HomeMy WebLinkAboutBuilding Permit #766 - 790 OSGOOD STREET 5/29/2010BUILDING PERMIT
=-TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: V Date Received 15
I
Date Issued: l ��
IMPORTANT: Applicant must complete all items on this page
LOCATION w tC3r 1 ltr')t,-`7r.v
"t.e° poi o
b� ;t�'� "� ' 6 OL
MUNN
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 e1J
'Fl lain 1/V.etlands
1lS tershed Dis#nct
OWNER: Name:
�` YgbL;KIP I IUN OF WURK TO B� PREFORMED: � I A
ate, VON _ >• •
���kW l
z learly)
! ♦ 05:c V,
ARCHITECT/ENGINEER Phone:
Address:
Reg. No
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE,I TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ 7.9-
Check
2Check No.: Receipt No.: 23
NOTE: Persons contracts with u istered contractors do not have access to the guaranty fund
Signature of Agent/Owri Signature of contractor
Plans Submitted Plans Waived f Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
II
Public Sewer
Tanning/Massage/Body Art
i
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
rPLANNING & DEVELOPMENT
4AOMMENTS
CONSERVATION Reviewed o
COMMENTS
HEALTH
COMMENTS
i
Reviewed on Signature
'tea
i
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision:
Water & Sewer Connecti
DPW Town Engineer: Signature:
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.$100-$1000 fine
Doc.Building Permit Revised 2010
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 Fa1 mily)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit I
❑ 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 I
Doc: Building Permit Revised 2008
Location 2 q
No. 76 Date 24 D
TOWN OF NORTH ANDOVER
S
Certificate of Occupancy $
Kwu Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 190
23116
72—
Building
2.._.-
Building Inspector
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The Commonwealth of Massachusetts
Department of .industrial Accidents
Office of Investigations
600 Washington Street
Boston, . MA 62111
www mQsS-gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrici
Mnlicant Information I ans/Plumbers
Name (Business//organiza6onn(/Idividual):
Address: r) cc, F)nj D A I
City/State/Zip:_V4// i Phone #:
Are you ane I
my oyer. Check the appropriate box: f
1. ❑ I am a employer
at�
with
4. ❑ I am a general contractor
2. ❑employees (full and/orpart-time).*
lam
and I
have hired the sub -contractors
a sole proprietor or partner-
listedon the attached sheet $
ship and have no employees
These subcontractors have
working for me in any capacity.
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We area
req ed_]
corporation and its
officers'have exercised
3 • a homeowner doing all work
their
right of dxemption per MGL
myself. [No workers' comp.
c. 152, § 14 .
), and we have
insurance required_] t
no
employees. [No workers'
applicant that checks box =? msst also riu out 'the
comp. insurance required.]
S'eTQ*_ C.=.'Q4.�
_
� 1'�OIIEOWnerS WIlO SnDatrT
.°_^.M Mag ? .� won er5' com..e.,co+:..n
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10-DElectrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
tnrs davit mdreatm the,,, are do— ..n ..._ r�- --
€ t h "in and then hire outside contxzsctom r{mst. submit a new affidavit indicating such.
'Contractors that chw:; this box must attached an additional sheet showing the name Of the sub -contractors and their workers' comp. poiicy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy information. ploy p cJ and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
' Expiration Date:
Job Site Address:
Attach It copy of the workers' compensation policy declarationF b (showing City/State/Zip:
aQe wing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL 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
Of up to $250.00 a day against the violator. Be advised that a copy of thi's and a fine
Investigations of the DIA for insurance coverage verification statement may be forwarded to the Office of
STOP WORK ORDER
Ido hereby certify trier the* and enalties ofperjury that the information provided above is true and correct
Signature: r
I r , r -'1n/_/. n
Official use only. Do not write in this area, to be completedc ,
bj its or town official
City or Town
Permit/License #
lssuitag Authority (circle one): {
1. Board of Healtb 2. Building Department 3. City/Towa
6. Other Clerk 4. Electrical Inspector 5. Plumbinb Inspector
Contact Person:
Phone #:
Information ail 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 wiiixen."
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 mamte7rlance, 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 licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to is onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of colimpliance 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 ut«yl 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
mcn bens or partners,. are not required to carry workers' comp enation 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 slue to sign and date the affidavit. The affidavit should
be returned to the city or `u 7 vvTi that the at1_li3Cd`uOr for the pe'. or l:ce�se LC being "e`S2:eS$ed, 2tQt the T ePart a !t. 0I
Industrial Accidents. Should you have any questions regardir><g the law or if you -
re wired 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 stamp � d or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future p,'r=t s or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license ori permit not related to any business or commercial venture
(i. e. a dog license or permit to burn leaves etc.) said person is INOT required to complete this affidavit
The Office oflnvestigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Deparmment's address, telephone and.faxnumber....
The Commonweal I of Massachusetts.
Department of lnditstHal Accidents
Office of lm estiaations
500 Wasliucton Street
Boston, MA 0.2111
Tel. 4 617-72.7-4900 emt 4 1 106 or 1-9-77-VIASSAFE
Revised 5-26-05 Fax # 617-72.7- 7/7/49
urvm7.mass._ cmv/dia
f µORTH
TOWN OF NORTH ANDOVER
O ssyeo ^b'S•i•0
6E b o� OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
y 9p�AwTeD •P°"'cy North Andover, Massachusetts 01845
his CH USE� 1
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings I Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:— — In
JOB LOCATIO]
HOMEOWNER
rnone i
PRESENT MAILING ADDRESS
Work Phone
City TovniI 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. I
The undersigned "homeowner" assumes responsibility for 6ompliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations. I
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and regements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540
PLANNING 688-9535