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Home My WebLink AboutBuilding Permit #55 - 70 MARBLEHEAD STREET 7/20/2009Permit NO: J Date Issued: / -- &V v / BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received ' IMPORTANT: Applicant must complete all items on this page LOCATION 7 E �.. j '� D �"AyJ V _.- �n •.�(- Print PROPERTY OWNER- �r- /1k Print MAP NC; _J_PARCEL: ZONING DISTRICT: !Historic District yes n Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, lacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer Ut5 .KIP..IION OF WORK TO BE PREFORMED: IdentificationPlea e Type or Print Clearly) OWNER: Name: d �r�. �� A Address: CONTRACTOR Name: Phone: Address:"i/ 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. Total Project Cost: $ 3, 5-0 0, �6 �% FEE: $ 7 �� Check No.: !l( ��pReceipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the su rants fund 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 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) ❑ 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 ❑ 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 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 Y Doc: Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco 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 Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS 4. 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 Town Engineer: Located 384 Us ood Street FIRE DEPARTMENT - Temp Dumpster on. siteyes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total Iland 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 21 A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup- Date Doc.Building Permit Revised 2009 Location No. �S Date HpRTM TOWN OF NORTH ANDOVER 3? ' 0 AL , 9 { Certificate of Occupancy $ ' • i i �' s'•^ t<� Building/Frame Permit Fee $ AC MUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /� 9 2-77.3 22229 Building Inspector Location -76— 12— HvkektA i No. 1 b q Date 01411 e ' TOWN OF NORTH ANDOVER • k Certificate of Occupancy $ t Building/Frame Permit Fee $CP/0 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # & //%,, ' 25418 Building Inspector The Commonwealth of 1V machusetts Department of Industrial Accidents Offlce of Invesfigations 600 Alashingion Street Boston, MA 02111 www m=sgov/dia . 'Workers' Compensation Insiwanee AMdavita Builders!Contractors/Eiectricians M/Plumbers iicant Information Name (Business/OWiration/individual):_ AdTe55: � V 1e city/state/zip: - N- A h d D f P i C -` CE, Phone #.. �j Are you an employer? Cbeek.the appropriate box: 1. ❑ I tun a employer with 4. ❑ 1 am a general contractor and I employees (foil and/or part-time).* 2• I am .asole proprietor or have hired the sul3-contractors partner- ship and have no employees listed on the attached sheet 1 These subs -contractors have working for me in any capacity. [No workers' comp, inswwc' a .. workers' comp. insurance. 5. ❑ We are a corporation and its mred.j 3 • am a homeowner doing all work officers have exercised their right of exemption per MOL myselc [No.workers' comp. t: 152, § 1(4), and we have no insurance required.] .t em to eeS, P Y [No workers' comp. itZsurance lead. Type of Project (requites: 6.. ❑ New construction 7• ❑ Remodeling 8• (] Demolition 9. ❑ Building addition I U.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs re9u icy m13.❑.Other I •Any appiicatit that checks bodf1 fil t must also l out the section below showing their workers' compensation polformahon t Homeowner¢ who sdbmit this afiiiinvit indicating they are doing in work and then hire outside contractors must submit anew affidavit indict* such. $Contractors that check this box nwst stitched an additions] sheer show' mg the name orthe cuh-contrsctors and limit work=' I ' ce„r, irirtnnnton.an emsioyer that ispr», actg:worilesinfornafott ¢ompes n insuracefor nr employe.M Below is thePONCy andjob site . Insurance Company Name: Policy # or Self -ins. Lie. 4: Expiration Date: Job Site Address: Attach a copy of the workers' com City/Sta�ip. pause, ioc policy declaration page (showing Failure to secure coverage the policy number and expiration dale as required under. Section 25A of MGL C. 152 can lead to the imposition of criminal fine up to $1,5050.00 aD and/or one-year =Pnsonment, as well las civil penalties in fire form of a STOP WORK O.l2AER 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 cerci ort lithe andta/ties rlury that the information provided above is true and Qon ed gate: ( 2 V Phone 4- [ : y- t�ciat use only. Do not write ire. this area, to be completed or town Official acral City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Hearth 2 Sniltfing Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Ins 6.Otbe'r g pector Contact Person- Phone #: Information a nd Intstructions Massachusetts General Laws chapter 152 requires all emp Ioyers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ":.:every person in the ser -vice, another under any contract ofhire, ; 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 includirnrg the legal representatives of a deceased employer, ar the receiver ortr utee 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 appurL-narrt thereto shall not because of such employment be deemed to be an empioyer." MGL chapter 152, §25C(6) also states dtat "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a baseness or *a construct buildings in the commonwealth for any applicant who has not produced acceptable evidence o'F compliance with the insurance coverage required." Additionally,,140L 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 corttracting authority. - Please fill out the workers' compensation. affidavit compimtely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es): acid phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, arc not requiredlo carry workers' cornpensaiion 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 kloe sure to sign and -date the affidavit. The affidavit should be.returned to the city or town that tine .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' coTgpensation policy, pleast call the Department at the nur.riber listed below. Self. -insured companies should enter their self-insurance license number on the•appropfiate 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 A10 be used as a reference number. In addition, an applicant that must submit multiple pennit/license applications in any given year, need only submit one affidavit indicating -current policy information (if necessary) and under "Job Site Address" the appiic= should write "all locations in (city or town)." A copy offhe affidavit that has been.officiaily 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 persori 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 Commonw6Llth of Massachusetts Department of Fndrastiiai Aacidents Mee of Investibaiiotns 600 Washington Stri.et Basfon, MA M111 TeL # 617-722.74900 ext 406 or 1-11.77-MASSAFE . Fax # 617-727-77491 Revised 5-26-05wwwmass.gov/dia m m X m X m U) m CO) 10 Cl)CD Z CD O ar d d o. a� O OCD v C. C7 CD O CZ O co CD CO) 10 CD .O� O Lei CO) d O CO) C!� c O c CO) d CD O CD a CO) CD CO) 0 CCD a O C CD 0 b M 0 cr 94 -COO N a C0 C m a M m o CO) Cl)N O=�� G x 0 O_0 C = torD C42 =r -0 , N r tTl C/)O b n' CD C=L -► a m CD .+ y 0 z<_.Cc" cn 0 -COO N a G a- oCL 171 w O=�� G x � O N w ,ora torD C42 �4 7d C G a =. a eo W rD 0 rt cn 0 w G a- 171 w C91 g G x tom" w ;ozn G a� torD y 7d C G a =. tTl C/)O b n' CD O x `, H 0 9 0 c KORrM TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 �s'�•.. ' North Andover, Massachusetts 01845 Gerald A. Brown ' Telephone (978) 688-9545 InspecW. of Buildings . Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION Please wint DATE:_ JOB LOCATION: 70 �cX S� Number Street Address 'n Map/Lot `' HOMEOWNER A� Name Home Phone Wark Phone PRESENT MAILING ADDRESS aL) (b If C.4. r City Town State ` Zip Code The current exemption fir "homeowners" was extended too 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 brat 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 family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The mWetsigned '" assumes "esPousibilitY for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" des that helshe understands the Town of North Andover Building Department minimum inspection procedures and requirerne.� and that he/she will comply with said proce&= and - - - - ____ts• ,,, HOMEOWNERS SIGNATURE n APPROVAL OF BUILDING OFFICIAL Rwined 10.2005 Form Hommmm Eamon BOARD OF TPE:M-S 699-9541 CU.\SER1.Ess-9530 1TE.1LTH 08-9540 PLANNING 6S8-9535 i