HomeMy WebLinkAboutBuilding Permit #159-11 - 676 OSGOOD STREET 8/24/2010 J
BUILDING-PERMIT of "°or"
TOWN OF NORTH ANDOVER �� h``?• `-�'6`6 0
APPLICATION FOR PLAN EXAMINATION
Permit NOds--5— � Date Received A��-°-�-�• �`
�Rwren��a�y.(5
Date Issued: �� ^�� AC
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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
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DESCRIPTION OF WORK TO BE PREFORMED: ;
Identification PIease Type or Print Clearly)
OWNER: Name:= `vrvt1^ QZ/ 411 Phone:
Address: —_1t/�?2
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F,
Total Project Cost: $ S FEE: $�-�
Check No.: 3 1 Receipt No.: '2�`
NOTE: Persons co tin h nreaistered contractors do not have access to the gasaranty fiend
C' nature {y+ �'
J 5 y c 4y rY
_9 raetr-_; -�y
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
i -COMMENTS -
CONSERVATION Reviewed on Signature
COMMENTS'
QTS
HEALTH Reviewed on Signature
COMMENTS
n '
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
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—
Locafed
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�F,�ir.e��D�-,e��ar�r-r�en=�t,sa• :t�a�r�rel�afe�-_ - - _�--`=Y�:;:....,..,-' - - -- - - -__ -- �.,.
i•'..._-::.:.',...:.:.':is�"'.._l4:•:r�._.4.'.'-1 ... :.•.:•`. - - -- - � - -
. -
11�:M�.NT
i
f
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)
I
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
J
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
o 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 ;
n .1..r Proposed
n� i n�
❑ Ue:idled roposed Mot Plan. r
❑ 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:Building Permit Revised 2008
N
Location
No. Z25 Date
MaRTh TOWN OF NORTH ANDOVER
F A
9
Certificate of Occupancy $
�ssuN�stt� Building/Frame Permit Fee $ �
Foundation Permit Fee $ 's
Other Permit Fee $
TOTAL $
Check # Z
233 ;
Building Inspector
NORT1.1
Town of And
No.
co, -o dover, Mass., 2� w
O COC MIC ME WICK
V
0RTED
7 BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
r BUILDING INSPECTOR
THIS CERTIFIES THAT..................G�!! .1.a.!' 5
..... ......... ,, .4�.�1. ..! ..........................................................
Foundation
has permission to erect..............:......................... buildings on .... ......... .... ......................... Rough
to be occupied as.. .. .N.4f-i.6L..... ..............S kA�,s...r. ?Z�ri.R%4 ..... .A.1jA-!n......yi...k ....... Chimney
provided that the person accepting this permit shall 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
3p , PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUC TARTS ELECTRICAL INSPECTOR
Rough
Service
............... .....................................................................
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE smoke Det.
OF µ°"T" TOWN OF NORTH ANDOVER
nb��
tie OFFICE OF
00
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36 -
"7 North�SAndover Massachusetts 01845 sac►+uSE� '
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 Address Map/Lot
HOMEOWNER 3 ,� �- q7-"�" &$0 A 2.9
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City Tov-n R+„t� lip rod=
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 family 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 that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirem d that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachuseas
Departnzenlo f Industrial Accidents
Office of investigations
600Washington Street
-Boston, .4q 0 111
�+'�+�►+�-snassgov/din
Wotkers' Compensation Insurance-AFdavit: Budders/Contractors/Electricians/PI
AD licant Information umbers
�Name (Business/Organization/Individual): /-V� .Please Print Legibly
�X45 � • �-�6 v� ��?I
Address:
City/State/Zip: N001t N00141V NOV W { d I �"
�1 Phone#: � I � L
Are you an employer? Check the appropriate boa;
1.❑ I am a employer with 4. ❑ I am a general contractor and IF7. 0
oject(required):
2.❑ employees(full and/or part-time).* have hired the sub-contractors construction
I am a sole proprietor or partner_ listed on the attached sheet $ odelingship and have no employees These sub-
working forme in any capacity. contractors have olitionworkers' comp,insurance.[No workers' comp, insurance 5. ❑ We are a corporationanditsinob additionrequire ] officers have exercised their rical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp.d re
i
uc. 152 I
insurance ret [No workers,and we have no
required.] employees. 1 ❑Roof repairs
coma.ins d.] 13.❑ Other
urance require
-n}'appIicant that:.L;. 1-„box=i must aso rYri ou!'Ecc
'
Homeowners who submit this ee owa�^aa_^eir were'con r sos Y by; -you
af�davIt indicting the; z.doing at 1✓G7} gild th®�11rC OWSIde C-nn7a �iS is .
'Conhactors that checl:tuts bo.=.must a� huau additional sheet showing the
submit a new affidavit indicating such,
am an employer that is providing
name of the sub-contractors and their workers'comp.policy information.
I workers'compensation insurance for my e
informadon. mployee& Below is the policy and,job site
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.paae(sho fr
Failure to secure coverage as required under Section 25A ofM ws�the Policy number and expiration date).
fine up to$1,500.00 and/or one-year imprisonment,as well as Glc' 152 can lead to the imposition of criminal penalties of a
Of up to $250.00 a day against the violator. Be advised that a co penalizes in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification Py of this statement may be forwarded to the Office of
Ido hereb ertify er a pains and penalties o.fP !uJ er' ,
th4rt the information provided above is a and correct
Sisnature:
_._. Date.:...._
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License#
Issuiaa Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspect5
6. Other or .Plumbin
f.'Inspector
Contact Persun:
Phone r:
Information an_ d 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 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 ox-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 mamteXiance,construction or repair work on such dwelling house
or on the grounds or building appurten=thereto shall not be cause of such.employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local Iicensind agency shall withhold the issuance or
c onstr
renewal of a license or permit to operate a business or to uct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co:xmpfiance 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 un:-til 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 situatiou,and,if
necessary,supply sub-contractors)name(s), addresses) and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(I.LC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,.are not required to carry workers'comp=cation 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 Industrsal
Accidents for confirmation of insurance coverage. .Also be store to sign and date the affidavit The affidavit should
be mt=n d to the city ar tonrn that the applica � nfor the^=r�ittioor license is being requested,not the Depaurt-m ent of
Industrial Accidents. Should you have any questions regard,-—the;a H- or if you are:,k;:ired 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 stamp-d or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future per-mits 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 Office ofInvestigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone.and..fammumber_.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Inrestiaat ons
600 Washington Street
Boston,M_A 0.2111
Tel. 4 617-72.7-4900 ext 40.6 or 1-877-MASS.AFE
Revised 5-26-05
Fan. 617-72.7 77,d9