HomeMy WebLinkAboutBuilding Permit #784-14 - 940 FOREST STREET 5/1/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: / Date Received �
IWORTANT: Applicant must complete all items on this pave I
/, Print
PROPERTY OWNER C.a �1,' �J 0 L' L - ) ! Unit #
Print
MAP NOA-5-PARCEL: ZONING DISTRICT: Historic District yes 0
Machine Shop Village yes no
100 year-old structure 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_p
0 Well ' �' r"--=
[WWdoo plaid R W, lan'�d�s)
tOj Wa e`rshed�tDis i-ctc
L' DWater/ewer`•'
DESCRIPTION OF WORK TO BE PERFORMED:
or Print Clearly)
OWNER: N
Address:
CONTRACTOR Name: °"`" Phone:
Address:
supervisor's Construction License:
lome Improvement License:
Exp. Date:
Exp. Date:
RCHITECT/ENGINEER Phone:
Jdress: Reg. No
FEE SCHEDULE. B ULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
ital Project Cost: $ ; (X 01 V-0 FEE:
eck No.:
y �� Receipt No.: �� Z
ITE: Persons contraWnd,vith �nregisteredr�Contractors do not have access to the guaranty fund
In
Permit NO:
Date
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
LOCATION
Print,
PROPERTY OWNER
Print 100 Year Old Structure yes no
MAP NO: 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 PERFORMtU:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
c
OrJrJrece•
CONTRACTOR Name: Phone:
I Address:
Supervisor's Construction License:
Home Improvement License:
ARCHITECT/ENGINEER
Exp. Date:
Date:
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 the guaranty fund
Signature of Age,#Owner Signature of contractor
Plans Submitted FE Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Location.?O, %/,,.o 7 l
No. 1 Date
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
8
Plans Submitted: ❑ Plans V1laived❑ Certified Plot Plan ❑ Stamped Plans~❑
' ;TI'EE O1{:SEWERAGED3Sf'O;;AL
Public Sewer ❑ Tanning/MassageBodyArt ❑ ... _Swimming Pools ❑
Well ❑ Tobacco.Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc._ ❑ - PermanentD unpster on=Site ❑
=THE -.FOLLOWING SECTIONS FOR -OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
:..DATE. REJECTED: DATE:A_PPR.OVED
PLANNING"&DEVELOPMENT CI
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
4
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comme
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date DrivewaV Permit
DPW Todv;2 Engineer: Signature:
FIRE DEPARTMENT - Temp Dump
Located -at 124 Mair, Street
Fire Departme►itsignature/date .-
e. t _
COMMENTS_
Located 384
on site yes no
Street
"7
=THE -.FOLLOWING SECTIONS FOR -OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
:..DATE. REJECTED: DATE:A_PPR.OVED
PLANNING"&DEVELOPMENT CI
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
4
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comme
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date DrivewaV Permit
DPW Todv;2 Engineer: Signature:
FIRE DEPARTMENT - Temp Dump
Located -at 124 Mair, Street
Fire Departme►itsignature/date .-
e. t _
COMMENTS_
Located 384
on site yes no
Street
"7
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑Swimming
Tanning/MassageBody Art ❑
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
CONSERVATION Reviewed on 3)a6)i 'Rk- Signature'—/)U --&L
COMMENTS s ,� -
HEALTH
COMMENTS
Reviewed
0
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
al
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
_Total land area; sq. ft.:
.ELECTRICAL: Movement of Meter location, rhast 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 2010
Building Department
r- The following is'a list of the required.forms to beYilled out'for the. appropriate, permit to be obtained.
Roofivg, Siding, Interior Rehabilitation Permits
Q 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 casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apwal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subwted with the building application
Doc: Doc.Building permit Revised 2012
TOVN OF 1'�ORT:HH ANDOVER
OFFICE OF
13UMDING DEPARTMENT
.:1600 Usgood Street Building 20, -Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9$45
InspecforofBtiildings -Fax (978) 688-9542
HOMEOWNERUCENSE EXEMPTION
AM)WG PERMIT APPLICATION
Pleaseyrint .. "
DATE:
JOB LOCATION:
Number StreetAddress Map%Lot
HOMEOWNER lt•✓
Name, Home Phone
WorkBhone
PRESENT M MING ADDRESS %LJO
*y Tn Jn fwtw 0
lip Code
The current exemption for "homeowners"
was extended to include owner -occupied dwelings to i�vo units o� ?ess and
to allow such h_or). 1 �ners to engage an individual.for hire who does not possess a -license, provided that the owner
acts as supervisor). State 3ulding (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Persons) Who awns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
b6, a one or two family structures. A person who constructs more that one home in a t hick there
eis, o shall not e
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Co
Applicable codes, by -jaws, rules and regulations. de and other
The undersigned "homeowner" certifies that he/she understands the Town ofNozih AndoverBuiIdingDepartment
minimum inspection procedures and requirements and that he/she will comply with,said procedures and
requirements,
HOMEOWNERS SIGNATURE 4
APPROVAL OF BUMDING OFFICIAL
Revised 7.2009
Porm Homeowners Exemption
•BOARlb OFAPPEALS 688-9541
• COI\rSERIA7Ti0N688-950 HEALTH 688-9540
PLANNING 688-9535
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y The Commonwealth of Massachusetts , -
Depariment oflndustrial.4ccidents
Office oflnvestagations
600 Washington Street
Boston, .MA 02111
-www.mass govklia
Wgrkers' Compensation Insurance Affidavit: Buidders[Contractors/Electriclans/Pliunberr s
Applicant Information Please Print Leg-1bk
Name (Businessiorgadzation/individual):
Address:
City/State/Zip: A, AZI" tMe Lt Phone A ��� 2�3 3 -,-5 15:4
Are you an. employer? Check the appropriate box:
Type of project (required):
1. C( I am a employer with
4. ❑ I am a general contractor and I
6. New construction f
employees (fall and/or part-tim.e).
2. [] I am a sole proprietor or partner
have hire dthe sub -contractors
listed on the attached sheet.
7• Remodeling
ship and`tave no. employees
These sub -contractors have
8. [] Demolition
working for me, in any capacity.
workers' comp. insurance.
9, F] Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
1011 Electrical repairs or additions
ecm. h.]
3. I am. a homeowner doing all work
officers have exercised.their
right of exemption per MGL
11.[] Plumbingrepairs or additions
myself. [No workers' comp.
c. 152, §1(4), and we have no
12.❑ Roofrepairs
insurancere ed. a �
employees. [No workers'
13.❑ other
comp. insurance required.]
,Any applicant that checks box#1 must also fi11 outthe section below showingtheir Workers' compensatlonpolicy information.
i -Homeowners who submit this affidavit indicafingthey 2're doing allwork and then hire outside contractors must submit anew affidavit indicating such.
lContractors that checkthis box must attached as additional sheet showingthe name of the sub -contractors and their workers' comp. policy information.
I arca an employer that is providing workers'compensation insurance for my employees Below is the policy and'job site
information.
Insurance Company
Policy # or Self ins. Lic. #: Expiration Date:
lob 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DTA. for insurance coverage verification.
Ido bier eby term under the pains andpe aloes ofperjury that the information provided above is true and correct.
Si afore• Date:
Official use only..Do not write in Mis area, to be completed by city or tort 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 Instructions
Massachusetts General Laws chapter 152 requires all employe,
s to Provide workers' compensation fox their employees.
fo tbis statute, an efrcployee is defined as "...every person in the service of another under any contract of; hire, -
express or implied, oral or written."
An employee is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore
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 notmore than three apartments and who resides therein, or the occupant of Me
dwelling house of another who employs persons to do maintenance, comttuciion 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 ofpubiic work until acceptable evidence of compliance with the insurance
requirements of this chapter have beenpresentedta 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) nam.e(s), address(es) and phone numbers) along with their certif icate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than the
members ox partners, are notrequired 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 Iudustrial
Accidents fox 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 thepemrit 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 polky, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. I
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,
chatmust submit multiple pemut/license applications in any given an applicant
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
towb:)." 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, A new affidavit must b e filled out each
year. Where a homeowner or citizen is obtaining a license ox permit not related to any business or commercial venture
(i.e. a dog license or permit to burn 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 questlons,
please do not hesitate to give us a call.
The Department's address, telephone acrd fax number;
`theQx oaw-ealtttofMas ache Pats
Depat ment offadusftial Accident
Me oURVedtigavona
600asltigon Sl7ree
Boson, M A 02111
Tel, 0 617-727-4900 oxt 406 ox 1•-877:;11�S�S
AM
Revised 5-26-05 `ay, RM27 7749
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