HomeMy WebLinkAboutBuilding Permit #303-2017 - 69 PROSPECT STREET 9/21/2016 Location (0 9 Pr I K., A-*c F
No. U,�'� Date
-t
r
• - TOWN OF NORTH ANDOVE
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check '
y.�� � •� Building Inspect�d
ORTH
BUILDING PERMIT NLE°
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
`. /
G/ • O 1e
Permit No#: 7 Date Received �y A�R,C
SSHCFIU`-'�
Date Issued: 01
IMPORTANT: Applicant must complete 11 ite s on this page
I
LOCATION / V
rint
PROPERTY OWNER Oe- //n/,//4?
Print 100 Year Structure yes no
MAP PARCEL: ,O-6 ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
- -1� New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial ='
6emolition
eration No. of units: ❑ Commercial
pair, replacement ❑Assessory Bldg ❑ Others:
❑We I, ❑ Other
S pf. ' _ _ ® Floodp a7n 1Net nds D_W.a,�tershed"®is'ct
.
DESCP,IPTION OF IWORK TO BE PERFORMED:
6
1&xtifi!Catio4- Please Type or Print Clearly ` 92 �
OWNER: Name: Phone: f� -
_ �
Address: /u
. 414),
Contractor Name: Phone:
Email:
i
Address:
Supervisor's Construction License: - Exp. Date:
Home Improvement License: _ _=Exp. Date: _
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $4',--) FEE: $
Check No.: Receipt No.: �
NOTE: Persons contracting with unregistey contractors do not have access to the guaranty fund
M !' � �...�. .
Sao 'TOWN 01b`�N0R�'H ANDOVER
()FFICL9 OF
o
_ BUILD;G DEPARTMENT
* 1600 Osgood Street,Building 20, S_uite 2035
�. North Andover,Massachusetts 01845
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings• Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION .
BUIDINC PERMIT APPLICATION
Please print
DATE:
JOB LOCATION: 17
Numberr Stree Address Map/Lot
HflMEOWNER , �Nam1�(
Home Phone Worlc Phone
I
PRESENT MAILING ADDRESS
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 I IO.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 OF CIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLA INNIPIG 688-9535
L
ne Commonwealth ofMassqkusefts
. Deparftnent offndustrialAceldents
1 Congress Street,SUUe 100
" gogton,MA 02114-2017
5 v www.ma&.Ygo7vfdza
y�•q�kexs'Compensatzon$isuxance.A�davzt:$xrilders/Cox�t�rac�orsllalleetAzciaxisslPlu�nbers.
TO BE.t+ILFD VIM THE PERMTUNC.AUTHORM.
A l:cant hforma'e`iOn Please PrSnt ,e�ly
Name gtsiness/Oxgagzation/Ind-ddual):
Address: �Z �0 .S
PA 0 � �� - �e6 �.�s�o
�ztyyl �atelip`� � �` �—�f Phone#:
Are you an employer? mecksa apliropxiale box: Type of project(TqC Efted):
1.Fil am a employerva s employees(falland/or parC Iime).* J: Now coxisfr ci ion
:Z.0I asoleproprieiororparfners
hip andhavenoemployees workiugformeia $. Iemodeag
capacity.[No wo3kers'comp.insurance regoired.] g Demolition
31 lam ahomeownerdoiagallworkmyself jNoworkere comp.insmneeregoirad.]i
10 Building addition
4.E]jam a homeowneranEvM bebiring cordmeLorsto conduct all-work onmyproperiy. Iwill.
emsnre that all contactors eitb er have workers'compensation iummee or are sole 11.[(Electrical repairs or a-dditions
propiietnrs-tvbhrnm�pWees. ingrepairs oradditions
3.❑Iamagenerdeorifraoforaudlhavehiredihemb-conb:actorslisiadcatbeatfachedshwt. 13_ Roo repairs
these sob-cnntcactorsliaYe employees andhaveworkers'comp_;nc�,ra„ce.�
14. Other
6.0 We are acorporatin Pd#q offieershave eaercisedtheirzight of egempuonperMGL c.
[�11.ployees.[No comp.imsLRAnceregmred j
152,§1(4),andwehavenq.em
*Any applicant That chad'Lsbax41 must also'01 out the seetionbelow-hov>heirworkers'compensation policyinrionnoom
iSomeowners-whosdb it-,tffaf6daviEmdicaCMgtheyaredoingallworkandihenhireoutsideconractorsmustsi]ibmtanewaffidavitmdicatingsnob.
d
?Coniraccors mat cbecl�tltis bogmnsca_�'-�acbed aD.additional sheet shox7ingthp name ofThe sub-con¢acmrs an state whether ornot-fhose entities have
e
'dethes workers'com . otic numb r.'
emrployees.Ifzhesub-con$aarorsT>aFeemployees,�eymmsEpravi _ P P y-Tain an e<riployer�&at as_Yoviding-ofkeis'compensation insurance for RV er7T/oyee 'Belo7v is thepolicy grid job site
I
� infor�natiora. _
Insurance Company
Policy 4 or Self-ins.Zic.#: Expiration Date:
rob Site.Address: City/'fie%Z.p:
.Attach.a.copy of the TForkers' compensation p 0licy daelara-Lion page(showing the pOReynumb 'r and eXpiratiOR 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 impriomneMt as well as civil penaNf.as i-atle form of a STOP WORK ORDER a-ad azme,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 verifcatiort-
IdoherebyceYtifyr ertliep a�zdper�aitiesofperj �ytlaaitheircforrrcaiionp�ovidedabove-is t ears co��ec�
Si afore: Date:
Phone 4--
Of
:
Official use only. JI a not tvxzte zn this area to be completed by city on t0V7z officzaZ
City or down: Pexmit/License#
Issuing.Arrthoritp(circle one): i
1.)3oard of l3ealtTa 2.BnUdingDepartm.ent 3.City/Town Clerk 4.Electrical faspector 5.Plumbingluspectox
6.Other
COWL-act Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'comp ensation for their employees.
�.T
Pursuant fo this statute, emproyee is defined as"...every person in-the service of another tinder any contract bf hire,
express or implied,oral or w.dtten."
Art employer is defined as"an individual,partnership,ass ciation,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,asso ciation or other legal entity,employing employees. However the
owner of a dwelling house having not more than tbree ap attmeats 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 to cal licenshag agency shall withhold the issuance or
renewal of a license or permit to op erate a business or to coxas tr act buildings in the commonwealth for any
applicant who lias notproduced acceptable evidence of compliance-with.the iusuxance coverage required."
Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any ofits 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 b can pres euted to the contracting authority."
Applicants
Please fill-out-the workers' compensation affidavit completely,by checldng=he boxes that apply to your situation and,if
necessary,supply gab=contraator(s)uame(s),address(es)and•phone numbers)along with their certificate(s)of
insurance. Limzted.Liability Companies (LLC)or LimitedLiability Partnerships(LLP)withno employ9os'otherthan.the
members orpartners,arenotrequiredto canyworkers'compensationinsurance. If an LLC or LLP doeshave
employees,a policy is required.,Be advised that this affidavit maybe submitted to the Depalt ent of-Industrial
Accidents for conation ofb=auce coverage_ Also be suxe to sign and date the a£ddavit. T u affidavit should
be retuned to the city or town that the application fox the pan it or license is being requested,not the Department of
IudustrialAccidenis. Should you have any questions regardingthe law ox if you'are required to obtaia a workers'
compensation policy,please call the Department at the number listed below. Self-iiisured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure tbattlie affdavitis complete and printed legibly. The Department hasprovided a space at the bottom
of the affidavit for you to fill out 1n the event the Office of-'nvestigations has to contact you.regarding the applicant.
Please be sure to fill inthe permit/license,number which will be used as axeference number. la addition,au applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and undar"lob 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 maybe provided to the
applicant as proof that a valid affidavit is on file fox future pexmits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit notrelated to any business or commercial venture
(i.e.a dog license or permit to bura leaves etc.)said person is NOT required to complete this affidavit.
1
The Department's address,telephone and fax number=
I
The Commonwealth of Massachusetts
Department of hadustrialAccidants
1 Congress Street, Suite 100
Boston,Na 02114-2017
Tel.# 617-727-4900 ext.7406 or 1877-MA.SSAFE
Fax#6177277749
Revised 02-23-15 wwwmass.gov/clia
0020
-t Date. ..��.........
p,ORTM
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACMUSEt
`�''-
This certifies that �
has permission to perform G' �.......4...............
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wiring in the building of..`.�6 -.... G! / V.. `W...............
.... .... ...................
• at //-- .!J .S .... ,North Andover,Mass.
Z Fee( Lic.No....5.vJ aC
ELEcmicAL INSPECTOR
Check #
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2.012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordancewvith the provisions of M.G.L.c.143,§3L,the
Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed "
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.GI c. 166,§32,an U
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c jO §K
Permits shall-be limited as to the time of ongoing construction activity,and maybe.deemed_by the lnspector_of_Wires abandoned_and_in-valid ifhperiod.Upon written
e--. _
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application. .
The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections.74 and
the Acts of 2012.The purpose of this act is to promote job 75 of chane furthers
t8 of
his
purpose by establishing an automatic four-year extension to ertain permits and licenses concerning the economic recovery and
oredeveloltment of real Extension Act property.
sWfluths
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending"through August 15,2012.
—Permit/Date Closed: /
**Mote:Reapply for new permi
❑Permit Extension Act—Permit/Date Closed: