HomeMy WebLinkAboutBuilding Permit #533 - 855 GREAT POND ROAD 4/10/2009BUILDING PERMIT
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: � J 3 s Date Received O egso
AC US
Date Issued: ' [�' i ! � C".
I ORTANT: Applicant must complete all items on this page
PROPERTY OWNER-
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MAP NO:J03PARCEL: _ ZONING DISTRICT: Historic District yes no`
Machine Shop pillage yes enol,
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 I
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
ARCHITECT/ENGINEER
Address:
Phone:
Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED C�O1S`tT��BASED ON $125.00 PER S.F.
Total Project Cost: $ 00 FEE: $
Check No.: � Receipt No.: CQ i 13 1
NOTE: Persons contracting witJ regi;�gred contractors do not have access to the guaranty fund
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE ISPOSAL
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
5
PLANNING & DEVELOPMENT
COMMEN SC✓G4 5 a O f —1,
CONSERVATION Reviewed on Si nature
/4'
d V
COMMENTS
V
HEALTH - Reviewed on Signature
COMMENTS Cj
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt.submitted yes
Planning Board Decision:
Comments
L
Conservation Decision:
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
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
❑ 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 f-r—A T f"'OY,y[
No. 4:z"?? Date
NORTH TOWN OF NORTH ANDOVER
f �
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L
Certificate of Occupancy $
,S'sAE11USEt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $—
Check # ""n( -
211
"n(211 969
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MoerM TOWN OF NORTH ANDOVER
OFFICE OF
1 0 BUILDING DEPARTMENT
4t
1600 Osgood Street Building 20, Suite 2-36
Nord, Andover, Massachusetts 01845
1Ss�cwustt
Gerald A. Brown Telephone (978) 689-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please vrint
DATE:
JOB LOCATION:
Number Street Address
HOMEOWNER u lu
Nam Home Phone Work Phone
PRESENT MAMING ADDRESS
/V -
City To" 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 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 responsibility for with the State Building Code and other
Applicable codes, by-laws, rules and regulations. OrF.
"iI4 f
s * =
regulations.
The undersigned "homeowner" certifies that he/she Town of North Andover Building Department
minimum inspection procedures and that will comply with said procedures and
requirements.
HON[EOWNERS SIGNATURE
APPROVAL OF BUILDING
Revised 10.2005
Form Homeowners FAmmption
BOARDOF \PPEA1.S639-9541
CONSER V. MON 68R-9530 I-TEAU11f 09-9540
PL. VNN IN G 6 S8-953 5
s _
The Commonwealth of Mijssachusettr
!
Department o
.f'Industrial Accidents.
Df.Tice of Ir�vestiaations
600 W
ashinoQton Street
Boston , l 02111
u'MM'-mss.; o�/din
Workers' Compensation insurance.Aff-
lopficatat Informatdavit: guilders/Contractors/Eleetrficisas/Plumbers
ion
Name (Business/Organization/Individual): 4%12'. -S(� S�
Address:
City/State/Zig: Xh cKVv.er. J62/ �y p� � Gj
�12 d 6 g jaC
Are you an employer? Check the appropriate box:
l . ❑ I an. a employer with 4. ❑ I am a trenemI co
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
I am a homeowner doing all work
myself [No workerscomp.
insurance required.] t
nua,^tor and I
have hired the sub -contractors
listed ori the attached sheet I
These Sub -contractors have
workers' comp. insurance.
5.. ❑ We area corporation and its
officers have exercised.thcir
right of exemption per MGL
c.. 152, § l (4) and we have no
employees. [No .workers'
comp. insurance re ,; d
Type of project (required):
.6. ❑ New construction
7. ❑ Remodeiing .
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
120 Roof repairs
q re) 13.[] Other
*Any appii a ; Wilt cheeks box11i# 1 .must also fill out the section below showing their workers' comprnsation poLcy mrormation.
l Contra wneth who submit •bo atFtdeNit iudicatittg titer art ua . Wit' wizr!t atyd Ehcn him outside contrat tors (oust submit a new affidavit mdicatin
�Contractars that e'neef this box.must attached an additional sheet showing the name.of the ;y o ;Mors and their worice[s' comn. ooiic�, ca
su
I g such,
am alt employer that is providirze workers' compensation i
information nsurance for, ,employees.
Insurance Company
Policy # or Self .ins. Lic. #:
Below is the policy and job site
Expiration Date:
Job Site Address:
Attach s copy of the workers' eo asation otic deeia Ott /State/Zip:
Policy ration page (showing the Policy- number and expiration date).
.Failure to secure coverage as requi d der Section 25A of MGL C. I52 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -ye i prisonment, as well as civil penalties in the form of a STOP WORK ORand a fine
of up to .S250.00 a day against the io tor. Be advised that a copy of this statement mai be forwarded to the Office DER DERa
Investigations of the DIA fo ns a coverage verification.
I do herebnlcerifi5, "nil
yucca vJ pe urf' zhar the infornmfion provided above is true and correct
Official use onlp. Do not write in this area' to be completed by city or town ofciaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. city/Town
6. Other Clerk 4. Electrical Inspector S. Plumbing Inspector
Contact Person:
Phone
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 ofhire,
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 mcluciiaxg the legal representatives of. a deceased employer, orthe
receiver or trustee of an 'individual, partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house having not more than .three ap artments 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
Cron the grounds or building appurt,Anant thereto shall not because of such employment bedeemed to be an empioyer."
MGL chapter 152, §25C(6) also states that "every state o r 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 forany
applicant who has not produced acceptable evidence mT compliance with the insurance coverage requireV
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 worl< until acceptable evidence of compliance with the insurance
requirements of this chapter have been present=ed to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit compl-etely, 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 affic avit may be submitted to the Deparnnent 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 reg- rding thtiam, or if you are required to obtain a workers
compensation policy, please call the Departm-nt at the no+T_'aiber1;s+.ed below. Self-insured companies should enter their
self-insurance license number on the appropriate imne.
City or Town Officials
Please be sure that the affidavit is complete and printed les -mbiy. The Department has provided a space at the bottom
of the affidavit foryou to fill out in the event the Office of' Investgations has to contact you regarding the appiiamt.
Please be sure to fill in the permitJiicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennit4icerise 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 starnped 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 Iicenses. A new affidavit must be filled out each
year. VArh=_ a home owner or citizen is obtaining a licenser or permit not related to any business or commercial venture
(i.e. a dog iicense or permit to burn'leaves etc.) said person is NOT required to complete Phis 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: j
The CommonwtELlth of Massachusetts
Department of lmdustrial Accidents.
Office of £avestigatioas
600'Was1ington Street
Boston, M- A G21 I 1
T51.4 617-727-4900 1e) -t 406 or 1-877 MASS.4FE
Revised 5-2645 Fax:9 61 7-7-7-7749
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Town of North Andover
❑ Base Map I I Zoning I 2005 Aerials
El -UL�u _- o
Watershed Zone Utilities Size ❑ Eff
Help Scale 1" = 105 ft
Get Pictometry Imaged Go v2.5 [beta 2] AppGeo Save Map as Image
Page 1 of 1
Selection 11 L
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(show all)
Owner
STUPNYSKYI,
m 71
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Property
Ownerl
Owner2
Address
Map/Lot
Lot Size
Fiscal Year
Land Use
Code
Last Sale
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