HomeMy WebLinkAboutBuilding Permit #1031-15 - 90 BOSTON STREET 6/9/2015 1'' of Nvrr aqti
14 BUILDING PERMIT �? 9tITltD i A�
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L,� TOWN O F N
ORTH ANDOVER
``'^ APPLICATION FOR PLAN EXAMIN
Permit NO: I�1"J Date Received
Date Issued:
t J ��SSACHII`��t�9
IMPORTANT: Applicant must complete all items on this page
LOCATION ( -0f;'fen -91)
Print
PROPERTY OWNER anzyA
,� Print
MAP _NO: _ . ! .PARCELO) _ZONING_DISTRICT; ._ , . _:_..Historic_District ves .n�,Ro�"
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building VOne family
❑Addition ❑ Two or more family ❑ Industrial
❑Hiteration i-qu. ui urliis. ❑ Uun-i nei ciai
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
_n_G.nn4in .F-I IA►nll.- -r- _, __ 7�_Cli+i+Anl�ain _n lA/n/1nnAn,. G'1.1Aln�nrnhnA rlinirin� _-.,-
lith," LlV Y611 `' - 4J 1-/YVV'.i1G1111 "1J'Y YC.CIG/IVJ' I_7.'V tlQIGI JI iGV LiIJ t11Ul -+
.._❑Water/Sewer 1
Identification Please Type or Print Clearly)
OWNER: Name: 8n 671 ���c,�,e�,L Phone:
Address:
CONTRACTOR Name: Phone:
aw 22
Address: �\^n
Supervisor's Construction License: ' Exp. D te:
Home Improvement License: Exp. Date:
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: $ 2-12 W,00 FEE: $ 3 .ao
Check No.: Receipt No.: 01
NOTE: Persons co tracting v6ith unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Location
No. tU ���'IS Date
. - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
.. Y
Check#
�! Building Inspector
Plans Submitted CI� Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
FWell
AGE DISPOSAL
❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
❑ Tobacco Sales ❑ Food Packaging/Sales ❑
etc. ❑ permanent Dumpster on Site ❑
I
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS (� �-1 t,J (it� `1 w v
CONSERVATION Reviewed on �e I� Si natur A
COMMENTS DON 5 a7 �S Co-
y'4
HEALTH Reviewed on , ' Q - Signature
COMMENTS 2j
I �
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 ®ump I er on site yes
>ocatetl at 124.Main Street
Fire Depakthent signature/date
COMMENk T5 1 �y
Dimension
Number of Stories: Total square feet of floor area, based on Exter' :dimensions.
I
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requiresrapproval 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)
- I
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i,
❑ Notified for pickup Call Email
1 Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The followingis a list of the required forms to be filled out for the appropriate permit to be obtained.
q
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application t
❑ 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/Cross Section/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
of
❑
Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
a 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 2014
NORTH
Town of t E ndover
to
so h ," ver, Mass, (lit 0 �5
COCMICMl WICK y1.
%
X1,95°R�►Te o � S
ll BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT .......... ... .l.re..... , ! BUILDING INSPECTOR
.... .... ...
has permission to erect buildings on �Q261!�.. ,,,,,,,,,,,,,,,,,,,,, , Foundation
.......................... ....... . .......6 .
�
` �/ P Rough
to be occupied as ..........141 ...1.53......4 ' .. �..•:•••. ............................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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
UNLESS CONSTRUCT S T Rough
Service
.............. .. ......................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
IN" 14 I
V#TPWW finaw sm Pam IM I i
arra: JENNFM 1t= ME STERED LAND
Bonk shed L01(s
Dam 12n3i2W3 ge
Asseamr's Mav SW Lot Carats Tad
MORT'GAGEHaPECTZONPLAN Scal�'i"�i0• �
90 BOSWNSTREET, NDRMANDOVER, AM
LOT 4
p6
LOT 3A
LOT 7
45,000 Std. FT.
Pov�
N/F
LOT 3B �r -7 GOODHUE
V ® `
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#90
BOSTON STREET
0�9T T07W AWM A77*WW EellIIK,AilID 77B03EIL IIiI E DYSDRANCE CObRANYTBATTBE MAIN 1;ZTDAIIiG.FOUNDA7iON OR
WAS later WI1H 1'EiG LOCAf.7L114DYG BYLAWS tG!1 FFFECt'WSFri(7Dt+b7'Ri1C[FD(WCIH�ECI'Tt)
SE1'BAIXSFQ�ITiREi�iIS ONLYlORis ts'7i�'t'F80M VIOIA710N�'ACTION If1rH1ER MASS.6�.NERAL
W MIM VH.(�ATI1Egt49A,81BCI7FRH T.
Flom DETla"BIGITTDN
SCALE.MMDWMMGSHOWNHBMDOESNOrFAILWLif1BIAMWALFLOODHAZARDZOMASDO NF TMONAMAPOFCMOKMTY
?.5WX02WASWWXDAYM74.2012 BYTHEHATMALFLOWDOURANCEPROMAM
�__tj}["OF Mgs
Wde Stone Piot Plan UC � NEIL �yG
P.O.Brix 1166 A N
Lakeof"ite,JA 02347- " tt 3 036
Teb(Wo 993-3302
Fax:(SOOj 993-33"
PLEASE MOTE This knpaaoa is rat the resrtof an irshmrrmtmnrey.The sVudaes as stoiem are swW&natemay-An wleri
sur4ey
waW be retried for an ddw ibahwi of bdlft iocWms,araoedsnerds,pmpety be dimasiDM teases WA tot aorr%WrMorr and
may refbd dffbmrd irdomr§an than shown bare.The bred ss shaven lsbased on cftdfunW ed idommTim only orassessoes map&
o=Vation all may be so]I l to fuller out•saies taimgs -as and dgft of xray. No wsparmUftyis exlerdnd m the iandowrw or
suveycr.ar oowpea Ttim is merely a mortgage kvwec m and is and tee be recorded_
TOWN
t-�-�c•r�.T t•�-�r�-� t� it
4 ty0ftTy JlO YC.L�i O 1�YORJlH DO iP,
.
O1• ICE OF _ •-
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• ' Q ,°" - :' 6fl0�Jsgood 19treetBuilding 20,-Suite?35
_ 7 37xn FsP�U5 �5 •NoithAudover7 Massachusetts 01845
�S�ACi-1 �� '
Ge,xald A.Brown Telephone(9 79)6889545
Tnspeetorof$uildings
Fax (978)689-9542
' xo oWNBR'UCBNSE IMEMPTION"
pleaseyrin� .
DATE: ot, ►�
SOB LO CATiON., o b p 9 j '5 ,UD &})?q
Number Sfrod- Address 3llap/xot .
150AMCMMER L eiei on
dame. . Rome Phone Wbrk1'hone
PRESENT MAMING ADDRESS ,n ° �
•�Uan� A,�byc�-rn ,�/�}- l�r��h
O To=
,tate• - 7;p Cod1
The current exemption for"-homeowners"was extended to include ownex occtip'sed dwellings to two units.oY ass a
= nd
%o allow Bubb ho_noo.Tcis to engage an.Lin dividual.for lure Who does notpossess a 1icG3ise,provided that the owner
acts as supervisor). l;;.ateBuizding (Code Scotian.108.M.1) -
DEF.INI.TION OP`HOMEOVMR ,
Person(s)who awns aparcel of land.on which he/she resides or intends to reside,on which-there is,or is iiufended to
be,a one or two family straetures. Apersonwho copstructs more that onehome in atwa yearpeztod shall notbe
considered ahomeowner.
The nuclei-signed"homeowner"assumes responsibility forcbmnpliances with the StateBuilding Code and other
Applicable codes,by laws,rales and-regoations. t
The nrndersigned"homeownex"oexlifxes that he/she hnderstands the Town of Nbrth AadoverBuilding Do�arknent
Min'm1T7'tuxn inspec tion prooedures and requirements and that lie/she will comply with�said procedures and
regvh-emeuts, .
HOMBOWN$RS SIGNATURE
APPROVAL OF BUMDXNG OFFICIAL
Revised 7.2909 y
P'oxm�omeownersBxBmpfion � - .
)3DARD OFAPPEAM 688-9545 COhrSERI''ATION 588-9534
HEALZH 688-954 PLANNING 685-9535
The Commonwealth of Massachusetts
M Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE RILED WITH THE PERMITTING AUTHORITY.
ADMicant Information /� nn Please Print Legibly
Name(Business/Organization/Individual): -8. On
Address: q 0 0 CJS On s�-
City/State/Zip: Voi,�fry An�ja)-t^ MA- Uk3lic Phone#: et?3'3P'j
Are you an employer?Check tiie appropriate box: Type of project()required):
1.❑I am.a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. F1 Demolition
In am a homeowner doing all work myself[No workers'comp.insurance required.]t
10❑Building addition
4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole l i.❑Electrical repairs or additions
proprietors with no employees.
12.[JPlumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.1 ❑ p
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.F1 Other
152,§1(4),andWe have no employees.[No workers'comp.insurance required.] ,
*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 affidavit indicating such.
tContractors that check thisbox 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 fiave employees,they must provide their workers'comp.policy number.
I aim an employer thai is providing workers'compensation insurance for my employees.'Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins,Lie.#: Expiration Date:
fob 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 required under MGL c. 152,§25A is a criminal violation punishable by 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.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 ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#: 4)-S'-3 OC-A 131
Official use only. Do not write in this area,to be completed by city or town officiax.
City or Town: Permit/License#
Issuing Authority(circle one):
1.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 theiremployees.
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 commonvVealth 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 may be submitted to the Department of Iindustrial
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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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