HomeMy WebLinkAboutBuilding Permit #711-13 - 984 TURNPIKE STREET 4/26/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building 'One family [I Industrial
El Addition Ei Two or more family [I Commercial
-
�Iteration No. of units: D Repair, replacement D Assessory Bldg El Others:
[I Demolition D Other
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. DESCRIPTION OF WORK TO BE PERFORMED:
_Jdwfification Please Type or Print Clearly) -7� I- U6 -2Y(,Z
OWNER: Name:— �_J- I�Vep
.
Address
'-Rhone*
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,Addhr 'n 1
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70-
4 "E
ense
trMtioh,Uc*
uperviso - � - -1 1. 1, -
E
-e-
A ht License x Date
Home, mpro. ome
ARCHITECT/ENGINEER ..Phone:
Address: Reg. No. -
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000,00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F.
Total Project Cost: $-34- —00�01FEE: $
Check No.: I < Oy — Receipt No.:
NOTE: Persons contracting h unre * *red contractors do not have access to the gitarantyfund
--Sig..nature
ofAa6nt1bWh'Siq
nature of contractor
Pians ..
Submitted ted Plans Waived F1 Certified Plot Plan ❑ Stamped Plans
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
. DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
DATE APPROVED
El
CONSERVATION Reviewed on Signature
COMMENTS
HEALTFI
"Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comm
Conservation Decision: Comments
Water & Sevver Connection/SDriveway Permit
DPW Towle Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yeas
Located at '124 Main Street
Fire De
pairtmert signature/date
COMMENTS
Located 384
no
d Street
E
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service Top requires approval of
Electrical Inspector Yes No
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
In
Building Department
The fol owing 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
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
a Floor Plan Or Proposed Interior Work
o- Engineering Affidavits for Engineered products
MTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
o Certified Surveyed Plot Plan
❑ Workers Comp. Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o 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
COTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o 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
o Engineering Affidavits for Engineered products
gOTEo 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 app: al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
ynust be subm;tted with the building application
Doc: Doc.Building Permit Revised 2012
Location
No. ! t _ Dated�vo3
• . TOWN OF NORTH ANDOVER
o ff 'SU:iy��
.�-- Certificate of Occupancy $
t Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
ry rt, �p
TOTAL $
Check # t
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TOMW OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
•1600 Osgood Street Building 20, -Suite 236
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (979) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER -LICENSE EXEMPTION
IBM DING PERMIT APPLICATION
Please print
DATE: 2G 20 t 3
JOB LOCATION: Y T4&Pk
Number Street Address
#OMEOWNER
Name N - "
.. Home Phone
PRESENT MAILING ADDRESS_eTs�
k AtV4j'-f
Majxf . of •
Work Phone
U`�
Cit; To.,m etatP
Zip Code
The current exemption for `homeowners" was extended to ?iclude owner-occupi
to aI1ow such hoed dwellings to two units or less and
meoii�ers to engage an i,Idividual•forbue who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
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 family structures. A person who constructs more that one home in a two-yearperiod shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" cergi es that he/she understands the Town of Forth Andover Building Department
minimum inspection procedures and require a is andthat he/sh ll comply with,said procedures and
requirements,
HOMEOWNLRS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 9.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CO)\*SERVATION 685-9530
HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 0,VID �XjGY1'kJA&
Address:
City/State/Zip: 4fil u/ ` ✓1 C� �`� Phone #: -7 21` G^ Z q12—
Are
12
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. #
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
'required.]
officers have exercised their
3. Nd I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11. E] Plumbing repairs or additions
12. oof repairs
13. Other /-1+kP U/J
*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 aie doing all work and then hire outside contractors must submit a new 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 thepollcy 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 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 DIA for insurance coverage verification.
Ido hereby cert! u der the pains an ices of perjury that the information provided7�e is rue and correct.
3 Cirmofi.ra• f�LJ nAtP.' 4
Phone #:7 8 (— qCC — 2_L((9_
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 Instructions
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 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 Iocal 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 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 -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. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be 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 pennit/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. A new 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 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 ofMassachimetts
Department of Industrial Accidents
Office. QUAVestigations
600 Washington Street
Boston} MA. 02111
Tol, # 617-727-4900 ext 406 or 1-877rMASSAFB
Revised 5-26-05 Fax 4 617-727-7749
wwWanass.gov/dia