dA��an Address: C T-f Y a 6' - M�1 U[8`l5 City/State/Zip: ' Phone#: q78-6(E5—Z-76(- Are 78-6tE5—Z-76(-Are you an employer?Check the appropriate box: Type of project(required): 1.❑Tama employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. gRemodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3I am a homeowner doing all work myself[No workers'comp.insurance required.]t _.4 10 ❑Building addition Kr am a homeowner and will be hiring contractors to conduct all work on my property. I will nsure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[J Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractlisted attachedet. ors sted on the she ❑ - 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.F1 Other 152,§1(4),and we have na.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. 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 state whether or not those entities have employees. If the sub-contractors have employees,tliey 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: 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 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. Ido hereby cert' under the pains and penalties ofpesjury that the information provided above is t7/5- and correct. Si e: Date: < aturp Q / Phone#: C ( U fO 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 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 o? '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 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 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 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'contractor(s)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 foi 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 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 Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-AIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia NORTH TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 ,SS�CHU`�ES i Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: too JOB LOCATION: 6 Zi ` Number Street Address Map/Lot HOMEOWNER ,2 755 Name Home Phone Work Phone PRESENT MAILING ADDRESS &6,j 67• A)044k-616a/r r- 11AA r)c S`-1 :- 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 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535