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Home My WebLink AboutBuilding Permit #692 - 808 GREAT POND ROAD 5/10/2010p►ORTH BUILDING PERMIT o`tt�o qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION0, ey Permit NO: Date Received y- gSSACHt1`'EC Date Issued:) l TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family , Addition Two or more family Industrial Alteration No. of units: Commercial epair, replacemen Assessory Bldg (tG-e— Others: e Other Septic Well Floodplain x , Wetlands =,, Fo- M r e W6tershed iD strict 1NateiZSewer 01 V;. P IdentificationPkse Tvix or Print Clearly) OWNER: Name: Ph — C? IVY -3. Address: 04-� V cr �% CONTRACTOR Name: Phone. a. Address: .Supervisor's Const uction License exp: Dater HomEdrriprovement -License: Exp. Date: t 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 Po UL FEE: $ / Ci Check No.: I A Receipt No.: NOTE: Persons contracting with u egistegd conlra#brndo not have access to the guaranty fund 5ignatureof , 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 Yf 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 Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: 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 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 ❑ Floo.r/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 Location® T inn No. Date HORTN TOWN OF NORTH ANDOVER • OL Certificate of Occupancy $ C14 Building/Frame Permit Fee $ �V Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # '90/3 25 t �'-,8 Building Inspector x w A o co v x ° E 19 U) z z p a v U wa U ow V) z a�' ci° u u "�, U w a� C � w CL OU w PW z d x w z w A w �, E� �w ° z8 CX o v o° cn 01 rY M ® ca ® C c C m co � ® i R® ® CL Co Cc C3 CA c COI c� o C3 c ` O N . � c VO L1 •dam . . CZ c A O � O W i N Ea CF v o a N E5 :cam o p u c m c E C A m m O L b N c o C p cc N O O O i O C7f :® N CD —LS ® pm G � PI2 O CO., Z O c �..: ® � h ®40 ® � LL -•rNof p F. �= C f + m • N Z CS LLJ C., CD ® E C C3 C/3 O' ®'C7 �a L- 01 rY M ® ca ® C c C m co � ® i R® ® CL Co Cc C3 CA c COI Gerald A. Brown Inspector of Buildings Please print TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION DATE: ,5——ro - J�e ! 0 JOB LOCATION: 47 ( Number HOMEOWNER Name PRESENT MAILING ADDRESS C/ CityTown � 0 yu Street Address Home Phone State Telephone (978) 688-9545 Fax (978)688-9542 Map/Lot 77Z-(9 j'7tY�3 Work Phone 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. The undersigned "homeowner" assumes responsibility 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 will comply with said procedures and requirements. D „ 1 _�7 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 The Commonwealth of A_yassachusetts Department o f fradustrial _accidents `— Office of Investigations. 600 Washington Street Boston, MA 02111 www•massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 3olicant Information Name (Business/orpnization/lndividuai): Address:_ d City/State/Zip: Phone#: df''%,P' _ e C 'i 3 Areyou an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I ama 2. ❑employees (full and/orpart-time).* have hired the sub-contractorsI 1 am a sole proprietor or partner- listed on the attached sheet I ship and have no employees These subcontractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. I am a homeowner doing all work right of �emption per. MGL %%%� myself. [No workers' comp: c. 15., § 14 . ( ), and we have no insurance required.] t employees_ [No workers' comp. insur-dace out ifie section Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. E] Demolition 9. 0 Building addition 10.[] Electrical repairs oradditions 1 l.❑ Plumbing repairs or additions 12 -IR Roof repairs required ] I 13.0 Other A-ny a* phcant that checks bo ::a muni ai .so zit? beton, W au W Flomeownees who submit this affidavit indicating the}, are doin^ -� wc- y'^ w er mss' cosy s==on Yv cy row e a„ and then hire outside contractors rfiust.submit a new affidavit in di sting such, +Contractors that ch� l: 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 information. insurance for my employees'Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration age (showing Failure to secure coverage as required under Section 25A of MGL c. 152canltoo the imposition the policy bof criminal er nd expiration date). fine up to $1,500.00 and/or one-year imprisonment, as well as civil pe�ties in the foam of a STOP WORK penalties of 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 der the pains and e es of perjury thw then formation provided above is true and correct. sone #: / - Official use only. Do not write in this area, to be completed hj, CM, or town offciaL Cita, or Town- Permit/License # Issuirc; Authority (circle one): 1. Board of Health 2. Building Department 3. Citv1Tow,n Clerk 6. Other 4. Electrical insoetn rr Contact Person: Phone #: Information an- 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 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 tie legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees. However the owner of a dwelling house having not more than three apartm.. eats and who resides therein, or the occupant of the dwelling house of another who employs persons to do mante;�ance, 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 coxnpliance 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 un-ti1 acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contraxting 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 . members or partners,. are not required to carry workers' comp c:ensation 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 in�e coverage. .Also be sure to sign and date the affidavit~ The affidavit should be returned to he cit Lir town that the auuttca ti - 11- Ica, -the perrixtor License is being reaursfed, not the Jep_rtaent or Industrial Accidents. Should you have any questions reg ardin g the law or if you are rek;:ired w 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 permittiicense 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 stampeel or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future perzaits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pest not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations 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 Depariment'.s address, telephone and .fax.number:_._ The Commonwealth of Massachusetts ' Depa,rbment of Industrial Accidents Office of Investiaatlons 600 Washmgton Street Boston, IVLA 02111 Tel. # 617-72.7-4900 eoxt 406 or 1 -977 -NLA SS_-4FE Revised 5-26-05 Fax # 617-72.7-7749 urvn-.mass.. aov/dia