HomeMy WebLinkAboutBuilding Permit #627 - 678 MASSACHUSETTS AVENUE 5/18/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued
1 IMPORTANT: Applicant must complete all items on this page
LOCATION t% &%its Nva M o Iy t
Print
PROPERTY OWNER_ M'ri
Nnnt
MAP NO: _PARCEL: .ZONING DISTRICT:Historic District yes
Machine Shop Village yes
v 4t l.cv '6•-•yO
o
Residential
Non- Residential
New Building
Ane family
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
Ane family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
epair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
11100
Identification Please Type or Print Clearly)
OWNER: Name: M I A4 Rkwz°- L S cow, 91we Tzx, Phone: 9'q P- "0 -2-W D
Address: G ? � ° 111c"� &,,e /U , Av\Jt,,, / , Nt A o 0
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: 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: $ ®fir FEE: $ 5-3 �—
Check No.: / Receipt No.:
NOTE: Per ns contracting with unregistered contractors do not have access to Ae guaranty fund
Signature: of Agent/Owner "'A Signature of contractor
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
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locatea &54 uS ooa Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 324 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: I Total square feet of floor area, based on Exterior dimensions. I o o
Total land area, sq. ft.: 1/00 � iab � Y''. k. -
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location—,�Ii
No. Date
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #
L-------
220146
Building Inspector
f NORTh TOWN OF NORTH ANDOVER
O•�,�.s
•; r. oA OFFICE OF
p BUILDING DEPARTMENT
_ * 1600 Osgood Street Building 20, Suite 2-36
s^. t
North AndOVel, Massachusetts 01845
Gerald A Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please mint
DATE: 12 Mow, 0!9
JOB LOCATION: %B Mass
Number
HOMEOWNER M'1 stn
Street Address
9�8�6�6-'lyi(
R . S 90.2YK'0
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 6 78 MaAs A u e
.A ndbu&r M
City Town State Zip Code
The current mon 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, prodded 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 tbat he/she understands the Town of North Andover Building Department
Imrnlmtrm inspection Procedures and requrremertts and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeownm F.=,W im
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f NoerM TOWN OF NORTH ANDOVER
O•t,��•
• : • �� OFFICE OF
BUILDING DEPARTMENT
* 1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
Please mint
Telephone (978) 688-9545
Fax (978) 688-9542
JOB LOCATION: 6'7 M" . Aue
.:.
Number . Street Address
HOMEOWNERPAh�t 4A,e �` . 6 Y6- Mf
Name Home Phone Work Phone
PRESENT MAILING ADDRESS (' h $ . ovum k—e—
k-) . A rodnue-4 mo 0l3 ysr
City Town State 4 Code
The current amniption far "homeowners" was extended to include owner-0=43ied dwellings to two units or less
and to allow such homeowners to engage an individual far 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
Perscm(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 strvcmres. A person who construe more that one home in a two-year period shall not
be considered a homwwner.
The undersigned "homeowner" assumes responsft)&Y for compliances with the State Building Code and other
Applicable codes, by-laws, Hiles and regulations.
The undersigned "homeowner" certifies that helshe understands the Town of North Andover Building Department
�mmum msPection Pres and rm uirments and that he/she will comply with said procedures and
requiTements•
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revises lomm
Form Homeowners Exemption
ROARD OF \PPF:\I.S (Axx ,)54j CONSERVATION ,g8_9530 HF.U.Tfi !,xx-9544
PL.�\��[\G 68x -y515
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ii Vis![
The Commonwealth of Massachusetts
Department of Industrial Accidents
Qfftce of Investigations
600 JTrashington Street
Boston, MA 02111
' www_mass.gov/dia .
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
r1t1l1Panr Tnirn...w..i:....
N (Business/Organirafion/individual):_ ►�\( nn�
Address: G
U
City/state/Zip: 1� . AjA t., r.,1 M R o t 8 y r. Phone #: 3� Y• 1'90 - Z V 6
Are you an employer? Check the appropriate
box:
1. ❑ I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a.sole proprietor or
have Dred the sub -contractors
listed
partner-
on the attached sheet t
ship and have no employees
These sub -contractors have
working for mein any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporafion and its
required.]
3.R I am a homeowner doing
officershave exercised their
all work
right of exemption per MGL
myself. [No•workers' comp,
C. 152, C 1(4), and we have no
insurance required.] t
employees. [No worker'
comp, insurance required.]
*Anv mmlironr fh., ..I.__I.. t__r u. -
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
1 I.❑ Plumbing repairs or additions
12.Er Roof repairs
13.❑.Other
.ul ou[ use secaon below snowing their workers' oompensetion potiey information
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating succi
$Contractors that check this box muststtached an additional sheet showing the acme of the sub -contractors and their workers' ccs p. psis..:_
r r� .., t'omlatian
! am an employer that is provrdsng workers' compensatron errsurance for m1' employees: Below is the o '
information p hcy and job site
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 dated .
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 $1,504.00 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 insurance coverage verification.
1 do hereby certfY under the pains and penalties of perjury that the information provided above is rue and carred
- — <.f.
—2
0fj°Icia1 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 S. Plumbing Inspector
6.Other
/ 8 M 60., o
II Contact Person:
Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all emp foyers 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 tnistee of an individual, partnership, association or other legal entity, employing employees. 'However the
ownerof 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 be 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 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 t3he 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 presmted 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 -contractors) 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 cavy 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 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, notthe 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 nuanber. listed below. Self-insured companies should enter their
self-insumnee'Iicense number on &e* 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 vvilI be used as a reference number. In addition, an applicant
that must submit multiple permitflicense 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 bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would lice to thank 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 fax number.
The Commonwealth of Massachusetts
Department of Industrial: Accidents
Office of lnvestigations
600 Washington Street
Boston, IIIA 02111
Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia