HomeMy WebLinkAboutBuilding Permit #458 - Lot Empire Drive 12/1/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:459- Date Received � pi�
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4
Date Issued: T
IMPORTANT: Applicant must complete all items on this page
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MAP NO: PARCEL#&Z ZONING DISTRICT.:ristrict yes ( pn
chine hop Village yes no'
TYPE OF IMPROVEMENT
1KNew Building
❑ Addition
❑ Alteration
❑ Repair, replacement
❑ Demolition
Floodplain q, Wetlands
N(5
DESCRIPTION OF WORK TO BE PERFORMED:
PROPOSED USE
Residential
❑ One family
❑ Two or more family
No. of units:
,WAssessory Bldg
SepYc;
J(Waten
OWNER: N
J ;as ')�/q'
Identification Please Type or Y
J
CONTRACTOR Name: sof i
C
Non- Residential
❑ Industrial
❑ Commen
❑ Others:
D Watershed.District _
OA1
on Or\ L
Address: M/40
Supervisor's Construction License:*J_a�_ Exp. Date:
Home Improvement License: 7 �� f Exp. Date:
ARCHITECT/ENGINEE' u.uy,- Phone: 3SV
Address:P24-0 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.:y Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund
`Si nature of A ent/Owner Signature ofcontractor ,
F_
Location
No. O 4 Date — zJ
NORTIy TOWN OF NORTH ANDOVER
o Certificate of Occupancy $
Building/Frame /Frame Permit Fee $
s uMU
9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I
23755 Building Inspector
Plans Submitted q• Plans Waived ❑ Certified Plot Plan % Stamped Plans 9
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
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
Reviewed on ' _1.1130 /t:) Sianature-�I'
Reviewed on Signature
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,
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
Doc:.Building Permit Revised 2008
r
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 Permii
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)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ 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)
o 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 Permi
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
Chat 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
Doe: Doe.Building Permit Revised 2008mi
Z The Commonwealth of Massachusetts
f Department of Industrial Accidents
1 " % `')% Office of Investigations
•1 !� 600 Washington Street
t Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information a Please PrinfLegibl_y_
Name (Business/Organization/Individual): 5V A%0 Q i LLA 6C Lti
Address: qq&P 1"1 0
City/State/Zip 6K . d tq2_1 Phone #: 76,�
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:W I ain a sole proprietor or partner-
listed on the attached sheet. t
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. ❑ 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.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. gNew construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
1 l.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then 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 acid their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:.
Job Site
Expiration Date:
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 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 fonn 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.
I do hereby certify under the pains and penalties ofpeijuty that the information provided above is true qnd correct.'
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town:
Permit/License #
11-76116-
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 aparhnents 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 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 numbers) 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 cant' 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 confinnation 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 pen -nits 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 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 questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
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