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Home My WebLink AboutBuilding Permit #682 - 70 SALEM STREET 5/7/2010BUILDING PERMIT TOWN OF NORTH ANDOVER /,/FIPLICATION FOR PLAN EXAMINATION Date Received -Q �IC� Permi Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION "79 1. ` JPrint PROPERTY OWNERjG'tT1.t Print MAP '210PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes m Oy [xwi[w[wn[ �1' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Iteration No. of units: `'ommercial Repair, replacement Assessory Bldg _ �^ Demolition Other — Se tic I Floodplain Wetlands � - Yom' Wate er DESCRIPTION OF WORK TO BE PREFORMED: OWNER: Name: r (DvJ 0o4 - Please Type or Print Clearly) n.1* ... Phone: Address: r 57(q ILr'y1 �1` CONTRACTOR Name: l "1� U' '� Phone: Address: Supervisor's Construction License: Exp. Date: Home'Improvement t-icense: Exp.. Date: = ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST yy BASED ON $125.00 PER S.F. /9 Arl Total Project Cost: $ FEE: $ DOC) �q) O 6 00 � Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I --I , , t "� v Si nature of contractor re of A6ent/Owner9... ®_ 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 ❑ -Pt -roto -Copy 0T -R1 -.C—. 7Vn—dT0—r--TS.L. Licenses ❑ Copy of Contract Q---rloor Plan Or Proposed Interior Work ❑—Engineer-ing-A#adavits 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) ❑ 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 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 Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Siggnature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = Temp Dumpster on site_ yes -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 land 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 21A—F and G min.$10041000 fine Doc.Building Permit Revised 2010 f.. Location No. �Date TOWN OF NORTH ANDOVER Certificate Occupancy $ of SA MU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ! 6" Check # Building Inspector The Commonwe¢lth of A4,assachusetts Department of Industrial Accidents Office Oflnvemigations 600 Washington Street Boston, MA 02.711 .Workers' Compensation Insurance Affidavit Build s/Contrac [ILcant Information tors/Electricians/Plumbers Name (Business/Organization/Individual):!"l -....ac 1 c iui LeQlpl - Address: (- City/State/Zip: k Phone #:_� Are you an employer? Check the appropriate box- oa:1•❑ [I-ElI am a employer with Type, of project (required): 4. ❑ I am a general contractor 2. ❑employees (full and/orpart-time).* I am a sole and I have hired the sub -contractors 6 ❑Neu construction proprietor or partner_ ship and have no employees listed on the attached sheet l 7• ❑ Remodeling working for me in any capacity. These sub -contractors have workers com ins 8. ❑Demolition insurance. 11/110 workers' comp. irmirance . . 5. 9. ❑ Building add ❑ We are a corporation and its ition equired ] 3. I am a homeowner doing all work officers have exercised their 10.❑ Electrical repairs ri t of ex additrons =Option myself. [No workers' comp. insurance per MGL 11-0 Plumbing repairs or additions . 152, § 1(4), and we have no cc.12.❑ required.] t Roof repairsemployees. [No workers ` comp. insurance required.] 13. [1 Other •'.IIj' '�-ppficant, that checks box #! Must also 1111 out the aectron i��on• showing ' wori a s' COmr Homeowners who submit this affidavit indicating :e� atioa i�� arc lion tbey are doing all work and then h +Contractors that check this box must attached an additional sheet the showine ire outside contractors must submit a new affidavit indicating such. name f am an employer that is providing workers' = of the sub -contractors and their workers' comp. policy information. information. compensation insurance for my employees.Below is the polio, aid, job Insurance Company Name: site Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: Attach a copy of the workers, compensation policy declaration page (showing City/State/Zip: Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impositione policy number bof criminal matron date). 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 penalties of a of up to $250.00 a day against the violator. Be advised that a copy of this statement �y be forwarded to the Office a fine Investigations of the DIA for insurance coverage verification - -� .v �u•uiy unaer tree Pains an =maples ofPerfury "Et � information ��f�•/j� t provided above is true and correct Si ature: _ Phone #: 0 ---------------- Of, ficial use only. Do not write in this area, to be completed b�, cite or town offcud Orf Town: Permit/License # issuing Authority (circle one): 1. Board of Health 2. Buiidin,, Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other b Inspector Contract Person: Phone #: Information an- d 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 apartmLcuts and who resides therein, or the occupant of the dwelling house of another who employs persons to do mainte3nance, 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 slates 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 un'Cil 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' comp ensation 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 stare to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pert or license is beiag requested, not the .Detm parent of Industrial Accidents. Should you have any questions regardirLg 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 oaf Massachusetts Depaartment of Industrial Accidents Office of Investibations 600 Washington Street Boston, MA 021.11 Tel. # 617-72.7-4900 ext 4.06 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 5-26-05 u,mrw-m&m.gov/dia U) m m m CO) CO) m D y C � d CO) Cl) 10 Cl CD n Z CO) CD CL n� r C CL _' y aCO -0 '=-% O 0 0 CD CD cro %ic CD CD CD wC13 a. C CD y CD O: Cl CA tG O CD � v y O 10 CD n .O� O CD O CCD 0 8 cn VJ n 0 z M 0= rn VJ 2 0 cn C c?moo d �_ O —• H O Q V� d0 m .0 y m m n o y C, m Z = vi -4 OS M O H T C=L. �* n 0 m �O m CO) C y o �m m = N co 0 o O y !9 00 o c co) V Y\ CLom,..; Jc o CD m y CD 0 CD c CL O d y . CL d N C W = o .c H C : gym: N H � O •D : � C, ...r O CD O CAa m ,w Cl o :� � m CD H M �. CD -CO m o+ o 'o CA -s �1 diPOW . �^ r :; w 0, a' °� pGq Ci7 ; C" = oGa "ti oGc a' a Cb n n. d o r� o r x to 0 rb z x y O b M M m n Mrn diPOW . list? PUMP �Tl "OAd �e h�d -6-D s<<� ��s J��1Q/' ��. clamor `�a,,,i�< yJJ hul4�-r oL C-,D&-PdD- Ai� Gerald A. Brown Inspector of Buildings Please print DATE: 15-- –7 — 0) d JOB LOCATION: HOMEOWNER TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION 70 Number �f Name 5g&n S (4 - Street Address � r Home Phone PRESENT MAILING ADDRESS 7D &/, Telephone (978) 688-9545 Fax (978)688-9542 Map/Lot Work Phone City TSwn State Zip Code The current exemption for "homeowners" was extended to 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 that 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 undersigned "homeowner" assumes responsibility for compliances with the 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.. ^ 1 . HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 689-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 �� , ,fie , ' a� ."`� � � ..Sn �i��`. ��°"v