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Home My WebLink AboutBuilding Permit #572 - 88 HERRICK ROAD 4/30/2009 BUILDING PERMITO� NORTH q TOWN OF NORTH ANDOVER y APPLICATION FOR PLAN EXAMINATION ew ,� Permit NO:� ' Date Received �4,oq .9 wreo �q DateIssued: 0-Ja SSACHUSF IMPORTANT:Applicant must complete all items on this page , t LOCATION ( r� Print - PROPERTY OWNER ` Tme-S 12r AS 2,C Print MAP NO:OQO PARCEL: ZONING DISTRICT: Historic District Ayen Machine Shop Village TYPE OF IMPROVEMENT PROPOSED USE Resid Non- Residential New Building One famil Addition Two or more family Industrial Alteration No. of units: Commercial Repa r, replacement Assessory Bldg Others: Demoli ion Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BP PREFORMED: 4-E-1 n J& b 6CJ C. -i&arc, o-.,\JL i a-v\.dL-IL, peva T--h a-B 0 6,-C Identification Please Type or Print Clearly) OWNER: Name: pct-e-r Phone: Address: (;��K f�-eCc'�c.� Qk CONTRACTOR Name: Phone: Address: "'t -V --" Supervisor's Construction License: Exp, Dater 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: $ `7 ark FEE: $ 2,& -� Check No.: 0 , t, Receipt No.: I�7 �I p NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne �Y -� Signature of contractor 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 i CONSERVATION Reviewed on ( Si nature r?�v COMMENTS W ( / HEALTH Reviewed on Signature COMMENTS k 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/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 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) o Mass check Energy Compliance Report (If Applicable) L3 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 f E Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 i Revised 2.2008 t Location 0-6 No. "d"' Date N�RTo, TOWN OF NORTH ANDOVER Certificate of Occupancy $ ` Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 1 9Q5 Building Inspector NORTH TOWN OF NORTH ANDOVER •• OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover Massachusetts 01845 sS�C►+us�t Gerald A.Brawn Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please p�t DATE: 3 0 JOB LOCATION: gNumber Street Street Address M HOMEOWNER:a4 Name Home Phone Work Phone PRESENT MAILING ADDRESS s C (2—PIL 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 hoense,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER t 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 mare 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 HOMEOWNERS SIGNATURE IM�C� APPROVAL OF BUEDING OFFICIAL. xevind 10.005 Fomo Homaowam fi mptim BOARD OF \PPEA1.S 6-?9!?541 CONSERVNri0\-Fg9-9530 HE.UXIi 688-9530PL.IV�i IG 68M535 XAORTM TO" . of No.c,,f ?Z - - _7 y T LAE dover, Mass., d • K COC MIC KE C WICK V �ds RATED PQM\ �� 7 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System � - BUILDING INSPECTOR THIS CERTIFIES THAT.......... . a.�.ti►...... .............................................................. .............................................. Foundation has permission to erect.. ................................... buildings on ..... . .'�/�.h.��,!.. .......� ........ Rough ..... . ,OI ................. ... �MrT Chimney to be occupied as......... ........ ...�1.l.�.........�..................... .,�.....................w�►..��.� ...... ................................ ............. . . . . provided that the person acc pting this permit shall in every r spect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR 3� UNLESS CONS UC STARS Rough .......... . .................................:.................................... Service BUILDING INSP R Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the .Premises - -Do Not Remove Final No Lathing or Dry Wall To .Be Done _ -- FIRE-DEPARTMENT - Until Inspected and Approved by the Building Inspector. Burner Street No. I F SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts kj ! Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual}; Q,ti.s W Address: City/State/Zip: �\J Phone#: . "7 $� ��3 �cv Are you an employer?Check the appropriate box: 1.❑ 1 am a employer with 4. Q 1 am a general contractor and I Type of project(required): employees(full and/or part-time).* have lured the sub-contractors 6• ❑New construction . 2.❑ I am.a:sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and have no employees These . sub-contractors have 8. Q Demolition working far mei'g . any capacity, workers comp.insurance. g, Q Building addition [No workers'comp, insurance 5. Weare a ❑ corporation and its uired.] officers have exercised their 10.Q Electrical repairs or additions 3. I�am a homeowner doing all work right of exemption per MGL I l.Q Plumbing repairs or additions myself. [No•workers'comp, c, 1.52, §1(4),and we have no 12, Roof insurance•re aired t ❑ repairs q ] .employees. [No workers' 13.Q.Other comp. insurance required.] *Any applicant that checks bot:#l must also fill out the section below showing their workers'compensation policy information, t fiomeowncim who submit this affidavit indicating they ars doing all work and then hire outside contractor must submit a new afiidavit indicating such, tCorttrt►etors that check this box must aft obed an additional sheer showing•the name of the sub•contmetons and their workers cam r' •' r Fo•:"5 nforrttation. information I ant an employer that is protiiding:workers'compensation insurance f or my.employees: Below is the policy and job site . Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: I Job Site Address: Attach a cCityCity/State/zip:tipy of the workers' compensation policy declaration page(showing the policy number and expiration da*4 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si tore: �^G Date: �u Gj Phone Qciat use only. Do not write in this area,to be coni plet-ed by city or town offdaL j City or Town: Permit/License# i Issuin Autho ' g r ity(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbin:Inspector 6.Othe'r Phone#: Contact Person 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 includirfg the legal representatives of a deceased employer,or the receiver or t ustee 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"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 evident a of compliance 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 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-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' 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' oorm;pensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insruance 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"ail 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 fdrure 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 lnvestigations 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.govIdle 7 r�r -71 . A I r� 4 4 TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: Q-�P1�� I� `"'I,W O Yp Est. Cost P Address of Work Owner Name: `J VA Date of Permit Application: hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND UNER MGL c. 142A. Signed under penalties of perjury: hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name