HomeMy WebLinkAboutBuilding Permit #776 - 92 LISA LANE 4/27/2012,AORTH
BUILDING PERMIT of si` E° ;b gtio
TOWN OF NORTH ANDOVER 0-3 - A
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received �SsgArav
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Date Issued:
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IMPORTANT: Applicant must complete all items on this page
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 Addition
❑ One family
❑ Two or more family.
❑ Industrial
0 Alteration
No. of units:
0 Commercial
0 Repair, replacement
❑ Assessory Bldg
❑ Others:
0 Demolition
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0 Other
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DESCRIPTION OF VVUMM i U tat FMtrUKnntU:
/fi �ove gra �oJ'
Identifica ion Please
OWNER: Name: '�iAllie- tv7E2�A�
nAA,^^� • 902 Ll SA
or Print Clearly) Phone: 9 7'? _ '01F4 _Ivy r
Lome- i /q r�4 41t r\,4
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: $ 60(.4./ FEE: $
Q
Check No.:VC/5—Receipt No.:
NOTE: Persons contracting witlydnregiyteredlcontractors do not have access to the guaranty fund
1.
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 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
❑ 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 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
PLANNING & DEVELOPMENT
COMMENTS / A
DATE REJECTED DATE APPROVED
❑ j
DATE REJECTED DATE APP R • VED
ONSERVATION El ❑'ell
�a
COMMENTS
HEALTH
'AD
/ DATE REJECTED DATE APPROVED
a
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
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
IVU I t5 and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
Location �►t.�L /�'
No. ��_ Date .z --
e - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
• Building/Frame Permit Fee?$"'
Foundation Permit Fee � $
Other Permit Fee $
TOTAL $
Check #_- T 7 �
25239 Building Inspector
The Commonwealth of Massachusetts -
Department of IndustriglAccidents
Office oflnvestigations
W. 600 Washington Street
.Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians[Plumbers
Applicant Information Please Print Legibiy
Name (Business/Organization/Individual): ��� I L t R"f
Address: 7 �L 4 s /4 1 �
City/State/Zip: P,/oM� f Jv,,,,— 1,14 Phone #: / 7F- �i�— ly�T
Are you an employer? Check the appropriate box: Type of project (required):
I. ❑ I am a employer with 4. ❑ T am a general contractor and I 6. ❑ New construction
employees (full and/or part-time.).* have Hired the sub -contractors
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. E] Demolition
working forme in any capacity. workers' comp. insurance. g, El Building addition
[No workers' comp. insurance 5. El We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3. 1 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.] employees. [No workers' .13. ❑ Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
I am an employer that is providing workers' compensation insurance for my employees Below is thepolicy 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 oneyear 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 maybe forwarded to the Office of
Investigations of the DIA. for insurance coverage verification.
X do hereby certo ander theain d penalties ofperjury that the information provided above is rue and correct.
1L_ a7 /2
Si afore: / Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
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 Instruction's
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 ofhire,.
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 j oint 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.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 ofpublic 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. Han 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 fillgd 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 orliermit to burn leaves etc) said person is NOTrequired 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
DepartmertoffndustrialAccidents
Office of 10-Vestigatirom.
6.00 Washinpto>a. Street
Boston? MA, 021. X I
Tel, # 617-727-.4900 est 406 or 1-877�,MA.SS.AFE
Revised 5-26-05 Fax # 617727-7749
'www.xaass"m iia
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TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, -Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings •
HOMEOWNER�LICENSE EXEMPTION Fax (978) 688-9542
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION:
►� �Q,��
Number
HOMEOWNER ' /D0.nt e,
Street Address
L
MaplL,ot
✓fiUma.�
Name
Home Phone
Work Phone
PRESENT MAILING ADDRESS / o� �i 5
,�o,,,�•
O(
C;1' Tev,n
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units -or less anGl
to allow such homPo.;,,.t ers to engabe an;adivid-ual-for hire who does
not
acts as supervisor). State Building (Code Section 108.3.5.1)
possess a license, provided at the owner
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 fancily 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 forcompliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner, certifies that he/she
minimum inspection procedures and requi;�
requirements,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
the Town of North Andover Building Department
omply with said procedures and
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530
HEALTH 688-9540 PLANNING 688-9535
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