HomeMy WebLinkAboutBuilding Permit #520 - 71 PLEASANT STREET 4/3/2009Permit NO: 6,,�
Date Issued:
LOCATION_
PROPERTY 0)
MAP NO: 5�_
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
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Print
CEL: 1 _ ZONING DISTRICT: #Historic District
Machine Shop Vil
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6 OL
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no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
tion
No. of units:
Commercial
r, eplacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District'
Water/Sewer
TO
Identificatiion Please Type or Print Clearly)
OWNER: Name: Phone:
ArlrlrPsc-
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT: $112.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $J��U FEE: $,�
c
Check No.: _9 Y Receipt No.:
NOTE: Persons contracting with unregisteredc actors do not have access to the Juarantyfund
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
o 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)
❑ 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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Chi• 111T
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT Temp Dumpster onsite
Located at 124 Main Street
Fire Department signature/date YZ&4
COMMENTS
uocatea su4 usgooa Street
yes M no
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.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doe.Building Permit Revised 2008
Location // Ae� 7 -
No.
No.fDate
N°RTM TOWN OF NORTH ANDOVER
oma,...° ,• �"°
• s n
* ; Certificate of Occupancy $ fes_
;,SSACNUS t� Building/Frame Permit Fee_ $ �-
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 50p--
21 909
Ap-2190}
Building Inspector
7.
f NORTH TOWN OF NORTH ANDOVER
° •'"�� �`"° OFFICE OF
p BUILDING DEPARTMENT
r: + 1600 Osgood Street Building 20, Suite 2-36
!•.�_b•,,.e ��•t� North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Begs Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
sage pfiLt
DATE: - o
JOB LOCATION:
HOMEOWNER
Street Address
Home Phone _ Work Phone
PRESENT MAILING ADDRESS
City Town staw Zip Code
T
The current exemption for" homeowners" was extendW 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 responsrbiliiy 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 willc mph with said procedures and
HOMEOWNERS
APPROVAL OF BUILDING OFFICIAL
1:evind 10.2005
Form Hommmun ExmWfion
TIOARD OF \PPFA1. S 6R8 `)5 I1 CONSERV.\'RON 1688-9530 NE.IL'11i 698-9540 PL.LNNING 688 9535
s�
The Commonwealth ofAfassachusetts
i
Department o Industrial
Accdes
Office Of .Investigations
600 Washineaton Street
;\
BostosZ, Its 02111
t WN�Ytt�gov/din
Workers' Compensation Insurance .Afday.iit: Builders/Co nitractors/Eleeiricians/Piumbers
At► hea.nt Information
Please Prinf Leaibi
Name (Business/Organization/individual): C
Address:
City/Slate/Zip:
Phone #:z�79--��-�%
2
Are you an employer? Check the appropriate box:
l • ❑ I an a employer with
4. ❑ I am a oe contractor
Type of project (required):
employees (trill and/or part -lime).*
2. ❑ 1 am a
b..neral and I
have hired the sub -contractors
6 ❑New construction
sole proprietor or partner-
ship and have no employees
listed on, the attached sheet t
These sub -contractors have
?• ❑Remodeling
working forme in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
�.. ❑ We are a corporation
S' [/�Demoiition
9' [1 Building addifi.on
required.]
3. I an a homeowner doing all work
and its
officers have exercised. their
right of exemption
10:0 Electrical repairs or additions
myself. [No workers' comp.
per MGL
C. I52, § 1(4), and we have no
11.❑ Plumbing repairs or additions
insurance required.] t
employees. [No .workers'
110 Roof repairs
comp. insurance re d
13-❑ Other
quare ]
`Any appiicant.thar checks box #I .must also fill out the section below showing
ers who submittheir workers' compensation policy information.
Homeown.tliis aiLidevit indicant, tlte;- art doiEtr, t; :t1
lconvactors Thal check this box m;d tust attached an additional sheet showirtr he n hir--outside contraciurs must submit a new atndavit indican
the name of the stb-c0„aactors and their workers' I comp Policy oil g such.
a,7 an employer that is providing workers' compensation insurance for ng, employees. Below is the poficJ�cy information,
information ondjob site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach s copy of the workers' compensation policy deciar-ation page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 c
imposition Of criminal pes o1a
fine up to 51,500.00 and/or one-year imprisonment. as well as civil penalties in then lead form of a STOP WORK OIa
of up to .S250.00 a day against the violator. Be advised that a copy of this statement RDERnd a fine d to the OfiS
Investigations of the DIA for insurance coverage verification. may be forwardeceof
do hereby, certify under
Pe
rjury that the information provided abOYe is true and correct
7 --
Official Use
Ufi%ciaLuse only. Do not write in this area, to be comPleted by city or town ggiciaL
City or Town:
issuing Authority (circle one); Permit/License #
1. Board of health 2. Euilding Department 3- City/Tovvn Clerk 4. Electrical inspector 5Pl
6. Other .umbing Inspector
'Contact Person:
Phone
iniormanon and Instructions
Massachusetts General Laws chapter 1S2 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 includi n.g the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on 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 em
-employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state ar local licensing agency shall withhold the issuance or
renewal of a license or permitto 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 chapt=er have been presented to the coritacfing authority," ,
Applicants
Please fill out the workers' compensation affidavit compl-etely, 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 ce-m-ficate(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 affida=vit may .be submitted to .the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the.affidavi.t. 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 regn—*Tdipg the leu or if you are required to obtain a workers'
compensation policy, please call the Department at the narnb r listed below. Self --insured companies should enter their
self-insurance license number on the appropriate ime.
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 appiioant.
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 permitAicense applications in arty 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 Iicenses. A new affidavit must be filled out each
year. Mrhe:re a home owner or citi=n is obtaining a Iicens� or permit not related to any business or commercial venture
(i.e. a dog license or permit to burnIeaves 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 Comrnonw;,alth of Massachusetts
Departm=ent of Industrial Accidents
Office of Lavestieations
600 WashEington Street
Boston; MA (12111
Tel. 4 617-727-4900 =t 406 or 1-8:77-MASS.4FE
Revised 5-2645 Fax:9 617-7-7-7749
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