HomeMy WebLinkAboutBuilding Permit #497 - 86 STAGE COACH ROAD 2/29/2008Permit NO: ` f
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
O�StLlG It*•NO\
I IMPORTANT: Avnlicant must complete all items on this page I
LOCATION 2(o '4-0, 9_e C .0 OL C k
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PROPERTY OWNER �a ,� - �,I awv_ - r; ► L t/
Print
MAP NO: VID PARCEL: G h- ZONING DISTRICT: Historic District yes {
!Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New BuildingOne
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
ESCRIPTION OF WORK TO BE PREFO
Ji ,G -til t-,6Mb 2.! w(tM 3'0" cut 4-,' lever
D h of 6v,
Identificahn Please Type or Print Clearly)
OWNER: Name:
Address: $(0 S+zk5-e COOLCA
CONTRACTOR Name: Phone:
V
Phone: I °I �S
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp, 'Date:
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ S lZ- — FEE: $�
Check No.:Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Li 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 i
o Building Permit Application I
o Certified Surveyed Plot Plan �-
o Workers Comp Affidavit D
a Photo Copy of H.I.C. And C.S.L. Licenses O
❑ Copy Of Contract
❑ Floor./Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable) D
❑ 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
o 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)
L3 Copy of Contract
o Mass check Energy Compliance Report
L3 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007 +�
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
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH • ' ' • ' ` � " � • . -�, ,
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
Located at 384 Osgood Street
v� FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at'124 Main Street —"
Fire Department tignatureidate
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
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
Location
No.
7 y 7 Date a/
�,. TOWN OF NORTH ANDOVER
.. A
Certificate of Occupancy $
Building/Frame Permit Fee $
S�CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #� �6
20966
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o� NowrM TOWN OF NORTH ANDOVER
,.";"Ve �ooL OFFICE OF
p BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
;,,; # North Andover, Massachusetts 01845
Gerald A. Brown
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
Please prig
DATE:—
JOB
I�
JOB LOCATION:
Number Street
HOMEOWNER -- lCVt:h Iv1-1',ck�(y t6 1
Name Phone
one
PRESENT MAILING ADDRESS S
Telephone (978) 688-9545
Fax (978)688-9542
Map/Lot
54)320-1
Work Phone
City Town 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.
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. 1--, _ �1
HOMEOWNERS
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
130,\RD OF WEALS (M-9541 C0.','SFRV.1TTpN 688-9530 HEALTH 688.95.30 PLAN'NI\G 688-9535
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, AL 4 02111
www.m.ass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers
Name (Business/Organization/Individual):
Address: .
. City/State/Zip: Y
Areyou an employer? Cheek the appy
L ❑ I am a employer with
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.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
)//T Phone.#:
riate bpi:
4. lam a general contractor and I
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.
5. We are a corporation and its
officers have exercised. their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance reouired.l
Type of project (required):`
6. ❑ New construction
7. [,Remodeling .
8. F� Demolition
9. El Building. addition ,
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aff davit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy .and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #:'
Job Site Address:
Expiration Date:
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 required under 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under t e ins and penalties of perjury that the information provided above is true and correct
Signatur`e: Date: 2 2 C
Phone #: q -1-
,icuac.use only. Lo not write in this area, to
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6'.. Other,
Contact Person:
or town official
Permit(License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
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 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 "ever state or local licensing agency shall withhold the issuance or
renewal of a license or permit to,operate2 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, §25CO) 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 LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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'
compensation policy, please callthe 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 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 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 or permit to bum leaves etc.) said person is NOT required 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 -:and fax number:
The Commonwealth of Massachusetts
Department Qf Industrial. Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
Tel. # 617-727-4904 ext.4.06 or 1-877-MASSAFE
`
Revised 11-.22-06 Fax # 617-727-7749
.mass-govldia
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30.00 '
19.36'
67.8'e,
UTILITYis z4
-- EASE,�ENT 75 37' 65.58'
LOT 32
57,698± Sf
'3•s • ss,
STAGE COACH ROAD
CERTIFIED T0: HUNNEMAN MORTGAGE CORP.
Flood hazard zone has been determined by scale and
is not necessarily accurate. Until definitive Plans
are issued by HUD and/or ' a vertical control survey
is perfarmed, precise elevations cannot be determined.
NOTE. This mortgage Inspection was prepared
nij4 cfy for mortgage purpose only and
ot to be retied upon as a land or property
line survey, used Jbr recording, preparing deed
descriptions, or construction. No corners were
set. Building location and offsets are
approximately located on ground and
are shown specifically Jbr zoning determination
only and are not to be used to establish property
lines. The matters shown hereon are based on
client—furnished information and may be subject
to further out—sales, takings, easements and rights
of way, and other matters of record and preserptive
or other rights. Northern Associates, Inc. assumes no
responsibility herein to land owner or occupant,
accepts no responsibility for damages resulting frorq
reliance by anyone other than the said mortgagee or
in connection with its proposed mortgage financing
Pieter
G.
Knowles
said mortgagor.
This mortgage inspection was prepared in accordance
with the Technical Standards Jbr Mortgage Loan
Inspections as adopted by the Massachusetts Board of
Registration of Profbsstonal Engineers and Land
Surveyors 250 CMR 605.
I further state that in my professional opinion that
the structures shown conform with the local zoning horizontal
dimensional setback requirements at the lime of construction .r
are exempt under previsions of X.G.L. CH. IO—A Sec. 7.
Wt. Property/House is not in Flood Hazard.
C=1 2. Property/House is in a Flood Hazard Area,
O 3. Information is insufficent to determine Flood Hazard.
Flood Hazard determined from latest Federal Flood
Insurance Rate Map Panel ZSC�)09g 0006 G—
Date f7z 93 Zone .[yA/Shl7F�