HomeMy WebLinkAboutBuilding Permit #826-16 - 95 LYONS WAY 1/21/20162!;-
Location A r P A —
No. hce Date /In2l
TOWN OF NORTH ANDOVER
Certificate of Occupancy $..
Building/Frame Permit Fee�'Y�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $�
Check #/� !
2.9,944 Building Inspector
IBUILDING PERMIT
AAW 4'O -WN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:
Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION � - Lc.( pY-�S [A)C---c.(
It
PROPERTY OWNED . L1r � G'i ` ?i , r1 ' iJC',
�a� Print — 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
NORT11
16
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
jzAIteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition❑
Other
_
❑Septic ❑�11Vell! i
r
`❑'Floodp ain ®Wetla.n s
❑ �WatershetlllD strict,
s
C[xWaterLSewerr
IY\
OWNER:
Address:
DESCRIPTION OF WORK TO BE PERFORMED:
- Please Type or Print Clearly
fie -L ,—A (', K (0 Phone:
Contractor Name: Phone:
Finail- _
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. D
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: $ d
Check No.: Receipt No.: C9
NOTE: Persons contr cting with unregistered contractors do not have access to the guaranty fund
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
4 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
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 .
OTE: 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
2012 I ECC Energy code
Engineering Affidavits for Engineered products
TOTE: 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
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning(Massage/Body Art ❑ Swiunining Pools ❑
well ❑
Private (septic tank, etc. ❑
Tobacco Sales
❑ I Food Packaging/Sales ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
,COMMENTS
HEALTH
COMMENTS
Reviewed On Signature.
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
t
Conservation Decision: Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
1 r%rnfor4 QQA
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
M
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA -- (For department use)
LI Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 20,000.00
m
$ -
$
240.00
Plumbing Fee
$
30.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
30.00
Total fees collected
$
400.00
95 Lyons Way
826-2016 on 1/21/2016
renovate bath and move laundry
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NORTH TOWN OF NORTH ANDOVER
OFFICE OF
~ BUILDING DEPARTMENT
a ; * 1600 Osgood Street, Building 20, Suite 2035
s,��RA;.; �•� North Andover, Massachusetts 01845
Gerald A. Brown
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Pleaserp int
DATE: — j -a01
JOB LOCATION:
HOMEO
Number Stfeet Address
Phone
PRESENT MAILING ADDRESS W5
Telephone (978) 688-9545
Fax (978)688-9542
Map/Lot.
Q
Work Phone
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,rop vided
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 I IO.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 understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS
APPROVAL OF BUILDING
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
I
Tdae Commonwealth of iVlassachusetts
Department of IndustrialAceldents
Z. `
y 1 Congress Street, Suite 100
`< Boston, MA 02114-2017
~ 9�t www.mass:gov/dia
sV4V
Workers, CoanpenTOBEFMED'4VITHTMP RMT 'NG.A.UTJ(OPJTY' iczans/PXuanbexs.
Workers,
NaMe (Business/Organization/individual)3
Addxess:
Di �iY
City/State/Zip: J�Qrk �oJ� IN�11r one #:
Are you an employer? Check tlie appropriate box:
1.❑ I am a employer with • : employees (full and/or pari -time).`
2. ❑ I am a sole proprietor or partnership and have no employees working forme in
any capacity. [No workers' comp. insurance required.]
3.❑ I am a homeowner doing all work myselt [No workers' comp. insurance required.] t
44;;tI am a homeowner and will be hiring contractors to conduct all work on my property. I will
elft,Ole
that all contractors either have workers' compensation insurance or are sole
5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors bade employees and have workers' comp. insurance.1
6. Q We are a corporation and ifs ofiigers have exercised their right of exemption per MGL c.
152, § 1(4), and we have nq employees. [No workers' comp. insurance required.]
Type of project (required):
7. [] New construction
8. kRemodelhiig
9. ❑ Demolition
10 Building addition
1l.❑ Electrical repairs or additions
13. [J Roof repairs
14. ❑ Other
Any applicant that checks box#1 must also fill outthe section below showing theirworkers'compensation policy information-
*Any
Homeowners who check and state whether or not those entities have
t ibis afCdavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such
?Contractors that check this box must attached an additional sheet showing the name of the sub contractors
employees. If the sub-con�racfors fiave employees, they must provide their workers' comp. policy number.
I am an erriployer treat is provg workers' compensation insurance for my employees ' Below is the policy and joie site
information.
Insurance Company
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.
c v lie: ehy certify under t%ie pains and penalties of per jury that the information provided above is true and correct.
Date:
Signature:
Official use only. Do not write in this area, to he completed by city of town official.
City or Towns:
Permit/License #
Issuing Authority (circle one): i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone
Massachusetts General Laws chapter 152 requires ag 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 Mike,
express or implied, oral or written."
An, employer is defined as "an individual, partnership, association, corporation or other legal entity, ox 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 constrict 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 ofthis chapter have been presented to the contracting authority."
Applicants
Please fill -out the workers' compensation affidavit completely, by checking theboxes that apply to your situation and, if
necessary, supply sub'con-tractoi(s) name(s), address(es) and -phone numbers) along with their certificates) of
--- - insurause.—Limited Liability-C-ompani:es-(L�-C)-on Limited3,iabxtity Farr-glups(L;LP) iitlti no emp oyees other an 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 Iirdustrial
Accidents for• confirmation of insurance coverage. Also be sure to sign and date the ailidavit. The affidavit•should
be returned to the city or town that the application for the permit or license is being requested, mot the Department of
Industrial Accidents. Should you have any questions regarding the law ox if you'are rcquired 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 perrnit/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 "rob 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 buin 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