Residential Building Permit Application

TOWN OF NORTH ATTLEBOROUGH Office Hours:
BUILDING DEPARTMENT
43 So. Washington Street
Monday-Wednesday 8AM-4 PM
North Attleborough, MA 02760
Telephone: (508) 699-0110
Fax: (508) 699-0144
Thursday
Friday
8AM-6 PM
SAM-12 PM
Inspection Hours “Subject to Change”
Building
Monday - Friday
8AM 10:30 AM
E ectric
Monday - Friday
4PM 6 PM
PlumbinglGas Monday -Thursday 3 PM 6PM
Friday
8AM 10 AM
REQUIREMENTS WHEN APPLYING FOR A RESIDENTIAL BUILDING PERMIT APPLICATION
1. Completed building permit application form including departmental sign-offs (required when
Note: Plat, Lot and Street number can be obtained and verified from the Assessors Office
or we have a book at the counter where you can look up the information.
applicable):
ALL APPLICATIONS MUST SHOW S GNATURES by BOTH THE PROPERTY OWNER and CONTRACTOR IN THE PROPER BOXES
ON THE APPLICATION
2. Approved septic design when applicable
3. Approved test report on well when Town Water is not available
4. (2) Two sets of detailed plans are required (one to scale ¼”) and (oneS x 11.5), including
floor frame, building elevations, set backs and cross section of house, wall section detail
foundation plan, ceiling and roof framing, detailed interior plan, deck plan, smoke and carbon
monoxide detector locations *approved set of plans must be placed at job site at rough
inspection.
All New Sheet Metal installs require PLANS (Showing Intakes & Returns) AND MANUAL J
5. Energy Compliance Report 780 CMR Energy Code Report signed and dated ~.ener codes. ov
Windows need U Factor/Doors need R Rating Values
—
—
6. Site Plan must be prepared and stamped by a registered engineer or land surveyor
Note: lot Grading, top of foundation elevation, assumed water table, location of proposed water
and sewer line and all minimum zoning requirements per intensity Schedule A REQUIRED on site
plan
7. Beam calculations prepared and wet stamped by a registered professional engineer are
required for all engineered buildings materials including LVL’s, steel beams, and engineered
roof & floor trusses. (when applicable) Please be sure that they coordinate with plans
submitted. *Note: if stamp is on individual pages, you do not need a beam schedule.
8. Construction Supervisors License and/or Home Improvement Contractors Registration (HIC)
(H.l.C not required for construction of new dwelling)
Certificate of Insurance (indicating workers compensation when applicable)
& Workers’ Compensation Insurance Affidavit
9. Homeowners building their own homes must sign a Homeowners Waiver Form to assume
responsibility for Mass. State Building Code, 78OCMR Compliance. Submit a Workers’ Compensation
Insurance Affidavit for themselves and all subcontractors working on site.
10. Permit Fee is paid by check only payable to the Town of North Attleboro.
WE DO NOT ACCEPT, DEBIT OR CREDIT CARDS AT THIS TIME
ii.
I would like to suggest that arrangements are made to have Temporary Sanitary facilities
on the premises during the construction unless you have facilities close by.
Rev 08 18-16
Residential Building Permit Fee Schedule
MT~t~ ~ jir~71 ~ [1
www.statama.uØbrs
Effective July 1, 2012
Later of Detenninaffon $100.00
-
One & Two Family ONLY- (certificate of occupancy included)
RESIDENTIAL (conventionally built modular & mobile homes, or re-location)
.40 sq.ft. of living area (habitable space)
—
Addition, Decks ikamps, Garages .40/ sq.ft (Mm. $100.00
-
AlterationsfRenoyadon .40/sqst. (Mm. $100.00)
-
J~ilation $50.00
-
W~dow AndA)r Door Renlacement ONLY $50.00
-
Roof ONLY- $100.00
Sidewall ONLY- $100.00
Acce~orv Structures (shed, cabanas, gazebos, barn)
40 sq. ft. (Mm. $40.00)
-
PooL LG. $75.00
Pool, AG. $50.00
-
-
av.A.c.
Complete New System $10.00 per ton (Mm. $50.00)
Condenser Replacement ONLY $5.00 per ton (Mm. $25.00)
-
-
Masonry ChiinneyiSolid Fuel Burning Anuhance $50.00
-
Fence (above 6’) & Retaining WaHs $50.00
-
Tents $30.00 (per tent)
-
Demolith $50.00
-
Trench 25.00
-
Relocate Single Family Dwellina $250.00
-
Trailer (temp. mobile home) -$100.00
Cony of Building Permit (lost) -$5.00
Name Traider (permit holder) $50.00
-
Sheet Metal $25.00
-
Solar Panel Is) $10.00 per panel (max. $100.00)
-
RE-INSPECI’ION FEE (failed and/or additional Inspections) $25.00
-
Starting Work Without A Permit Will Be Subiect To A Si 00.00— FINE
N te. If you indicate multiple projects on description of work area, you will be charged based on
ea h eparate project from the above fee schedule. Example: Roof. Sidewall and Window
Replacement $250.00 permit fee
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS (APPENDIX 1202)
The Commonwealth of Massachusetts
State Board of Building Regulations and
FOR MUNICIPALITY USE
Standards
(revised 01/20/2015)
Massachusetts State Building Code 780 CMR W” edition
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
This Section For Official Use Only
Building Permit Number
Date Applied:
Signature:
Building Commissioner! Inspector of Buildings
Date
SECTION 1 -SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map & Parcel Numbers
1.la Is this an accepted city/town street: yes_ no
Map Number
1.3 Zoning Infonnation:
1.4 Property Dimensions:
Zoning District
Lot Area (sfl
Proposed Use
Parcel Number
Frontage (ft)
Building Setbacks (It)
Front Yard
Required
Side Yards
Provided
Required
I.? Water Supply (M.G.L c. 40. 6 5-4
Public C
Private C
Rear Yard
Provided
Provided
Required
1.5 Flood Zone Information:
Zone:
Outside Flood Zone C
1.8 Sewage: Disposal System:
Municipal C
On site disposal system I]
—
SECTION 2: PROPERTY OWNERSHIP! AUTHORIZED AGENT
2.1 Owner of Reeord:
Name (Print)
Address for Service: Street
Signature
Telephone
2.1 (a) Is this a new or existing owner occupied one or two family? Yes C No 0
City/Town
State
Zip Code
2.1(b) Number of Units
2.2 AuthorIzed Agent
City/Town
Name (Print)
Authorized Agent: Street
Signature
Telephone No. for Authorized Agent
State
Zip Code
SECTION 3: CONSTRUCFION SERVICES
3.1 Licensed Construction Supervisor
Licensed Construction Supervisor
Address
License Number
City/Town
Signature
3.2 Registered Home Improvement Contractor
State Zip Code
Expiration Date
Telephone
Company Name
Address
Signature
Registration Number
City/Town
Telephone
State Zip Code
Expiration Date
Restriction Code
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS (APPENDIX 120.P)
SECTION 4-WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L c. 152.8 25C (6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance ofthe building permit.
Signed Affidavit Attached
Yes
No
U
SECTIONS- DESCRIPTION OF PROPOSED WORK (check all appilcable)
New Construction I] Existing Building C
Accessory Bldg. Cl Demolition
C
Brief Description of Proposed Work:
Repairs(s)
Cl
~4istoric Preservation
I
Alteration(s)
I Addition
oI
Other C Specifr
Cl
TOTAL ALL FLOORS (Sq. Ft.)
(including garage, finished basement/attics, decks or porch)
GROSS LIVING AREA (Sq. Ft.)_____________ HABITABLE ROOM COUNT______________
NUMBER OF FIREPLACE
NUMBER OF BEDROOMS
NUMBER OF BATHROOMS______________ NUMBER OF HALF/BAThS_______________
NUMBER OF DECKS! PORCHES___________ ENCLOSED
OPEN
HEATING/COOLING__________________ TYPE
SECTION 6- ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs (Dollars) to
include both labor and materials.
I. Building
$
2. Electrical
$
3.Gas
$
4. Plumbing
$
5. Mechanical (HVAC, Fireplace, S
stoves, chimney, power vent)
6. Mechanical (Fire Suppression
$
Note: Fees are non-refundable
1.
2.
3.
4.
5.
Ofiiciai Use Only
( N/l means not included)
Building Permit Fee: S
Electrical Permit Fee : $
GasPermitFee:$
Plumbing Permit Fee: $
Mechanical Permit Fee: $
TOTAL ALL FEES: S
7. TOTAL PROJECT COST:
$
Check Number:
Section 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
authorize
matters relative to work authorized by th s building permit application.
Signature ofOwner
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I
Cash:
as Owner of the subject property hereby
to act on my behalf, in all
Date
1,
as Owner/Authorized Agent hereby declare that
the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
be alf.
Print Name
Signature of Owner / Agent
(Signed under the pains and penalties ofperjury)
Date
Owners please read before signing: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HA YE
ACCESS TO THEARBITRATIONPROGRAMOR GUARANTY FUND UNDER MGL a 142A.
TOWN OF NORTH ATTLEBOROUGH
BUILDING DEPARTMENT
REQUIRED SIGN-OFF
PRIOR TO ISSUING OF BUILDING PERMIT
Property Address:
PlatlMap:
_____
________
Lot:
Permit:
Signature
Date
Board of Selectmen:
(Common Victualler’s License, Class I and Class II)
Assessors Dept:
(verity address: new dwellings or commercial buildings)
Planning Board:
Conservation Commission:
Site Visit Required Prior To Construction Q
Permit Required Prior To Construction Q
Permit Issued D
Zoning Board of Appeals:
Board of Health:
Historical Commission: ______________________________________
(For Structures 80 Years And Older)
Department of Public Works (49 Whiting St)
(Telephone# 508.695-9621):
Water Permit
# 508-695.7790
Sewer Permit
#508-695-7790
Highwayicurb cut
North Attleboro Fire Department( 50 Elm St.):
Telephone #508-699-0140 Residential I #506-699-0141 Commercial
Tax Collector:
A final review of the departments listed above has been completed and a building permit can now be issued:
Building Inspector
Date
Rev. 3114
43 South Washington Street North Attleborough, MA 02760 Phone (508) 699-0110 FAX (508) 699-0144
TOWN OF NORTh ATfl.EBOROUGH
BUILDING DEPARTMENT
43
S.W-~ig1un St.
North Attlebacugh, MA 02760
508-699~O11O
SPECTION POUCY
i
The I%aty site ~ be marked with the Street Number.
2. PerS card — be Posted & Available for Signatun.
3. ALL PFRMrT’S (Building, Electncal, Sheet Meal, Thuch, Plumbing, & Gas) MUST be p..shd In
the dwelling for ALL Inspections (Typically In Pruut Window). A copy of the stamped plans Is
required to be an the ps’up’aty from rough Inspection lh~nö fiik
4. The following Information needs to be given whoa requesting an lidper4ion: (
applicaffi applying for the p ...lL).
a. IL.~J~Ntunbu
b. Address ofPrepay
C.
Owner ofPrepay
b QNfl by the
d. Typeofinqedion
e. ContractWe name & 1,li~—s #
5. Re-Inspection for Failed and/or Additional inspections will be a $25.00 fee
6. The fr&w~.m,≠n~n me required:
a.
prior’ to installation of any stone, engineered fill or form work
F
and
don. all wall ties moved mid holes filled with hydraulic cana (Not
Plastic Roofing Cans), oundations shall be waterproofed torn top offooting to findi ~ada
a Pie Foot~ for decks, additions, sheds etc. shall require open bole Inspection (prior to
a
‘Sheds over 400 eqS.
d. Piraplact all flrqlaccs require throat and smoke thamba’ inwethoa request inspection at
a~ting ofS flue tile. (Masonç plan accerdb~y).
a Rough Elecfrie (Must be called in by Elaicima unless homeowner is doing the work)
N~ Please be sure that all other electrical pa. ..Jla have been Inspected (
and low volta_ge)
£ Rough Plun*lnWGas (Must be called in by Plumber)
g. Rough Mechanical & Sheet Metal (will be done the ~an thu. as the rough frame (plan
Ii. Rough ha_mr
*p~a~ ~ ~ ~fld~i~g Inspecd~ Rough Sectik Plumbing and Gas must be Signed Off
o Weather Tight (Exterior siding 100% ~‘nqiletej Windows, Doors dc).
o All isdes sail penentions a the
envelope mint be fr..2.ed
or fire ~tu1ped @ top
& ba~1. plates w/a fire rated materiaL
o Guard ralla/bandrails (w en applicable) Riser (whoa applicable) Attic pull.down (insulated &
pufldiainonlijd)
o Mi hoihuntal holes stud to stud on aic.or walls only. Shall be framed as per 2009 IECC.
-
Over>
inspection Policy Cant
I. insulation
• All rafter v~’ting baffles stapled in place.
o Insulate behind electrical boxes.
j.
Final Electric, Plumbing & Gas prior to Building FInal
t Final Mechanical & Sheet Metal (will be done at the same time as the final building-should
be up and running-plan accordingly)
I. Final Fire Department inspection: Coordinated through (NAFD) (508) 699-0140.
Smoke Detectots, Carbon Monoxide Al~ni and 011 Burners Inspection are a Separate Fee paid
to the NAFD. (Including Additions atid Basement Remodels)
m. Final Board of Health when applicable
n. Final Building: Required IWor to inspectiorn
I) FInalAs-Built (Residential & Commercial)
2) FInal Constng(jon Control Docwrgentfrom AwJdtect on record. (Commercial)
3) Certificate ofInsulation @~ electrical box. (Residential)
4) Needs manualsfor appliances (Heatbxg Hot Water & Air Handler). (Residential)
Na When requesting a Certificate of Occupancy, bring the original Building card with all the sign-off
signatures and your Certificate ofCornpliance (septic only) receipt from the Board ofHealth with you to
the Building Department We will call you when it is ready to be picked q.
Certificate of Occupancy fee must be paid (if applicable) $100.00
***~bafl Building Inspection
-
M~4lIlII[~OLY
for AU ~)pjfrfrj***
Anal As-Bath Is required prior to final Inspection & Certificate of Occupancy
for New Dwellings & Commercial BtJdlngs being Issued.
As-Bulk MUST Include the following (at 40’ =1 “Scale)
• Address
o Mcurate fbotpdnt of all structures including decks (set-backs of all structures)
o Elevation ofT.O.F. (top offoundation)
o All underground utilities (water, sewer; electric telephone cable, eta); if overhead, note on plan
overhead electric
All easemafts and rights ofways
• Any adnning walls over 4’ in height of unbalanced fill.
o Driveway
o Septic system and well location
o Wetlands
°
Topography on Finished Cite To Show Run Off
o
Rovfocd 2113
0°
.0
~
,:
1.1,111
TOWN OF NORTh ATTLEBOROUGH
BUILDING DEPARTMENT
43 So. Wasldngton Street
North Attleborough, MA 02760
Phone: 608:699-0110
Fax: 508-699-0144
SISAL
C
t#______
780 CMR gth Edition., Subsection 105.3.12, Other Requirements, 5. Debris
Removal. Signature of the permit applicant date and number ofthe building
ermit to be issued shallbemdicatedonaformprovidedbythebuilding
department, and attached to the office copy ofthe building permit retained by the
building department. Ifthe debris will not be disposed of as indicated, the holder
of the permit shall notiI~ the building official, in writing, as to the Location what
the debris will be disposed; also refer to DEP Regulations 310 CMR 7.09(2) and
310 CMR 7.15, when applicable.
The debris will be disposed of~
Name of Waste Facility:____
Address of Facility:______
Signature ofPermit Applicant:
Rev. Apr2011
TOWN OF NORTh ATrLEBOROUGH
BUILDING DEPARTMENT
AiTIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c.142A requires that the “reconstruction, alteration, renovation, repair, modernization, conversion.
improvement, removal, demolition or construction of an addition to any Dre-exlstlflu owner occupied
building containing at least one but not more than four dwellinu units... .or to structures which are
adjacent to such residence or building” be done by registered contractors, with certain exceptions, along
with the other requirements.
Type of Work:
Address of Work:
Owner Name:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
—
—
—
—
—
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULUNG THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONThAC~ORS FOR
APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBiTRATION
PROGRAM OF GUARANTY FUND UNDER MGL c.l42A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner
Date
Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date
wwwmass.gov/dia
U
Department ofIndustrialAccidents
Workers’ Compensation Insurance Affidavit Builders/Contractors/ElectricIans/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Please Print IaIbIv
Applicant Infonnatlon
Name (Business/Organizadon/Individual)
_________________________________________________________
Address:
City/State/Zip:
Phone #:
_______________________
Are you an employer? Check the appropriate box:
Type of project (requIred):
i.Q I am a employer with
7. 1] New construction
8. []Remodeling
employees (MI and/or pazt4ime).’
2Q1 am a sole proprietor or partiership and have no employees working for me in
any capacity. INO workers’ camp. insinuate required.]
I am a homeowner doing all work myself. ThIo woilcers’ ~
9.
Demoliflon
IOQ Building addition
1I.Q Electrical repairs or additions
12.0 Plumbing repairs or additions
13
Roof re irs
Pa
14. QOtlier________________
~
4.Q lain a homeowner and will be hiring contractors to conduct all work on my properly.
I will
ensure that all contractors either have workers’ compensation insurance or nit sole
proprietors with nO employees.
5.0 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.Q We ale a corporation and its officers have exercised their right of exemption per MOL. c.
152. § 1(4). and we have no employees. [No workers’ comp. insurance required.)
My applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
who submit this affidavit indicating they are doing nil work and then hire outside contractors must submit a new affidavit indicating such.
Contnctors that check this box must attached an additional sheet showing the name of the sub-contractors and state ntether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers’ comp. policy number.
~
lam an employer that is providing workers’ compensation Insurancefor n~ employees. Below ft the policy andjob site
Information.
Insurance Company Name:
Policy # or Self-ins. Lic. II:
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.
I do hereby certify under the pains andpenalties ofperjury that the information provided above ft true and correct
Signature:
Date:
Phone #:
Official use on(p. Do not write In this area, to be completed by city or town official
City or Town:
Permit/LIcense
Issuing Authority (circle one):
I. Board of Health 2. BuIlding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
_________________________________
#_______________________________
____________________________
Contact Person:_________________________________________ Phone
#:_________________________________
Inform lion 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
ofthe foregoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer, or the
receiver or trustee ofan 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 ofthe
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 I 52, §25C(6) also states that “every state or local licensing agency shall withhold the Issuance or
renewal of a lIcense or pennit 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 perfonnance 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 pemiit/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 firture 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 thx number
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-7274900 ext 7406 or 1-877-MASSAFE
Fax fi 617-727-7749
Revised 02-23-IS
www.mass.govldia
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