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HomeMy WebLinkAboutBuilding Permit #685-14 - 70 BROOKVIEW DRIVE 4/7/2014Permit NO: . �- 3 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: I IMPOR ANT: Applicant must cot LOCATION ! sti'�t lete all items on this page Print ' PROPERTY"OWNER.'✓ P �1 t r t"'°f-J Print ,MAP NO: (0 4 f PARCEL: a t 49 ZONING'DISTRICT: Historic District Machine Shop J yes no e ves no TYPE OF IMPROVEMENT PROPOSED USE J I�5��1( Residential Non- Residential ❑ New Building ❑ One family 11 Addition EI Two or more family ❑Industrial ❑ Alteration No. of units: ❑ Commercial VrRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic Well is Floodplain D, Wetlands I ' Watershed District 0,Water/Sewer fa'_ArN[ Ick J I�5��1( C or h e r 5 koc,JeY Uti t� 1► r''tou-2 `tif 1J'vQIrd pvCSt� l I rep )ac�( eX(CJ in�- t/O,At�� Identification Please Type or Print Clearly) OWNER: Name: Z iV ; t %�Y- t�4e v' w e Phone: 33 _ WO Address: r7 0 .' roo t<v l -e `%.1 � a Phone:CONTRACTOR Name: ray jAddr'ess ;,:-- Pi Supervisor's Construction icense ,gym Exp. Date: Y Home Improvement -License:# t; Exp ''Date: ` e ^ p 6F W a . I•:.. Mme.:. { .,; -a: r WiJi i. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COS_ T BASED ON $125.00 PER S.F. Total Project Cost: $ 13 0 o d FEE: $ Lnk I--- A Check No.: Receipt No.: NOTE: Persons contracting wit unregist ed gptractors do not have ac s to the gua anty fund 1 I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: - oil IMPORTANT: Applicant must complete all items on this page LOCATIONPrint- PROPERTY OWNER Print] 100 Year Old Structure ye's no MAP NO: PARCEL: _ ZONING DISTRICT: _ Historic District yes no Machine Shop Village yes no. .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 p Septic 0 Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: ArlrirPcc• CONTRACTOR Name: ...Phone: Address: Supervisor's Construction License: _ Exp. Date: Home Improvement License: Exp. Date: 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. r Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature•"of Agent/Ovuner . _ 3 ighature. of contractor Plans Submitted LJ Plans Waived ❑ Certl;;ed7 -,ot Plan ❑ Stamped Plans ❑ Location �?"��/'' �Wy ! Date f �' No. / i TOWN OF NORTH ANDOVER 07 - Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 26 2, 741.ij Building Inspector t r - - Plans -Submitted ❑ Plans Waived '❑:: Certified Plot Plan ❑ Stamped Plans ❑ -TYPE O-SEWERAGE_DISPOSAL ' Public Sewer ❑ Tanning/MassageBodyArt ❑ ... Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ -Food Packaging/Sales ❑ Private'.{septic tank, Tj Permanent Dumpster on Site El THE.:FOLLOWING SECTIONS FORDFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF U FORM PLANNING &DEVELOPMENT` COMMENTS 1. CONSERVATION COMMENTS HEALTH COMMENTS DATE. REJECTED DATEAPPROVED ❑ ❑ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water .& Seger Connectionisignature & Date Driveway Permit Y DPW Toiv;� Engineer: Signature: Located 384 Osgood Street FIRE DEPARTllil -Nt=.Teriip Dump'ster on site yes—'. no `Located7at.124,Mair, Street �. - 'Fire"Departme►it signatu'/dater`e ­ 'COMMENTS r' -- Dimensiam Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land -area; sq. ft.: I - , ELECTRICAL: -Movement of. Meter.locatlon, rust or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: Yes No MGL-.Chapter166.Section 21A --F and G min.$10041000..fine NOTES and DATA — For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fohawing. 84—list of.the required,forms to be filled outfor.:the appropriate -permit to .be obtained. Roofivg, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And%O'rC.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) 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 ❑ 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 o 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 apwal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doe: Doc.Building Permit Revised 2012 Enter construction cost for fee cal - North Andover Fee Cakulat1on Construction Cost $ 13,000.00 m $ - $ 156.00 Plumbing Fee $ 19.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 19.50 Total fees collected $ 295.00 70 Brookview 685-14 on 4/7/2014 Bathroom Remodel 0 ENO LLI LL O D 0 m O N u j[ -0U O LL E N N NO N U z z co O O (6 'lS LL t O d' a U1 C t U O LL oc O W z z a L O C' LL oc 0 a z U W J W t O C O U N In _ C I.L oc a cna Z O d' _ O LL z cW oG W LL 7 m O z Y (n v Q N Y N C, _ . O v t ^ •� L o Y= D t u W ♦O+ O I ,v E i Q h c a a 4 m a CD _ d cn o =_ ayi > = o 0 _tom goo QNz � - � = o as o = � ) c 3 .tm > Lo- � .CLc •� (1) CD m 0 Q i O 2 m CL '� N co N V m d LUW = � +�+ O O �' �- in Q s N o 0 E � . 0 W v Q a� N Q H $ 0- o U 5 w 0 V W a - CO 'Z V z 0 J m LQ w ti 5 U w 0 0 F— U LU I O CL C7 z LO X LU U.1 G L O 3 _! {n 0 E E O H V • E • of _ W c C a: 'm L u m ate, O • C • L m 0 A o O • -°aX N _ LU L 03a a " E • o0 _ r m LA line M E d' o � v N n r 0 WN HQZSLZ z 0 a 0 LL z 0 U I l LI Y L O 3 N -o 0 E E clew g • .0) • IA E C H o 4J f0 L u m a0+ Y '• G • th O Y QO • v L G N O • oX r UJ 03a Q•• E • °o � r °A m I11 p • M E d' O u N n �i cD W; 001 •. i1 • Lu 0 • •• i CL i1 WN HQZSLZ z 0 a 0 LL z 0 U I l LI Y L O 3 N -o 0 E E clew g • .0) • IA E C H o 4J f0 L u m a0+ Y '• G • th O Y QO • v L G N O • oX r UJ 03a Q•• E • °o � r °A m I11 p • M E d' O u N n �i cD W; 001 i • Y tG i O co 3 tkD• �1 V1 0 O E E 0 } C u N E O w 0 Cl C N i m v m ' «+ 0 Y • a O i+ co a w ,0 0 0 r • -0 X UJ 0 O o3a L a £ -p • 00 00 LA G• M E d' 0 Ru p N e-� t/1 tG co .0 �1 • 899Z ° 3 mo •. N 0 C E G z O LL O U • d • N N � ro 0 rC um+�.� O D W Y O •� _ 4-J • Q m 00 LL Y c> "� O O o O � ' o � � L o3a z c a , a 0 -� co • 0 W = s �a tl! (D m U0 z LU 0 a � O � J °- o 1..� co • 899Z ° 3 mo •. w Z N 0 C E G O • d • N N � ro 0 rC um+�.� O Y O •� _ 4-J • Q m 00 Y c> "� O O O � ' • •O uj O � � L o3a E a 0 -� • 0 = s �a tl! (D m 0 .. A d = N o 00 w Z TOWN OF NORTH ANDOVER OFFICE OF BUMD1NG .I)E-PARTMENT I600 Dsgood Street Building 202 -Suite, 2436 North Andover, Massachusetts 01 S45 Gerald A. Brown Telephone (978) 688-9545 InspectorofBuildings - Fax (978) 688-9542 HOMEOWNER•LICENSE EXEMPTION BIDING pERI�CC'�` CATIrON pleaseyr3nt DATE: `)/J4- :JQB LOCATION: "i•D Number SiaeetAddress Map)Lot Name. . Home Phone Work Phone PRESENT MAILING ADDRESS ---------------- ly' icl ove-r f MA C".?y Town state %7 a The current exemption for`$omeowners" was extai d to include owner -occupied citveltings to two units ox lass: and to allow su:h ?�omeo IDUs to engage an. individual•for hire w1t0 does notpossess a license, provided That at the owner acts as supervisor). S,feBulding (Code Section x08,3.5.1) DEFINITION OFH01120WNER. Persons) who Awns a parcel of land on which. helshe resides or intends to reside, on which there is, or is infended to , be, a one or two family. structure which A person who constructs more that_one home in a two h there o shall not c considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Co Applicable codes, by-laws, rules andregulationsde and ocher, The undersigned "homeowner,, certifies That he/she understands the Town of North. AndoverBuilding Dep ' artment 'minimum inspection procedures and requirements and that he/she will comply with,said procedures and requirements, HOAMoWNPERS SIGNATURE APPROVAL OF BUA,DING OFFICIAL, Revised 7.2009 Form Homeowners Bxdmption , 'gOARb OF APPEALS 688-9547r , ` s� CONSERi ADON 688-9530 HEALTH 688-9540• PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston MA 02.114-2017 °M `P www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Y t (i 'C 6 ("2 dt p" �Cy � I .p V/^ Address: City/State/Zip: lw't� Ad"", 'PIA Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp, insurance.$ required.] am a homeowner doing all work myself. [No workers' comp. insurance required.] t ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 33�--yq-© - 3� 57�_ Type of project (required): 6. ❑ New construction 7. (Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F-1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 -contractors have employees, they must provide their workers' comp. policy number. 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. #: Job Site Address: Expiration Date: 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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ccy ify under the pains -- LILi 0'-3 `l of perjury that the information provided boveis true and correct. _147A % Tl�ta• 211-$ ) 14 Official 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 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-contractor(s) 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 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 burn 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 of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/dia