HomeMy WebLinkAboutBuilding Permit #244-11 - 680 FOREST STREET 9/22/2010 BUILD(NG'PERMiT tlORTK
Q�S'LED ,6�5
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:C)1�_ Date Received
°Rwren�e¢y
Date Issued: -4 �SSACHus��^
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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:
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e tification PIease T e or Print Clearly)
OWNER: Name: Q Phone: AZ
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Address:
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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: $ h FEE: $ .
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Check No.: Receipt No.:
NOTE: Persons con acting with unre 'st ed cont/ cto o not have access to t e guaranty fund
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Location
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No 11 Z Date '` /
NORTq TOWN OF NORTH ANDOVER
A
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Certificate of Occupancy $
. . —�
Building/Frame(Frame Permit Fee $
s4c►wst 9
S
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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Check # �,"
234 `14
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/MassageBodyArt Swimming Pools
Well To
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 Siariature
YCOMiviENI t7
4
HEALTH Reviewed on Signature
r
COMMENTS
Zoning Board of Appeals;Variance, Petition No: , Zoning Decision/receipt submitted yes
Planning aoard Decision: Comments
Conservation Decision: Comments
Wafer & Sewer Connection/Signature&t7afe Driveway Permit
I
DPW Town Engineer: Signature:
_ Located 384 Osgood Street
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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)
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❑ Notified for pickup- Date
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Doc.BuiIdiug Permit Revised 2010
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
o 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
a Workers Comp Affidavit
❑ Photo Copy of H.I.G. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevatlon Pfan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
13Mass 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
t
-- New Construction (Single and Two Family)
Building Permit Application
n •t•e' n.opvF' 'In'i Plan Ue{sL {l : vu {' { i•
❑ 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
MOTE: 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
NORTH TOWN OF NORTH ANDOVER
2o
f �
OFFICE OF
0 ~ -�.1 , BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
9 cawn`...r.. �•
North Andover,Massachusetts 01845
SgcHus
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:_ 5�0 rQ ke4-T--- 5;
Number Street Address Map/Lot
HOMEOWNER 6 U Y r_� C) 0't:. ®Q'1
Name Home Phone Work Phone
PRESENT MAILING ADDRESS IC&ALO S7'
Arvoc ,K
City Town S+wry 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 that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and at 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
ORTH
-Townof And
No. _ -
s A o dover, Mass.,
COCMICMEWICK
7� ADRATED
SS BOARD OF HEALTH
PERMIT. T D Food/Kitchen
Septic System
UBUILDING INSPECTOR
THIS CERTIFIES THAT
.Y�v Go/
........................................ ...............C ..... ��...................1�*/v J ... .............�....... Foundation
has permission to erect........................................ buildings on ......6...................... ..... ................................. ......... Rough
to be occupied as.............0�.,�.......f......�. ... . .................... c imn y
........ . . . .. . . . . . .............. .
h' e
provided that the person accepting this permit shall in every respect form 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
UNLESS CONSTRU O ART'S ELECTRICAL INSPECTOR
� 2Rough
:......... „r:.......................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Ocmpy 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.
The Commonwealth of Massachusetts
Department of Industrial_accidents
Office Of. nvestigations
..600 Washinporz Street
Bostorz, 114 02111
WWW
a4Ss°ov/adWorkers' Compensation insurance-Affidavit: Bulders
/ContrctorsEleciAn licant Information trcians/Plumbers
Please Print Legibly
NaMe (Business/Organization/Individual): C So
Address: ] tl
City/State/Zip: /Ids DI s
Phone#:_9
Are you an employer?Check the appropriate box:
1•❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): .
2.❑ employees(full and/or part-time).* have hired the sub-contractors 6 ❑Nev,construction
1 am a sole proprietor or partner_ listed on the attached sheet x 7• ❑Remodeling
ship and have no employees These sub-
contractors have 8. ❑Demolition
working forme in any capacity, workers' comp.insurance.
[No workers'comp. insurance 5. ❑ We area corporation and its 9• Buil ' Q
❑ ding addition
required] officers have exercised their 10•❑Electrical r
3. I am a homeowner doing all work right of ex; ��or additions
-exemption per MGL 11. Plumb ing repairs or additions
m
insurance�required]st comp. c.employees.152, (4),and we have no 1 ❑ airs
[No workers �jRoofrep
comp.imgurance required.] l3•❑ Other
t•--n ppIic:-t that ch—IN yo . mus!2?so a:uu!the section be..1-•-: �� ]
"Omeowu=who submit this oY ��-ir workers
affidavit indicating they nma aciag aL'„ot;i�¢ m hire outside contractors L4,i.;Rublliii a new amdavit indicating such.
�oniraCCO28 that eh ,r';tuti'f_-.}sng W
est attached au r ddirioua1 sheet showing the name of the sub c
onuactors and their workers'comp.PoiicY information.
I am an employer that is provide workers'compensation insurance for
my employees'mployees' Below is the policy and job site-
Insurance
iteInsurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declaration age(showing
Failure to secure coverage as required under Section 2 p ( v�ng the policy number,and expiration date).
fine up to$1,500.00 and/or one-year imprisonment,assWellfasM viilc' 152 can lead to the imposition of criminal
penalties in the form of a STOP WORK ORDER and opezialtieg f�e
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify cr the pains and enal crJr�
P J Qt die information.provided abvv a a and correct
Sisnature:
Date:.._.:. _ _ /o
Phone .
Official use only. Do not write in this area, to be completed by cit),or town offccud
City or Town:
permit/License#
Fssuin<e AutLority(circle one):
I. Board of Health Z.Building Department 3. City/Tonu Clerk 4.Electrical Inspector 5.PIumbiQR
6. Other b Inspector
Contact Person:
Phone r:
Information an d Instructions
Massachusetts Ge cmc 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 foregomg engaged in a joint enterprise,and including t3he legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association oY other legal entity,employing employees. However the
owner of a dwelling house having not more than three apart rL ent s and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maim mmce,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be:cause of such,employment be deemed to be an employer."
MGL chapter 152, §35C(6)also states that"every state or local Iicensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to a anstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coimpUmce 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 acceptable evidence of compliance with the;ncunre
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-contractors)name(s), address(es) and phone number(s)along with their certificate(s)of
ir*umce. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,.are not required to carry workers'comp ensation 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 sxwe to sign and date the affidavit. The affidavit should
be Mtlarn—ed to the city or town that the a-plication tur the^ertyiit'or license is,beng w 1..�
in auesF.ed,not Departv:�t of
Industrial Accidents. Should you have any questions mgardi--the law or if you m e ra ix.1 1 obtain a workers'
compensation policy,please call the Department at the.numbe:r listed below. Self-insured companies should-enter their
self-inc=ce 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 bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations 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 addms's,'tefephone and.,fax.number....
The Commonwealth oaf Massachusetts.
DePartmmt of fndusirial Accidents
Office of Inresti atims
600 Washington Street
Boston,MA 02111
Tel. lut 617-72.7-4900 eaft406 or 1-97/ -NLASS_FE
Revised f-26-05 Fax#617-727-7749
V<',Arv'.I11cass..gov/dia.