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HomeMy WebLinkAboutBuilding Permit #597 - 75 BRIDLE PATH 5/11/2009 BUILDING PERMIT 01 1'"ToT TOWN OF NORTH ANDOVER c? APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 9 q�R•7ED I.PP' .(5 Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION P` t PROPERTY OWNER �. g,w /7SG J'--e C c_ c Print MAP NO: PARCEL: q ZONING DISTRICT- Historic District yes no Machine Shop Village ye 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: -e C) l P-0 cam 4" VA-11 I entification Please Type r Print Clearly) OWNER: Name: /��, � -,:� 4�6- su JcCc- Phone: 3t ? .,/ r t 7 �- Address: 7i 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. Total Project Cost: $ ?0,410o FEE: $// o , Check No.: Receipt No.: o10 NOTE: Persons contra ing WwithArisered contractors do not have access to the guaranty fund Signature of Agent/Owne Signature of contractor Location / �7 / �� 4-�� No. Jr Date �ORTM TOWN OF NORTH ANDOVER F p • i } Certificate of Occupancy $ CNUs<� Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ { Check # t?73 k r� 222 4 Building Inspector ✓ Jl Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Taming/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: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street J hO ;FERE DEP�►RTMENT Temp Duanpstgr�n site Yes bcated 5tt 124 Main Street a �' Eire.Department.si9nafure%late - 4. COMIUJ;E�1�-S _ 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 Doc.Building Permit Revised 2008 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) ❑ 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 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 The Commonwealth of Massachusetts j 1 Department of Industrial Accidents Ogee of Investigations +l�igl .r 600 TMashington Street ` Boston, MA 02111 ' www-mass gov/dia . Workers' Compensation Instuance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizaboOndividual): A&4, Address: 7 City/State/Zip: r.-�dy Phone#•_. J-' Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ 1 am a genual contractor and I 7`YPe of Prelim(required): employees(full andlar part-time).* have hired the sub-contractors: 6. ❑New construction 2,❑ I am.a:soie proprietor or partner. listed on the attached sheet:t 7. ❑Remodeling ship and have no employees These su6-contractors have 8. ❑Demolition working for mein any capacity, workers' comp.insurance. .insurance 5. 9• Building addition [No workers'comp. ❑ We are a corporation and its C11 m1ed- 10.❑Electrical officers have exercised their repairs oraddi#ions 3. m a homeowner doing all work right of exemption per MGL l 1.❑ Plumbing repairs or additions myself,[No-workers'comp. G 152, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs q ] .employees.[No workers' 13.r7 Other comp. insurance required..] * Any applicant that checks bo)f#l must also fill out the section below showing their workers'compensation policy information• t Homeowners who submit this affidavit indicating they are doing an work and then hh outside connectors must submit a new affidavit ;Contractors that check this box must atwehed an additional sheetshowing•the name of the sub•contmetots ansuch d their workers'comp.peric;i n�indicating ing suc. I ani an employer tkat is prgtvi4ng:workerscompensation insurance for my and employees Below is the licy job site . information po Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/StatelZip: 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 certify a ns and penalties of perjury that the information pravWed above is true and correct Signature: Date -�5- )I/p7 Phone#: EaDonly. Do not write in this area,to be completes!by city or town of ciat n: Permit/License# horhy(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing ltispector son: Phone#: i MORTM TOWN OF NORTH ANDOVER •` °� OFFICE OF BUILDING DEPARTMENT s 1600 Os good Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Pleesr mint DATE: 7 d JOB LOCATION: Number Street Address - HOMEOWNER �" JP 3 r 7 / /7 � Name Home Phone Work Phone PRESENT MAILING ADDRESS t , d J,�i— • S S p( �{�� City Town 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 Persons)who owns a parcel of land on which helshe 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 responmribihty for cmpIiances 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 re4nire�ts he/she will comply with said procedures and requizements. HOMEOWNERS SIGNATURE APPROVAL OF BUR DING OFFICLAL Revised 10.2005 Form Aomm mm E=n4,fios R ARD OF \PPF:\I..S 6sg.)541 CONSERVXTIOA(,,Y8-9,;30 ]iE.11:T1i GXR-9510 PI_AX_-NING(M-9535 Information a nd 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 ormore 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 ownerof a dwelling house having not more bran 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 chat"every state or local licensing agency shall withhold the issuance or renewal of 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 requir-ed to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance Iicense number on the'appropriate line. City or Town Officiais 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 permitAicense 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 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 600 Washington Street Boston, MA 02111 Tel.9 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax 4 617-727-774 vvww.mass.govfdia NORTH Tovwmn o t 4 over No. �� 9 ~ _ Apo 0 A dover, Mass, L COCHICHeWICK TED P"P' BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 14 --As od it BUILDING INSPECTOR THIS CERTIFIES THAT.....L410#......... :rn...................................... ............... Foundation 007 Ado has permission to erect........................................ buildings on.... ......... Rough , -A - js 1W Chimney I . . ....to be occupied as....... xW--Wr--M—— ..............W.--.-.-W................................................ provided that the person accepting this pe shat very respect conform to the terms of the application an file in Final this office, and to the provisions of the C and IT-Laws relating to the Inspection, Alteration and Construction of. Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit, Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough Service UIL,5 Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT. Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.