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Home My WebLink AboutMiscellaneous - 98 BEVERLY STREET 4/30/2018 (3)TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: — "d IMPORTANT: Applicant must complete all items on this nage LOCA PROPERTY OWNER �. MAP NO: PARCEL: �5-JgL,L I Print -T11 IN 4-10 k -A) ZONING DISTRICT: =Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer ur,,�cKiPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR blame: Phone: Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Date: 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: $ D00 FEE: $ Check No.:2//Z Receipt No.:?2. NOTE: Persons contract' unregisteygd contractors do not have access to the guaranty fund Signature of Agent/Own - Signature of contractor Plans Submitted Plans . ived C rtified Plot Plan Stamped Plans Location /O ,4 'if— No. Date f " ,.. TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ • Other Permit Fee $ TOTAL $ Check # r LJi;J l B ding Inspector 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 Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 1 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comm 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 t1ORTH TOWN OF NORTH ANDOVER 6,11 '`Eo ^° �ti°oma OFFICE OF A BUILDING DEPARTMENT * 1600 Osgood Street Building 20, Suite 2-36 yq��AAre,.•^�5 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: l 0 / JOB LOCATION: IDT[ �1'Cll l Number Street Address HOMEOWNER c�'Uof�G S T_"Y Name Home Phone PRESENT MAILING ADDRESS Map/Lot q 7b 6 5E sz� Work Phone AADOVOL I�T 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) 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 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. 11_� The undersigned "homeowner" certifies that minimum inspection procedures and requ' requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption .ands the Town of North Andover Building Department he/she w�llpmply with said procedures and BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly C Name (Business/Organization/Individual): 0 )o Address: q` �6- it �I City/State/Zip:AD11a Phone #: Iq?s )6,5s -- Are you an employer? Check the appropriate box: L ❑ 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. ❑ 1 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. [No workers' comp. insurance required.] ;. I am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ 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.] Z Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also *311 out the section below show; -g their workers' compensation policy information. I 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 and their workers' comp. policy information. 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. #: Job Site Address: 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- risonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day ag ' t the vio or. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D for ins;ce coverage verification. I do hereby ce� unA5Xe pains and penal#s of perjury that the information provided abope iltrue and correct 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 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 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 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 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia C 0� p u w° cn o w w° U w o w n°' w 0 w a a°' cn w a p w H w go cis V) c c ;® o c : o ` C N O_ C r.+ O v C) •dam CL C W O m C p i Ea E--+ :=ts .tea z N ES O O O cm coCL C E m a�m O 0 3 z Cf)H . C M -,-II C/) ^� C13 C/ ) cO z L \1 y p O 7 �E� w U I co y m f/1 C CO) W C= m //-� � y O C r 1�1 v N O O Z ca _ o : o� 3 N $ ymo� m _ «. m co c o CO3 CL= . O `r m .y O C CD � Q cm h O. CD _ c h = OCLZN CV) C C O•— y Q '� C .CO2 O O E m m CD 0 CD CL T L O� O O Q 0 m O d a Ca o c O O v J .O .Q O CD C CD CL cj h C — CA rd� 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 MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NU I t5 anci UA I A - (i -or awartment use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 Im. 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: Doc.Building Permit Revised 2008 el Date. �/ .g%1�. ......... o? ` TOWN OF NORTH ANDOVE • PERMIT FOR GAS INSTAL ION • a [ �9SSACHUSEt This certifies that .. .�.Jy SZ, P `''............ ........... has permission for gas installation .. ./.t .................... in the buildings of . ivA '. .) ............................... . at .. . fi.. E��.< <�. (�. 7.......... , North Andover, Mass. Feeq.� ..... Lic. No.. 2.R �AS INSPECTOR Check # � 0 1 l v 5 6 i. 2 '"iTTt t1G MASSACHUSFTS UNIFORM APP TION OR PERMiT TO D0 GASr (Print or Sype) fr \ s. to '�=' Pe it # ✓ itding Location '� pwner's Name 4 New p Renovation L'"] Rep�acemen# Plans Submttted; YestJ' No N C N W N ]L C vi N N U C T �- y W O O V IDG C L _ < �+ iz . O � p r Nl�q`u �lU, U! t rn,r1-1?lLrW In W W J ,d,. _ W O ? W f+ V C W >I dWT.`1=i. st a C'J U.O I I C S D 4 SUB—Bs, #A 60.SEMENT iST FLOOR I I I 2ND FLOOR aRD FLOOR ATH FLOOR I I I I I 1 5TH FLOOR I I I I I I 6TH. LOOP 1 II I I ( I t I I 7TK FLOOR I 1 I 1 STH FLOOR Check one: .Certtftczte instaliing Company'Jame COQ � L�Corporaiion _ � �_� AddressS- �1 Z3. Partnership BusinessTeiephone �lSs1 "�� i aIAC�� D Name of Licensed Piumber or, Gas Fitters FfiabUfty OVERAGE: . tiabltty insurance' poiicy ar its sut�serfia equt:alent :Which meets the requirements of MGL Ch. 142. No cked v. es. picric indicate the type coverage by' checking the appropriate box. nce poiicy D Other type of indemnity O Bond D OWNER'S INSURANCE WAIVER: 1 am aware that theiicensee does not have the insurance coverage .• required by Chapter 142 of the Mass. General laws, and that my signature nn this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Gwner or Cwner s Agent I hereby certify that all of the details and intormation I have submitted for entered) in above appiicatron are true and axurate to the nest of my knowledge and that all plumbing work and rnstal=ons penormed under fie permitassuad for this applrt�iion will be in compliance with all pertinent provivons of the MassachusetL State Gas Code and Chapter 142 of toeGeneral lBvrs. 'j�:JPe oflu Sy mbenature of Licensed Ptumoer qr True Gasittter �� _ c��--) JMaster license Number L1ty(town L1.foumevman Apppp�ED (r L.t t. NL 1 V-0 fr T M m T p �N ttm f� n Ila {T Z 0 to tx �m N tN N V T n to Z