HomeMy WebLinkAboutBuilding Permit #506 - 990 JOHNSON STREET 3/27/2009Permit NO:
Date Issued:
XOTOTTIM mol
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received 3 -
IMPORTANT: Applicant must complete all items on this pate
Print
rvr S
'.6 \• r0
OL
of
Resi .e I
Non- Residential
New Building
C2a2 famil i
Addition
f V Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yesCn0o
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Resi .e I
Non- Residential
New Building
C2a2 famil i
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Sep is Well
Floodplain Wetlands
Watershed District
'Vftrer/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: bid -^l ouSS►9-.i %�-' Phone:
Address: 6 �() -i-b/IVsa-•/ 5 '
CONTRACTOR Name: 4rgn/ ✓sS ..• � Phone: 2 93T^-57,? ` f
Address: 7�4) 0 .,V S 3 --,
Supervisor's Construction License: Ll6 Exp. Date: 12-
Home
2Home Improvement License: i � Exp. Date:
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $1 00 PER S.F.
Total Project Cost: $ `/DDD, FEE: $ '�
Check No.: I s a Receipt No.:
NOTE: Persons contracting2ddrwnregistered contractors do not have ac ess to the uaranty fund
Signature of Agent/Owner Signature of contractorK.
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 DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Sianature
COMMENTS
HEALTH
COMMENTS
r
Reviewed on Signature
ZQ�ning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
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
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)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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: Building Permit Revised 2008
Location 9 / y f tljo n S-
No. SoG Date
�oRTh
TOWN OF NORTH ANDOVER
0
W.
F w
9
Certificate.of Occupancy $
;�s'•n•E<�'
sAcNus
Building/Frame Permit Fee $ 1 a1._
t
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2856
1
V Building Inspector
Gerald A. Brown
Inspector of Buildings
tease p&t
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION: ��y `S 4,,r S Z�-j
Number Street Address
ST_
Telephone (978) 688-9545
Fax (978) 688-9542
HOMEOWNER U'* ` 7$/-9SS5—/
Name Home Phone Work Phone
PRESENT MAII.ING ADDRESS / fy Jo /L -✓j,) -J S
AA) C)yaz/ — )4% AO-- (!f) l 9 C
City Town State Zip Code
The current exemption for" homeowners" was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies
inspection procedures
HOMEOWNERS SIGNA
APPROVAL OF BUILDING OFFICIAL
Rid 10.2005
Form Homaownas Fx mptkm
ands the Town of North Andover Building Department
he/she will comply with said procedures and
TIOARD OF APPEALS 6RR0541 CC)\SERVATIp\ 6g9-9530 ITEAL'I'H 688-9540 PL —NINI\G 6R$-9535
5 The Commonwealth of Massachusetts,
Department of IndUstrial
14ccident
ii �.L' Office of Investigations
'
600 W
ashinoton Street
Boston , MA 02111
r ` wx�rs."Wss.gov/dia
Workers' Compensation Insurance .Affidavit: g-yders/Cont,actors/Electridians/Plumbers
Apniica.nt Information
Name (Business/Organizabon/Individual): l
Address: 1 [ 0�J .-"/
City/sia&zip:_N 19AO6 ✓� _
Are you an employer? Cheek the appropriate box:
1771 .
Phone #: % 78 "ZSr-- f 6 z S—
I .
—
1. I an. a employer with 4. ❑ I am a Qen, l co
employees (full and/or part-time).*
2. ❑ I am a sole pr mor or partner-
ship and ha�se no employees
woe - ng/for me in any capacity.
o workers' comp. insurance
reui
qred ]
I am a homeowner doing all work
Myself . [No workers' comp.
insurance required.] t
-u —Lor and I
have hired the sub -contractors
listed ori the attached sheet I
These sub -contractors have
workers' comp. insurance.
5.. ❑ We are a corporation and its
officers have exercised.their
right of exemption per MGL
c. 152, § l: (4); and we have no
employees. [No .workers'
comp. insurance re,- d
Type of project (required):
.6• ❑ New construction
7. ❑ RernodeIing
g• ❑ Demolition
9. ❑ Building addition
] 0:❑ Electrical repairs or additions
1 l .❑ Plumbing repairs or additions
11D Roof repairs
4u e ] 1.3.❑ Other
+ �o*Anmcowuerat ho subm .ibis a, de tt nuicatBIsO linu d ee; nanUt obelow s>Z wing their workcn' compensation poi:cy i formation.
Contractors that ebecf: this box mrict attached anadditional shxt howing he nine of t�:eus., _c, tractors and ti:eir work= nrw
co devil
I cv iniartnnt; .
ind:�ur.� scat.
ase an. ernploper feat is providing workers' compensation insurance for �' employees.
informadoa
insurance Company Name:
Policy # or Self -.ins. Lic. #:
Job Sit~ Address:
Below is the policy and job site
Expiration Date:
City/Stat~/Zip:
Attach a copy of the workers' compensation policy declaration page (showinb the poFicy number and expiration date).
.Failure to secure coverage as required under Section 25A of MGL c. 152
fincan lead to the imposition of criminal penalties of a
e 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 .S250.00 a day against the violator. Be advised that a copy of thi
investigations of the DIA for insurance coverage verification. s statement may be forwarded to the Office of
Official use onip. Do not write in this area, to be completed by city or town occur[
City or Town:
Issuing Authority (circle one):
Permit/License
I. Board of Health 2. Building Department 3. City/Tovvn
6. Other Clerk 4. Electrical Inspector S. Plumbing Inspector
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 ar implied, oral or written."
An employer is defined as `pan individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and inciudiTr.z the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house having not more than three ap artrnents 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 dweiling 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 a r local licensing agency shall withhold the issuance or
renewal of a license or permitto operate a business or to construct buildings in the commonwealth forany
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 uniil 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 compti-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) 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 afficlavit may submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Theaffidavitshould
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 rega -ding the Iain or if you are required to obtain a workers'
compensation policy, please call the Department at the nm--rnbe;r,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_afndak is complete and printed IeQibiy. The Departmenthas provided a space at the bottom
of the affidavit foryou to fill but in the event the Office of- Investigations has to contact you regarding the applicant.
Please be sure to fill in the pernitnicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in arty given year, need. only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Add-ress" 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. Whem a home owner or citizen is obtaining a Iicens� or permit not related to any business or commercial venture
(i.e. a dog license or permit to burnleaves 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 of Massachusetts
Department of I ridustrial Accidents.
Office of f avesfigat-isons
600 Washington Street
Boston, SLA X2111
Tel. # 617-727-4900 eo t 406 or 1 -977 -MASSA -FE
Revised 5-26=05
Fax # 617-7-7-7749
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