HomeMy WebLinkAboutBuilding Permit #595-14 - 69 HIGHLAND VIEW AVENUE 2/13/2014 TOWN OF NORTH ANDOVER
i
APPLICATION FOR PLAN EXAMINATION
Permit NO: �f Date Received
Date Issued: _
Af
IMPORTANT:Applicant must complete all items on this page
51
-�� -� .c.-G=.xn-�`�`.C- �Yiw'"� �-_"��..., �`-�' �$ .. +�'.'ams.• - c'--,w�^�. �+- sn s�-�a�.-=S'w'F � , -,-F _
�. ' S. g-', k4l - A `'O''i .1r "i* r $} c c. `mak , •a`! W. s+{' ,fit
PRQPERTrY ®UVNER }
y77
iP intim '' =14OYea[OId�Sfructu�re yes ' n `
f _
tMAPNO`' PARCE —ZONINGS®I:StTRICT FlistonAc ®istr t ye � i
°� chin"�--°P.�U�illa9e Y.es� nop,�r
Isla
TYPE OF IMPROVEMENT. PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition XTwo or more family ❑ Industrial
Alteration No. of units: r� ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
tee -¢-_ fit^ ��— ' �--=,
r❑Sep c ��Wellh {Y t D FIo®gdplain,, * ❑:1Netlantls ?rt �. ❑ `Watershed ®istnct f
F.
� d & It , may
,�❑:Water/Sewer,: ,'�_. , - -, . �T�.�_ T. ����—, _.�_ ��_ti�• �� � r_n
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please�ype or Print learly)
OWNER: Name: ���°I�'l-, Phone:
Address: i
71_r 1 .. _ - � x �� T � .�- � �tea•
tC�ONiTRACTOR� Name ./ 1 - La
'Address
Superytlon License 4 , �: : Expky� Date _ ...
Home�IrnprouementlLlcense ____ ExpDate � ��`�
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: $ ���('' FEE: $
Check No.:
��rZ Receipt No.: 3—:�--,-7,(�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
SI-nnature of Agent/Owner • .�{ `Se -nature
gk_r.
Plans Submitted L.J Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
- .. Plans Submitted ❑ Plans Waived-[] .: :.Certified Plot Plan ❑ Stamped Plans ❑
' ;TYPE-OF SEWERAGE RISROSAL
Public Sewer ❑ Tanning/MassageBodyArt ❑. . .Swimming Pools ❑
Well ❑ Tobacco.Sales ❑
Private:(septic tank,etc.- Packaging/Sales
- oo ❑
❑ =Permanent Dempster ori-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
4,
FIkALTH Reviewed on
Signature
COMMENTS
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 To`v:: Engineer: Signature:
Located 384 Osgood Street
FIRE DEPART1 N1` Temp Dumpster on site .yes no
.Located at 124�MairStreet �;,,z,
Department signature/date '
C011lIM.ENTS ��. .. try"b� v r€ :t, .. •
I
\ _ d
..Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total-land area, sq. ft.:
..ELECTRICAL: I►fllovement of Meter location; rraast 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
.bo
B Notified for pickup - Date
€F
E
Doc.Building Permit Revised 2010
I
I
_ . . I
Building Department
rhe foh#-)wing is`a list of-the retluired.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
o 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
o 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)
o Mass check Energy Compliance Report (If Applicable)
o 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
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ Mass check Energy Compliance Report A
o 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 ors special permit was required the Town Clerks office must stamp tk decision from the Board of Appeals
P
9 P PP
that the apw•al period is over. The applicant must then et this recorded at the Registry
P pp g of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Bui?ding permit Revised 2012
i
i I
I
1 �
'y
ct„�t5�.�at'.�!5+�"�„[k,�.�..''4���k ; • .r-,,yrr tiX4^.;rs ad•'�:. � i:..• -; _
Location I
e
i
No.5q6_ � Date4viv//91
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
a Foundation Permit Fee $
i
' Other Permit Fee $
TOTAL �
$
Check# t
VL.
2 7 01 Building Inspector
� �ORTFi
7own of
O ry in
Z 6
h ver, Mass a
OLAKI
Ish coc«icnewocw
p0RA TE O 'IV
S U BOARD OF HEALTH
PER IT T LD Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT .............. .. . ..... ........ .. ...................... Foundation
has permission to erect .. buildings on �t
•
Rough
4
to be occupied as ..(�1Y1./ ....�.Q��00r.!!d..... ..... .. . ......I.K.... ... ....`!.................. 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. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
b UNLESS CONSTRUCTIO S TS Rough
- Service
Ill.... .... . ............................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
SEE REVERSE SIDE
I
TO"OF NORTH
ANDOVER
OFFICE OF
a
rd
z BUILDING DEPARTMENT
' oey 7 600
0sgood Street Building 20 Scute 2-36 r
7�SSs�tiu5���5 North Andover,Massachusetts o 845
Gerald A.Brown Te phone Inspector of Buildings phone(97$)68$-95
• HOMEOWNER•LICENSE EXEMPTION
Fax
(978)688-9542
BIDING-PF-RMT APPLICATION
• Pleaseprint •
DATE: a ( C f
:JOB LO CATION: ITO.
Nu b
er
S e
tr t d
A dress
J Map/Lot
IMMEOVJNERIrS�Gt of G3
Name. ��0 J
Home Phone
WorkPhone
PR
PSENT MAILING ADDRESS
t (--y Tot=m f
�t,„ate. ?dp r7o
Co_e
The current exemption for"homeowners"was extended to
to allow su;h born eo,,- �ch�de owner-occupied dived'Ags to two units-OT less and
uers to engage an;lca�,idaal.forbire wno does notpossess a license,provided that the owner -
acts as supervisor). State Building (Code Section 108.3.5.7)
DEFINITION OFHoYmOWNER
Persons)who Qwns aparceI of land on which be/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 h there
O shall not be
considered a homeowner.
The undersigned"homeowner"assumesresponsib
latioAPPIicable codes by-Taws, ues andre niityforcom Iiances
wz
fb the State
Building Code and other
c
The undersigned"homeownez"certifies that he/she iunderstands the Town of North i
Andover Building Dep"
art en
tmznmuminspection roceduresandreqi
requirements, uremeuts and that 7�e/she will ll conpl
oc
pr edures and
ter'
HOMEOWNERS SIGNATURE
•APPROVAL OF BUMDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
`'BOARD OF APPEALS 688-954I
COJ�r J `s
SERVAUON 688-95304
HEALTH 688-9540 MkNNING 689-9535
The Commonwealth of Massachusetts
Department of IndustrialAccidints
Office of Investigations
UIP 600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual):
Address:
City/State/Zip: LA " ,0,W Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4: ❑ I am a general contractor and I
6. El New construction
employees(full and/or part-time).* have hired-the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. E]Building addition
[No workers'comp.insurance 5. El We are a corporation and its
required.]
officers have exercised their ;. 10.❑Electrical repairs or additions
3.K11.am a homeowner doing all work' right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. '
i Homeowners who submit this affidavit indicating they Lire 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 their workers'comp.policy information.
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-Lic.#s 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe,DIA for insurance coverage verification.
Ido hereby certi rider the pains and pen ties o erjury that the information provided abov is true and correct.
Si ature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town offrcial.
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 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 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 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 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-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 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 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
p 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/licene 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 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 ofInvestigations
600 Washington Street
Boston,MA 02111
Teel,#617-727-4900 at 406 or 1-877-MASSAFB
Revised 5-26-05 Fax#617-727-7749
wwwanass,gov/dia
r
Boar Chusttts- D�lrt�tn
d°ttBuildill .0 int rrt' 1,
CO
ons actio '` Rc l` l•tt,v uh S
tt' \
license: CS 1p4639SUperviso n.L enseand<trd. r
KEIT 4
20 PA ARNAR.0 '
SALEM H!o oR�
NH
'
79
Expiration: 3/S1201
4
Tr7. 104639
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
1 Opo.00 m
$ - $ 120.00
Plumbing Fee $ 15.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 15.00
Total fees collected $ 250.00
69 Highland Vew Ave:
595-14 on 2/13/14
Master Bedroom and Bath on Third Floor
I