HomeMy WebLinkAboutBuilding Permit #961-15 - 7 OLYMPIC LANE 5/22/2015L_
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
PermitNOM
Date issued:
impoRTANT:
LOCATION 0 - )11/
PROPERTY OWNER
__ �11�
, E L .
MAP lal— PARCEL:
TYPE _0F IMPROVEMENT
[I New Building
[I Addition
DkAlteration
D Repair, replacement
D Demolition —
2'1i� I
01^�
OWNER: N
Address:
01
71 J I
Date Received
naiist corn-plete all items on this page
C I _J/1 I
0
4C
Lx J�
no
Print 100 Year Structure yes
ZONING DISTRICT:—Historic District yes rno
Machine Shop Village yes. no
f�R`OPOSED USE
esidential
_341n�e family
0 Two or more family
No. of units: —
0 Assessory Bldg
0 Other
V'�_s
_E R
n an -
W
0 B P
E C� PTIO OF
Non- Residential
o industrial
Ei Commercial
El Others:
ht �,V, Loa
V4--2:.
,te�
�a
tifleation 7:, Pleasgi
J
11 117 )1'117
9
or PrbiLt Clearly '-'
f9 — Phone:
f. /U/4
Contractor Name: Phone:
Lrnail:
Address:
Supervisor's Construction License:
Horne improvement License:
ARCH ITECTIENGI NEE
Exp. Date'.
Exp. Date:
Phone:
Address: H I Reg. No. PER S.F. 1L_
FEE SCHEDULE. BULDING PERMIT.- MOO pER $1 . OOO.00OFT E TOTAL EST MATED COST BASED ON $125.00
Total Project Cost: $ —FEE:
Check No.:— // C9 -7 Receipt No.:
NOTE: Persons contracting with utyeg-stered contractors do not have access to the guarantyfund
-A
Plans Submitted [I Plans Waived [I Certified Plot Plan 11 Stamped Plans
TYPE OF SEWHR-AGE —DISPOSAL
Public Sewer El Tanning/Massage/Body Art El Swimming Pools
well n Tobacco Sales
Private (septic tank, etc. E] Food Packaging/Sales [I
n Permanent Dumpster on Site [I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On Signature.
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals. Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comments
t
Conseevation Decision:
Comments
Watd��& Sewer ConnectionS
v Permit
DPW Town Engineer: Signature:
�(F
(fte
C A.
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_N
IT,
A�11
Located 384 Osgood Stree—t
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRIGAL: 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.sloo-si000 fine
Doc.Building Permit Revised 2014
—A
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
OTIE: 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/Cross Section/Elevation Plan of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
4. Mass check Energy Compliance Report (if Applicable)
,4� Engineering Affidavits for Engineered products
OTIE: 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
46 Workers Comp Affidavit
46 Twd Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
IOTIE: 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
Doe: Building Permit Revised 2014
Location -7 04-44,4 �2,"c 4.,4,r
No. z!! Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL $
Check # //07 4
el) — 16
Building Inspector
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6/09/2015 TUE 16:37 FAX 7816722570
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V
NORTH ANDOVER BUILDING DEPARTMENT
DEBRIS DISPOSAL FORM
0001/001
Tel: 978-688-9545
In accordance with the provision of MGL c 40 S 54 a condition of Building Permit
at: till (J-)" is that the debris resulting from this work shall be
disposed o in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permitsare required under Fire Prevention laws Chapter 148 Section
I OA.
The debris will be disposed of in:
X
(Location of Facility)
Sign�aiure of Permit Applicant
Date
19fis �5sac
4
du,11-J5 5-14t- -7 ,
;z (4412Y 4
The Commonwealth ofMassachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, PM 02114-2017
www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: BuUders/Contractors/ElQctricians/Plumbers.
TO BE, FILED WITH TIRE PERNHTTING AUTHORITY.
NaMe (Business/Organizationlindividug):
Address:
City/State/Zip: /L) adIA
i '' fi ". ...
Are you an employer? Check t e appropriate box:
Ahoonel:q 5- JW_ C5 -q (a & 3 Z-0
LF -1 I am a employer with - — i employees (full and/or part-time).*
2. [] I am a sole proprietor or partnership and have no employees working for me in
ity [N workers' comp. insurance required.]
_�Ay capaci . o
9q11 am a homeowner doing all work myself [No workers' comp. insurance required.]
4.FJ I am a homeowner and will be hiring contractors to conductall work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. [] Iprj� a general contractor and I have hired the sub -contractors listed on the attached sheet
Thes'e s�b-contractois fia-i� enWo�ee's and have workers' comp. instrance.1
6.FJ we are a corporation and i ts officers have exercised their right of 'exemption per MGL c.
152,§1(4),andwe ay.e no ?pp oye�s. [No workers' comp. insurance required.]
Type of project ()required):
7. New construction
8. FJ Remodeling
9. El Demolition'
10 n Building addition
I i. F1 Electrical repairs or additions
1�. E]PIumbing repairs or additions
13. E] Roof repairs
14�K�the, V(A f r\_Q
I ------ - _1J
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inforination.
t Homeowners who submit this affidavit indicating they are 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 state whether or not those entities have
employees. If the sub-c6ii6ciors ii�4ej�pli�yeeq,'%cy must provide their workers' comp. policy number. ' . %
la M an employer thai ispiovidiiig workers'compensation insuranceyor my emplbyees.'Below is thepolicy and)ob sit�
information.
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 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 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do h erebjy certify un der th epa, ins an dpenalties ofperjury that th e information provided above is true and correct.
e -
Official use only. Do not write in this area, to he completed by city or town official.
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cit7j�own 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 eipployees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contrdict'U''Hire,
expres's 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 ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associa ' tion 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 bd 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 commonNyealtli 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-contrac.tor'(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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. lie advised that this affidavit may be submitted to the Depaftment of Ifidustrial -
Accidents fbi confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the c or town that the application for the permit or license is be' requ�sted not the Department of
.ity. Ing
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensatioii. 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 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
J.A"XLJyj AINIJU vj�JK
OFFICE OF
D IIL
I 'A WmrnmNT
1600 DsgoDdStrcctBIifdiug2O,-Silite,2--36
NoithAndovar,,Mas.-achusattqOI845
Gerald A. Brown. Tolapilone (979) 68 8-9545
YUSPBUtor of Bliff dings Fax (978) 689-9542
6XIERVICENSE MMAb 110X
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rPLICATION
DATE:-
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Numb or S'- PtAd asg Map/Lot
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PRESENT MAKiNG ADDIWSS—
Ali Al C-40,1�e A 11;:t I
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-:ETTi
The current oxonjp�ou for �.homoowna&, wag uxtoaaOd to iurblda ownor-ocrofifled ftelliagg to tvvo units-qr Ims, and
to all DIN.SUbb hDM--D!-,,W "I to WigaZge an hffivjdual-f�rhiro Vho cI0osXL0tPDBSOS8 a Jimnso, pro v! do d that thc,- ovmor
acts as s up ervis or). 91ato D 01 &g (Co do S F'o-b-, D.0 10 S. 3. S. 1)
DEFI%TION OFROMEOVMR
POISDII(S) who _qwns aparcol of hmcl onv�RCIII�dsharoslaas oriatolids to rosido, ort wInchthore, i oxisinfoucludto
considered a homoDwAor.
ThO mdc-rsigned WA the, StatoDuilding Co
Applicable codes., by-lawg, liales and-rogula . tions. do a -ad ogler
Tfaauudor&jgiaadIIfiomeowja0]?, coMOB that
mblimum impootion. Procodures and requirements and ffiat h a comaplywithsaidpxecodures and
requirenjents,
ROAMOWMERS ;31CMT�
A)?PROVAL OF 13MDWC, OFFICIAL
P-Yised'7-2009
)FOnn Roraeownars 33xmpflon
I
30ARD OF APPEATS 688-9,541 CONTSERVAUON 688-9530 RHAUff 689-9540 PLANNING689-9535