HomeMy WebLinkAboutBuilding Permit #306-2017 - 91 WEYLAND CIRCLE 9/21/2016 p2 �I L--
BUILDING PERMIT ` S°o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION * �*
Permit NO: ro A Date Received
Date Issued: �-6
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IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building A16ne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
wile—pair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ] ❑ Other �!
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,Q Identification Please Type or Print Clearly)
OWNER: Name: � r� �1p� 4'/1/6t)& 444' Phone: 97Lf-,/We
Address: CY tleyl"4 Cfvc6Q '
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ARCHITECT/ENGINEER Phone: t
Address: Reg. No.
FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST WE„ D ON$125.00 PER S.F.
48.
Total Project Cost: $ / S�'"d FEE: $ ccJ".r-�
Check No.: 15t
p Receipt No.: �;6 4 Si
NOTE: Persons contracting with egistered contractors do not have access to the guarantyfund
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i ure o ! h: ne $ of
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NORTH
BUILDING PERMIT 0
TOWN OF NORTH ANDOVER 0
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APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received 74ADRArED
gSSACHUs��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION _ -
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
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 ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: _ Phone:
Email
Address:
Supervisor's Construction License: Exp. Date:
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: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to theguarapty fund
Signature of Agent/Owner Signature of contractor I
i r Z •
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
i
Well ❑ ❑ I
Tobacco Sales Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp-Dumpster on site yes. no
Located at 124 Main Street
Fire Depa, tngmt 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)
41)
❑ Notified for pickup Call Email
Date
Time Contact Name
Doc.Building Pennit Revised 2014
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
a Building Permit Application
o Workers Comp Affidavit
o 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
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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
a Photo of H.I.C. And C.S.L. Licenses
Li Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
o 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
Doe:Building Permit Revised 2014
Location LjP (4�+�G� .�
I
No. _30(w- Date
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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Check# 0-0
PB
ector\j
NOR
Tfy
Town of
s _ 1, s ndover
O
h ver, Mass,
CoCNICKaWICK �•
o�RATED
lS U
BOARD OF HEALTH
PERMIT T LD
Food/Kitchen
Septic System
THIS CERTIFIES THAT ...........�;(...... ........ . . .. ..... . ...... BUILDING INSPECTOR
has permission to erect buildings on Foundation
Rough
tobe occupied as .................... . ... ... ............0...�........... ............................ Chimney
provided that the person accepting this p rmit 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 CONST TIO T Rough
Service
.. ... .. .. W6P*'EC
Final
BUILDIT0R
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.
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
+� 1600 Osgood Street,Building 20, Suite 2035
+j gra North Andover,Massachusetts 01845
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings, Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUDING PERMIT APPLICATION
Please print
DATE: "l�Z 0116
IN
JOB LOCATION: �� f/✓�y�Gi ACCP
Number Street Adch-ess Map/Lot
HOMEOWNER /10160 ?&K1 /�, t aldl2ie-d
X
e 06-It
Name Home Phone Work Phone
PRESENT MAILING ADDRESS fe?W
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided
that the owner acts as supervisor.
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 dwelling,attached or detached structures accessory to such use and/or farm structures.A
person who constructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR
Section 110.R5.1.2)
The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable
codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she rstands the Town of North Andover Building Department
minimum inspection procedures and requireme d that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 683-9535
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)
i
❑ Notified for pickup Call Email
Date Time Contact Name
--- --
Doc.Building Permit Revised 2014
9/21/2016 20160921 075230.jpg
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hUps://mail.google.com/mail//#inbox/1574c9f565b37b3f?projector=1 1/1
_ The Commonwealth qfmassqchuseffs
. Department ofbIdustrialAccidents
I Congress Stpeet,Su to 100
d Roston,MA 02114 2017
vwv mass govfdia
Wg3ke.&CompensationbsuanceMadavit:Builders/CarytrractorsMpg4icimslPlumbers.
TO BE'Y f- D WrM TEE PRR11T']NG AVBSORM.
A Iicant�n£oxana-.on Please Print iogibl
j�
Name (Business/(�rganization/Indivzduat): �C - f 4 a
Address:
city/state/zip:_n�?r l il� � Phone
Areyou an employer?C3ieek]ie appropriate box: Type of project(Tegred):
1.�T am a employer rtb s employees(firlt andlorpart me).x J.• Nu-w colistr ction
2.0 lam a sole propiieb:zorpmtaarship andhave no employees working forme in $. 0 g
auy achy.INo wooers'comp.insurance required] 9. ❑Demolition
34!d
lama ezdoingall workmyseliIND workere--omp.inGmaneezaganed]T
10 ❑Building addition
4_ am a hnmeownezand wM bebii ag confractors to conduct all work onmyproperiy: Iw�1
ensm,that all contractors either have workers'compensation iuso ce or am sole 11:E]Electrical repairs ox addition s
proprietors vnno employees. 12:Q Plumbing rep airs or additions
5.n Jam agenmd coritra ctor and Ihaye hiredtlie sub-ooni<actors IisLed on the attached sheet. 13.Q Rao=repairs
''�esesnb-ooulract�-shaveemployees andhaveworkzrs'comp_insurance
6.Q We areacorporaL�apacl#q,off i r, have exerdsedihehzightofegemptionperlVlGZc.
14.El Other
152,§1(4),andw-ipfiaveno„eeraployees.j1�Toworkers'comp.insmancereq�ed]
*Any applicautibatchedlosbdx4lmust also': outtbesectionholowshowingtheirworkers'compensationpolicyinfonnaiion.
ersFtliosiiliiiiiiE� davitmdica�gtheyaradoingallworkandihenhire
igameewnouisideconiraetorsmusts�mitanewaffidav >ndicatmgsib
?Contractors hatribeckrl�isbogmfdaatfaehedanadditionzlsheetshowingthenameofthesah-contraotoisendstatewhetherornotthoseentitlesh_ave
employees.Ifthe sub-corifracfors have employees,`tlieymnst provide then worlds'comp.policy number.”
.2 arra an erriploy9T&at isprovidi gww,-kers'compensadan insurancefo:rrip eryiplayee�:'Below is thepolicy acidjob site
info�natiar�. _ .
Insurance Company 31Tame:
Policy#or Self-ins.EG.#: ExpirationDate:
Tob Site.Address: City/State/Zip.-
Attach a copy oftheTFOKkers' coanpeWaEonpolicy declaration page(showiugthe poReynumber and expiration daze).
Failure to aecure 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 imprionment;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-, py of this statement may be forwarded to'rhe Office of Investigations of the DIA for-b=ane
coverage vermoation.
Ido ereby eY ' c�&epains and peva[ sf 5j rj ,-y that the infonvaiionXoWded above is rzse and col�ect,
h
Signature- Date: It>A.
Phone# 9��' 'Af 37 0
Official rise only. llo not-tvrite in this area,to be cOMPleted by dV 0r-t0Wn official.
City or Town: Permit/License 4
IssuingAuthorip (circle one): i
1.Board of Heath 2.BuRding Department 3.CitylTown Clerk 4.Electrical Tnsp ector 5-?21 bing Zxzspector
6.tither
Corataet Person: Phone#r:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation fortheir employees.
Pursuantto this statute,an employee is defned as"...every person in the service of another under any contract bf hire,
express or implied, oral or written_"
Aa employer is defined as"an iud vidual,partnership,association,corporation or other legal entity,or any two or more
Of the foregoing engaged i a a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trr stee of-an individual,partnership,association or other legal entity,employing empl6yees. 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,consfruction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b 6 deamed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shalt withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth,for any
applicazot wRo I%as not prod-aced acceptable evidence of compliance with the insurance coverage regdr•ed."
Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any ofits 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 b een presented to the contracting authority."
Applicant
Please fill-out•theworkers' compensation affidavit completely,by checkingle boxes that apply to your situation and,if
necessary, supplysub=contractors)name(s),address(es)and•phonenumber(s)along with theircerdfoate(s)of
insurance. gimitedLiabilityCompanies(LLQ or Limited Liability Partnerships(LLP)withno employees'otherthan the
members orpartaers,arenotrequiredto carryworkers'compensationinsurance. If an LLC orLLP doeshave
employees,apolicyisrequired. Be advisedthatthisaffdavztmaybesubmitted tothe Departmentof-Mdustrial
Accidents for confirmation ofinsurance coverage. Also be sure to sign and date the afdavit. 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 regardingthe law ox ifyou'are required to obtain a w6rkers'
compensation policy,please call the Department at the number listed below. Self-ii�srrred companies shpuld'enter their
self-in-sura-6a 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 Investigation has to contact you regarding the applicant.
Please be sure to fill inthe permit/license number which will be used as areference number. In addition,an applicant
that must submit multiple permit/licemse applications in any given year,need only submit one affidavit indicating current
poll6y information(if necessary)and under"lob Site Address"the applicant should mike"all locations in (city or
town)."A copy of the affidavit that has been officially stamp ed 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 filed 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 wwwmass.govl(Ra
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