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HomeMy WebLinkAboutBuilding Permit #823-13 - 80 OSGOOD STREET 5/31/2013Permit NO: IAC Date Issued: LOCA ` BUILDING PERMIT ►� ``°° "° ti moi.' L. i 3.t. b� ::,,_ .• ° TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received ANT: sac®L Sj, must Print PROPERTY OWNER14/LdrQW Qiast. Print MAP NO: O PARCEL: ZONING DISTRICT all items on this -b%SL)5 Historicbi nct es no Machine Shop Village yes (n� TYPE OF IMPROVEMENT PROPOSED USE Residen " Non- Residential New Buildingne fam", 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 it Xa if Identification Please Type or Print Clearly) OWNER: Name: _N."Inv ?t b.S� Phone: Ccet (�'� -Q 2 \ -bt�� Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULD/NG PERMIT: $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $�L) . 5-,o d FEE: $ 511. to Check No.: Lo 10 42T3 2. Z— q Receipt No.: 7_(,,4c3-1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/0wner,A-.1rct,, 9?,_. Signature of contractor, Permit N0: Date Issued: t TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page ' • m. _ m. x.: .: -.. ..=s�-...� r0 -+r ^m = R ..v x - t ssr c � i.-. _.gv-� =.cs ay.-wa-.z-:v.c. z-� Prim PROP,ERTtYI01VN_ER__.._4..__ P t u 100T�1'ear�OldtStom" �nnt c urea yes} no) MAP NO: P,, -R Z®,NING)®IS.�T¢RIC;T. Hist6ric�Disfricq) yes nog 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 ��®1Septic�✓Ox1Ne11�� w,_V�;�. � �IFloodplaln3 ` ©rWetlands� r OiWate}rshed�®istr¢ct .- �' I❑tlNater/Sewer_ r DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: AdrirP.-,- M C:O.NTRACT®.Rt NamQ A°ddress - - + S:uperviso�isConstrucfiose ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. 'Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty, fund nature of:Agent/Ovvny;*:. Signature of contractor. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ s Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF-SEWERAGE.DTSPOSAL Public Sewer ❑ Tanning assageBodyArt E]. . ,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 PLANNING & DEVELOPMENT COMMENTS DATE APPROVED 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 & Sevver Connection/Signafure & Dafe Driveway Permit DPW Toivd2 Engineer: Signature: Located 384 Osgood Street FIRE ®EPARTMFNT -Temp Dumpster on sites no Located at •124 Main Street Fire Depa mer t,s_igriat0re/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.$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 Li Photo Copy Of H.I.C. And/Or C.S.L.- Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products 10TE: 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 o 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 I0TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application Q 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 OTE: 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 app>>al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm'tted with the building application Doc: Doc.Building permit Revised 2012 Location a6 No. �0?3'�.3 Dates 3 & TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ " Check # 6 /D y0? 7 26457 0� Building Inspector P Ar L, D J O LU am C C i o •� L Q � Q N V E Q • L N o (� L N: Q„ cc N J cc J� o oo c: 0 z CL %- 0 0 c > H L Q a a> 4) 0 0 = c RS o 'N tm 0 O C Q. 0 .� N m d 'O O O R N C •O :E, .2 W.— i 0 -0 wN -0 •0 W- C . 00 $ aov Lm CL H t N ;a N C cc am m L 0 cn 0 N d yam.+ .F- O Z O J O J ti N O w S E W O 0 O d Z N O = d CM w� a W Q N - .E m m S � O CD v D O Om a CL a� Q O C� J � �CL O = Z' O CL 0 cn c C. 0 LLI 0 W W 19 W H p O 0 Qui Wa f - 2 v� z LL. ? Z H a Z D Z Z V W D: m Q W J_ mJ W LL m L C Qr W ate+ 2 O to Z Q u 'o s C s s U s +-� v o OD to Y O Q f6 O LL (n LL d' U LL O.' LL CC to LL LL m ti N D J O LU am C C i o •� L Q � Q N V E Q • L N o (� L N: Q„ cc N J cc J� o oo c: 0 z CL %- 0 0 c > H L Q a a> 4) 0 0 = c RS o 'N tm 0 O C Q. 0 .� N m d 'O O O R N C •O :E, .2 W.— i 0 -0 wN -0 •0 W- C . 00 $ aov Lm CL H t N ;a N C cc am m L 0 cn 0 N d yam.+ .F- O Z O J O J ti N O w S E W O 0 O d Z N O = d CM w� a W Q N - .E m m S � O CD v D O Om a CL a� Q O C� J � �CL O = Z' O CL 0 cn c C. 0 LLI 0 W W 19 W H The Commonwealth ofMassachusetis , Department o• f IndustriglAccidents 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 (Business/Organization/lndividual):_ Address: O �c'.rs� �-� �� �N Y��A 6» U j City/State/Zip; Phone #• °` �- `� b✓'3"1 . 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 (fall and/or part-time) * have, hiredthe sub -contractors 7• El Remodeling 2111 am a soleproprietor orpartner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance, 5. ❑ We are a corporation and its g, n Building addition [No workers' comp. insurance officers have exercised their 10.[] Electrical repairs or additions required.] 3. f0 I am a homeowner doing allwork xight of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and wehave, no 12.❑ Roof repairs � insurance required.)employees, oye[No workers' 13.❑Oilier comp. insurance required] 'Any applicant that checks box#1 must also fill outthe sectionbelbw showingtheirworkers' compensationpolicyinformation. T Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this 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 and job site information. Insurance Company Policy 4 or S elf -ins. Lic. lob Site Address: ExpirationDate: pffy/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 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cerityy under the pains andpenalties of perjury that the information provided above is true and correct. Phone 4 4 S— 3 l O 1 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. PIumbing Inspector 6. Other - " lufOrmation and 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 a express or implied, oral onother under any contract ofhire, r. 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 df 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 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 `Weither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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 phonenumber(s) alongwiththeir 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 required to obtain a workers' compensationpolicy, 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 printedlegibly. 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 (ciiy or town)." A copy of the affidavit that has been officially stamped or marked by the city or town maybe 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 orpermit to burn leaves etc.) said person is NOTrequired 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 anal fax number. Tho CommoRmalth ofM-assaehvsett Depa> tment of zrldustdal Acel�.az�ts Office of JAVesbigatto.m. 6.00Wash WO'a Stxoea Boston? MA 021. Z x 617-727-4900 ort 406 or 1-877�,M 1S,SA.�`., A67-7_197'vAn TO" OF NORTH ANDOVER A uo o OFFICE OF BUILDING DEPARTMENT ' :"1600DsgoodStreet Building 20,-Suite 2-36 y�S�AFHus��� North Andover, Massachusetts 01845 Geral dA. Brown Telephone(978) 688-9545 i F Inspector ofBmIdings -Fax (978) 688-9542 . HOMEOWNER-LICENSE EXEMPTION GUIDING pERMiT APPLICATION lease rint DATE: `? I� � 17-0 1 JOB LOCATION: U ✓� �� ey I � Ll � Number e t Address Map/Lot oMEoWNER Name HomoPhone WorkPhone PRESENT MAILING ADDRESS `� , 5A th VA Qif Tt Qfa+P Zip Code . The current exemption for "homeowners" was extended to Include owner-occupied dwellings to two units ox less and to aI1ow subb homeoi;rers to engage an ildividual•for hire -who acts as su ervisor• . t does not possess a license, provided that the o Sate ; caner P Bu1dm C g (ode Section 108.3.5.1) -) DEFINNITION OFHOl MOWNER Persons) who Awns 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 perio d 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 andregulations, t The undersigned "homeowner" certifies that he/she understands the Town of Forth Andover Building Department minimum inspection procedures and requirements and that he/she will comply with�said procedures and requirements, HOMEOWNERS SIGNATURE - APPROVAL OF BT7II.,DING OFFICIAL Revised 9.2009 Form Homeowners Exemption ' •BOARD OFAPPEALS 688-9541 CONSERZ' KnON 688-9530 HEALTH 688-9540 PLANNING 688-9535