HomeMy WebLinkAboutMiscellaneous - 85 AUTRAN AVENUE 4/30/2018NO
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Location S' 4 V Te PrN VC
No. -75-1 - (')-Q 17
Check # #16
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Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 9 �•�"'
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
1-7
(% Building Inspector
Permit NO: ��'-
Date Issued:
PROPER�T�Y�
M4
t/ TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received d3l lol-ot T
IMPORTANT: Applicant must complete all items on this page
Yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
<rwo or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
�WSeptic;I cWell� #'
_ MIFloodpla n; �VVetlantls; ''
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_atershed�Di_stnct`�'
DESCRIPTION OF WORK TO BE PERFORMED:
OWNER: Name:
-'& ez�l
Type or Print Clearly)
Address: 0"-S. A/71.4,/ At—
.7
c •
CONTRACT®R' Name _..___/1.�_Qht✓ _ _.
Phone:
Phone:'
�d�ress• -
1,5'u perviso_r's,ConstrucfiontLicense:_�._w Exp; Dater.
I Horhe.Imarovemer tkLicense
r
ARCHITECT/ENGINEER m(c Phone:
Address: Reg. No.
FEE SCHEDULE., BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $ 25.00 PER S.F.
r
Total Project Cost: $ fr/ ODU FEE: $ 9
Check No.: /d Receipt No.: '7 %
NOTE: .Persons contractin with unregist ed retr
a
actors do not have access to the guaranty fund
Signature of Agent/Own _ pature-of contrctor : .
:.
Plans Submitted ❑ Plans Waive Certified Plot Plan ❑ Stamped Plans ❑
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Building Department
Tine 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
❑ 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
40TE: 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
dOTE: 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
must be- submAted with the building application
Doc: Doc.Bui?ding P-brmit Revised 2012
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE-OF-SEWERAGEDISROGAL
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 Signature
Reviewed
- Sianature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_..
c
Planning Board Decision: Comments
Conservation Decision:
Comm
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 Mair.,' Street
Fire Departmer'it 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 !Deter location, mast or service crop requires approval of
Electrical Inspector lies No
DANGER ZONE LITERATURE: Yes N
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
NUTES and DATA — (For department use
Q Notified for pickup - Date
Dor-Building Permit Revised 2010
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
8,000.00
m
$
96.00
Plumbing Fee
$
12.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
12.00
Total fees collected
$
220.00
85 Autran
751-2017 on 1/31/17
kitchen remodel
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The Commonwealth ofMassachusetts
f Department of lndustrialAccidents
X Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Naive (Business/Organization/Individual):
Address:
City/State/Zip: • ,/yI/�yll9 n Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/or part-time).*
2.n I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.1Z I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6. ❑ We are a corporation and its officers have exercised their right of'exemption per MGL c.
152, § 1(4), and we have no, employees. [No workers' comp, insurance required.]
Type of project (required):
7. ❑ New construction
8. OTRemodelirig
9. ❑ Demolition
10 [] Building addition
11. F1 Electrical repairs or additions
12. Plumbing repairs or additions
13.E] Roof repairs
14.0 Other
*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 are 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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy 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 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. -11
I do hereby
that the information provided above is true and correct
Date:
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 S. 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 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-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 affidavit may be submitted to the Department of Industrial
Accidents fbi 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'
compensatiod'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 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 burn 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
Donald Belanger
Inspector of Buildings
Please print
DATE: A/��
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
JOB LOCATION: 85� jTj V /'r7/C
Telephone (978) 688-9545
Fax (978) 688-9542
Number Street Address Map/Lot
HOMEOWNER 41V /*r_1'kj1,1j ?7�_ J &-
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
d18C/�
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, provided
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 110.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 SIGNATURE
APPROVAL OF BUILDING O]
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535