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Home My WebLink AboutBuilding Permit # 9/22/2015 1 BUILDING PERMIT � oar aq o TOWN OF NOR`I'I-I ANDOVER �$ APPLICATION FOR PLAN EXAMINATION s Permit Noi Date Received acH Date Issued: .... ORT7ANT:Applicant must complete all items on this page LOCATION_ r/r✓Gi,SS4.C�1+-iJ{t"�` �f' P nt PROPERTY OWNER„r4nC LL ,1 Jy ll elf Pnnt 100 Year Structure yes. MAP ARCEL: ZONING DISTRICT: _Historic District yes nno Machine Shop Village yes -no TYPE OF IMPROVEMENT_ _ PROPOSED USE _ Residential _ Non-Residential _ ❑New Building a One family u Addition u Two or more family n Industrial u Alteration Non of units: _ _.. a Commercial _ F1 Repair,replacement u Assessory Bldg u Others: Ll Demolition fl Other' _ u Septic a Well u Floodplain u Wetlands u Watershed District ❑Water/Sewer _ ... I DESCRIPT"nm OF WPRK gTO,'BE^p PERFORMED:,,/ Location IdenLific No.. o ?`. Date 604 111 OWNER: Name: Address' is TOWN OF NORTH ANDOVER Contractor Name: certificate Of occupancyEmail: Building/Frame Permit FeeAddress: Foundation Permit FeeSupervisor's Construction LicensOther Permit Fee $ Home Improvement License:_ TOTAL "� ! ARCHITECT/ENGINEERCheck p,4JJ Address: a iiding mspedor FEE SCHEDULE:aULDING PERMIT.$12-1 Total Project Cost:$ �� FEE:$_ Check No.: Receipt No.r,-;;)� _ NOTE: Persons contracdn tth :re contractors do not have access to the guarantyfund Signature of Agent/Owner�V ,.;R Signature of contractor eTOWN OF NORTH ANDOVER OFFICE,OF BUILDING DEPARTMENT 1600 Osgood Street Building 20,Suite 2035 North Andover,Massachusetts 01845 Gerald A.Brown Telephone(978)688-9545 InspectorofBaildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION please oriot DATE: �Ol JOBLOCATION. �5' iG��uu_��t, f/f fir. Number 'JStreet Add—, Map/Lot HOMEOWNER Nemo Hum,Plastic WmkPhone PRESENT MAILING ADDRESS City Town State Zip Cade The currentexemption 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,Prro,vided that the owner acts as sunervisoc DEFINITION OF HOMEOWNER Person(s)who owns a parcel upland or 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 struetmes accessory to such use and/or farm structures.A person who constructs more than one hone in a two-year period shall not be considered a homeowner.(780 CMR Section l IO,R5.12) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rales and rogulations. The undersigned"homeowner"certifies that he/she understands the Town of Noth Andover Building Department minimum inapec it.procedures and req rren en s and that h/1 e will comply with said proccdrm.s and q errs. IIOMEOWNERS SIGNA'1'URF. APPROVAL OF BUILDING OFFICIAL, Ro,&d 8 2015 Forth Homeowners Rxomptioa ROARO OF APPEALS 6889541 CONSERVATION 688-9530 IIGAL'I It 688-9540 PLANNING 688-9535 . _The Commonwealth of Massachusetts Department ofbedustrhtlAceidents I Congress Street,Suite 1007 Boston,MA 02ZIQ-2027 www.mass.gov/dia Workers Cmnpeusath"Ins..more Affidavit.Bwldere/ConCractme/rL)ecddciana/Plumbers. TO BR FILED WITH TILL PURNIfI TING AUTHORITY. AnnlieantinfermaHen PleaseMat Legibly Name�namess/orgaa;2.ation�aivianaq: /' ? Add,.,,:1 -.)�� UJq't�P City/State/Zipf7yc.-",, /G 1'"Mr'�t)a`CN'r°� a Phone#: Are yon an ernployerl Cho,kthe appropriate box: Typeof project(required): I.❑/am emPmyerwith employees(full avd/.r part-time).' 7.❑New construction z.❑Io:naanmpmpdemr orpmmemmp ane novena mnpmyees working mama hn 8.ORemodalmg arty capacity.[No workers'comp insurance u,u d.] 3 Ir ma homeowner dein Il workmsclf.No woA—'cam d. 9.❑Demolition .❑ ga y H. p.insurance pad.] 4❑I em a homeowner and will be hiring eenhnetors m c,M.a all work on my property.twill 10❑Building addition me mat Ot contrauora elms howworlmra'eompensarroninsv..oraresole 11.❑Fieckicolrepoirsoradditions pmprieromwithno employees. 12.❑Plumbing repairs or additions 5.❑Irma general contractor sudlhay.huedthe sub-c.Nrnctors11,d.ntheattachedsheet. 13.❑Roo£iepois These sub-c.nhacrors have employee andnave workers wrap.insurance,t 6.❑Weareacorporation and its officers have exercised Nevnght ofexempti.n per MGLa 14.❑ether 152,§i(4),end weheva no employees.[Noworkers'comp.insurancerequired] 'Any applicant that checks box#I must also fill out the sermon belowshowing�heirworkem'wmpeusationpolicyirS.rmation. t Homeowners wfio sunmitthis affidavitiMicatwg they are doingall work mrdthen hne.utside conhactbrs must submftanewa[Gdavit indicating such, ro,play[.m that check this box must attached an xddili.nal sheet showing tnpnameofa subligoacrors end smm whether or notth.se entities have employees.Ifthe sub-contractorsnayo employees,ltiey mus[prnvide thew workeis'comp.policy number. f ran an employer that a•pr iding ivorhers'conpensation insurance for my employees.Befew is the policy andjob rite infornwuom. Tucnrance Company N _ Policy#or Self-ins ic.#: Fxp3ration:Date:___ Job Site Addres Jr/%f� .1.(GLt'LUC f City/Stumaip: Attach a copy or the workers'eompepsation policy declare iou 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 Sue atop to$250.00 a day against the violator,A copy of this statement may be forwarded to the Office of Investigations fdo,DIA far insurance ,average verification. Ido hereby car j undee, to,rmdpa fides ofperjary that the inf mationprovded(above is true andeorrect. Sienanna ."Jtc/ V.', ,tDate--] v7 r7 / -/...d_. Phone# In�l1 t I Official use only.Do notwrite in this area,to be c pleted by city or loon official City or Town: Permit/License# btsuingAuthority(circle one): 1.Board of Health 2.Building Department 3.City/Town Chmlc 4.Blcetrica1Inspector 5.Phrmbingluspect- 6.Other Contact Person: Plar-4: Information and. Instructions Massachusetts Gammil f,w chapter 152 requires all employers to provide workers'oompwuatirnrfortheir emplyees. Pursuant to this statute,an employee is defined as`...every person in the service of another under any contract ofliire, express or implied,oral or written." An envoyer is deflaed as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives o£a deceased employer,or the or trustee of an individrml,pmtnership,association oe other legal entity,mploying employees.However the er cifa,dwelllaghouse baving not more than three apartments and who rosidos therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction orc pair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be au employer." MOL chapter 152,§25C(6)also states that"every state or Ideal licensing agency shall withhold the issuauce or wal of a license or permit to operate a business or to censure.buildings in the cdmmouwealth far any applicant who has not produced acceptable evidence of cornpliarau with the insurance coverage required." '.. Additionally,MGL chapter 152,§25C(7)states"Neither fire commomvealth—my ofits political subdivisions shall enter into any contract for the performance of niblic work rmtil acceptable evidence of compliance with the insurance requhtarman ofthia chapter have been presented to the contracting authority." Applicants Please fill at the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-eontraetor(s)name(s),address(es)and phone number(s)along with their certificate(s)of n c.Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the embe s or partners,are not required to carry workers'compensation insurance.I£an LLC or LLP does have employ'.a policy is required.Be advised that this offidavitmay be submits d to the D,infla rent of Industrial - Accidents fdi confirmation of fi suranoe 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 '.. lndusfialAccidents.Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Den aztment at the number listed below.Self-housed companies should enter their self-insurance license number on the appropriate line. City or Town Officials please be sure that the affidavit is complete add printed legibly.The Department has provided a spade at the bottom of the affidavit foryon to fill cut in the eventric Office of lnvestigations has to contact yen regarding the applicant. Plesse be sure to fill in the peroit/foense number which will be used as a reference member.In addition,an applicant that—at submit mrdtiple permit/license applications in any given year need only submit one affidavit indicating current policy information(if necessary)add..der"Job Sit.Address"tiro applicant should write"all locations in _(city or town)."A copy ofthe affidavit that has been officially stamped or marred by the city or town may be provided to the applicant as proofthat a valid affidavit is a file for future permits or licenses.A new affidavit must he filled out each year.Where a homeowner or citizen is obtaining a license or permit net related to any business or commercial venture (i.e.a dog license or permit to bon leaves es.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax—her- 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 8 617-727-7749 Revised 02-23-15 www.mass.gov/dia