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Home My WebLink AboutBuilding Permit #302-14 - 781 WINTER STREET 10/1/2013 TOWN OF NORTH ANDOVER PPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issue I PORTANT: Applicant must complete all items on this page LOCATION.. _� � ✓� - Pri t_ PROPERTY OWNER - _. Print 100 Year Old Structure yes n0 MAP NO: L PARCEL: "t v ZONING DISTRICT: Historic District ye 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 PERFORMED: :E�NS7�vu Identification Please Type or Print Clearly) OWNER: Name: Sa, Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date:- ARCH ITECT/ENG I NEER ate: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. , l �t Total Project Cost: $ _ �U FEE: $ �( Check No.: Receipt No.: (0NOTE: Pe ons co trachwith unregis eyed contractors do not have access to the guaranty fund Signature of Agent/Owrie Sigature of contractor $ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit K DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE-DEPA ATMENT --Temp Durn 'ster on site yes.. . no Located at 124 Mair Street Fire Departirie►it-signatureldate`' COMMENT'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.$10041000 fine NOTES and DATA— (For department use El Notified for pickup - Date E Doc.Building Permit Revised 2010 Building Department The fol[swing is--a list of the required forms to be filled out-for the appropriate-permit to.be obtained. Roofivig, Siding, Interior Rehabilitation Permits u` Building Permit Application u Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses u Copy of Contract a Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire-Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application Li Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) u 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) o Building Permit Application u Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 apo,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 Location /� J No. Date v • - TOWN OF NORTH ANDOVER. • Certificate of Occupancy $ s Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# v r * - - (2C)2 J `� Building Inspector �G��7ten Rbs NQ "OFNORTH ANDOVER OFFICE OF BUILDING DEPARTMENT ` :'1600 Osgood Street Building 2 24 North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688_9545 I QMEOWNER•LICENSE EXEMPTION Fax (978)688-9542 117IDMG pERMT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot OOR Gc Ci' Cv S Name. Home Phone Work Phone PRESENT MAILING.ADDRESS C!fv T o im. State zip Code The current exemption for thomeowners"was extended to include owner-occupied dwellings to two units.or less and to allow su�In homeo:rers to engage an individual.for hire who does not possess a license,provided That the owner acts as supervisor). State Building (Code Section 108.3.5.7) DEFINITION OFHOMEOWNER Persons)who gwns a parcel of land on which he/she resides or intends to reside,on which there is,oris intended be,s one or ho family structures. A person Who constructs mote that one home in a two-year eriod shall to considered a homeowner. P not be The undersigned"homeowner"assumes responsibility for .Applicable codes,by-laws,rules andregulatiom, compliances with the State Building Code and other t The undersigned"homeowner,,certifies that he/she understands the Town of North Andover Building D minimum inspection procedures and r uire is and that he/she ll com g apartment requirements, with said procedures and HOMEOWNERS SIGNATURE < APPROVAL.OF BUILDING OFFICIAL Revised 7.2009 Foran Homeowners Exemption 'BOARb OF APPEALS 688-954] r T `=' CONSER1 AT70N 686-9530 HEALTH 688-9540 PLANNING 688-9531 i The Commonwealth of Massachusetts - Department oflndustric�lAccidents Office of Investigations 600 Washington.Street Boston,MA 02111 www massgov/dia 'workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name usiness/Or aa!2ationftdividual): �� II . Address: �] 1 Aer - ` /� q S3 City/State/Zip: N� \ '�"`' Phone#: �`I �� Z Z —4 . . Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time)* have hired the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition o workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3. 1 am a homeowner,doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs required.]insurance re employees.[No workers' a 13.❑Other comp.insurance required.] 'Any applicant that checks box41 must also fill outthe section below showingtheir workers'compensation policy information. T Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name:. Policy#or S elf-ins.Lic.0: Expiration Date: Job Site Address: 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 requiredunder Section 25A of MGL o.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 DTA for insurance coverage verification. A'doJiereby cert u er thepains dpenalties of ju ae information provided above is true and correct. Signature: Date: v i Phone#: 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 - - .-. .Y. _ Phnnaff• 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 11"nsing 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 LT C or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confim ation 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/licens a applications in any given year,need only submit one affidavit indicating current olio info >; information P ifnecess Y ( ary)and under Job Site Address the applicant should write"a11 locations m (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 fillgd 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 orpermit to burn leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance fox 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 Gommonwoalt� ofmossachmetts Depaztbn.eut of fadusWal Accidents Office of Iuvestigali olm 600 Washiupa Reef Basion, 021 X l Tel,#617-727-4900 oxt 406*4x 1-877 MASSAFF Revised 5-26-05 Fay,#617-727-7749 NORTH own of t EAndo' ver o - No. Z• 1 - _ i h ver, Mass O "r,K1 COCNICHIWICN x,95 RATED 1111, y tl BOARD OF HEALTH Food/Kitchen PERMIT T ..LD Septic System THIS CERTIFIES THAT ........ . .. hr. ..........L s%'s................................................ BUILDING INSPECTOR .... Foundation has permission to erect ..................... .... buildings on ...� �..........wSA.4owr4ra .....J ................ Rough tobe occupied as ................ ....................... ..........� ...... ......................................... Chimney provided that the person acc ting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-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 Final PERMIT EXPIRES IN 6ONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST Rough Service .............. .. .... ........ ..................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Smoke Det. SEE REVERSE SIDE