HomeMy WebLinkAboutBuilding Permit #771 - 9 COBBLESTONE CIRCLE 4/25/2012ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F.
Total Project,Cost.. FEE: S
1 �
Check No.:�1-- Receipt No.:�
NOTE: Persons contracting with unregistered contractors do not have access t t a guaranty fund
_Signature-ot contracto_ - r.� : -
Location I �W�
No. 7?/
Check # C� qj�—__._
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $✓"
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee �$
TOTAL '$
25232 Building Inspector
i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Seng Pools ❑
Well ❑ Tobacco Sales
❑ Food Packaging/Sales ❑
Private (septic tank, etc.
I ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
r,AFI
COMMENTS
r
Q
DATE REJECTED
DATE APPROVED
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
Zoning' Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water '& Sewer Connection/Drivewav Permit
Located' at 384 Osgood Street
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 2007
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 Co.mplian`ce Report ('If Applica�ie)
❑ 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: INSPECTIONAL SERVICES DEPARTMENTMFORM07
Revised 2.2007
The Commonwealth ofMassachusetis . -
Department oflndustriglAccidents
Office of Investigations
600 Washingtoxt. Street
Boston, MA 02111
lop www.massgov/d'ia
Workers' Compensation Insurance Affidavit: Buildelrs/Contractors/Electritcians/Plumbers
Applicant Information Please Print Legibly
Naive (Business/Organization/Xndividual):
Address; L?P,� bLS_6 he.. Ui.
City/State/Zip:1(i 9/7Gt l/f')e✓ zw Phone M 917�'
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/orpart-time) *
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. ?
, ,/ tL"
7• Irl remodeling/
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.g,
5. El We are a corporation and its
❑Building addition
officers have exercised their
10.[] Electrical repairs or additions
3. [grequired.]
I am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp,
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] Ti
employees. [No workers'
13.❑Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showiingtheir workers' compensation policy information.
Homeowners who submit this affidavit indicating they Ere doing all work and then hire outside contractors must submit anew 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.
lam an employer that is proviaing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Nan
Policy # or Self -ins. Lic.
ExpirationDate:
Job Site Address: 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 requiredunder Section 25A of MGL o. 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. $e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby cent under thepaZ andpenaTties ofperfury that the informationprovidedabovei?ue � dcorrect.
Official use only. Do not write in this area, to be completed by cify or town official.
City or Town Permits cense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5—Plumbing Inspector
6. Other - - -
Contact Person: Phone M
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 orbuilding appurtenant thereto shallnot because of such employment be, deemedto be an employer."
MGL chapter 152, §25C(6) also states that "every state or Ideal 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.aceeptable evidence 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 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 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 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. Anew 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 burn leaves etc) said person is NOTxequired to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and shquld you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho GoMY40Awealtf of Mas sg,-h- :set s
De .arimeut ofkdustrlal Accldonts
4fuoe of IIRVestigatitm.
600 WasWngto a. Street
Bclston} Q�X�,�
Tel, # 617-72.7-4900 QA 406 or 1-877MASS.AFE
Revised 5-26-05 Fax # 617-727-7749
www.mas%R-ov daa
The Commonwealth ofMassachusetts . -
I D2 Department ofIndustriglAccidents
Office oflnvestigations
600 Washington Street
Boston, MA. 02111
UV. www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Auulicant Information Please Print Legibly
Name (Business/Organizationffndividual): l AU ,may/ y_�, �/ oQ2,_a_Z2/ 4
Address: AX c /1,-- Cly
City/State/Zip: Phone #:
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. j] New construction
employees (full and/orpart-time) * have hired the sub -contractors
2. F1 am a sole proprietor or partner- listed on the attached sheet. x 7• E] Remodeling
ship and'have no employees , These sub -contractors have 8. ❑ Demolition
working for mein any capacity. workers' comp. insurance. g, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing. repairs or additions
myself. [N o workers' comp. c. 152, § 1(4), and we have no
Y p 12.❑ Roofrepairs
insurance required.] t employees. [No workers'
comp, insurance required.] 13.❑ Other
'°Any applicant that checks box Of must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew 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.
X am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. '
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 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
ofup 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 DTA for insurance coverage verification.
Ido Izereby c t, under file pains andpenalties ofperjury that the information provided above is true and correct.
hone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:. PermitUcense #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
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 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 "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 `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. T'he affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Depattm ent of
Industrial Accidents. Should you have any questions regarding the law or if you are required to 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.
pity 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 (ifnecessary) 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 maybe provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 massacliv.:setts
Dop.aftent ofIndustdal Accidents
Office of I>RYestfgat>io.w
600 WasWooa Street
Boston, MA, 02111
Tel, # 617.727-.4900 Qxt 406 or 1-877,MA.SS.A.k`B
Revised 5 26-05 Fay,# 617-727-7 749
tvww.mass,govAia
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Gerald A. Brown
Inspector of Buildings
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
::1600 Osgood Street Building 20, -Suite 2-36
North Andover, Massachusetts 01845
Telephone (978) 688-9545
HO
Fax (978) 688-9542
ROWNER-LICENSE EXEMPTION
BUIDING PERMT APPLICATION
Please print
DATE: 5
JOB LOCATION:
Numbere vv
Street Address Map/Lot
UOMEOWNER
Name Home Phone
5
Work Ph�
one
PRESENT MAILING ADDRESS ! .
Cit; Tot:m_
Sri Zip Code
The, current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less anal
to allow such homeou,�ners to engabe 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 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 period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the Slate Building Code and other
Applicable codes, by-laws, rules and regulations.
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 11 DMAf/ n ,.
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Foran Homeowners Exemption
BOARD OF APPEALS 688-9541
CONSERVATION 688-9530A'
HEALTH 688-9540 PLANNING 688-9535