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Home My WebLink AboutBuilding Permit # 2/3/2017 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: Z IMPORTANT:Aplicant must complete all items on this page LOCATION F PROPERTY OWNER Pant Y 0�Year�Id Sfruct[�re yes n`a MAP NO PARCEL ZONING DISTRICT Histor[c D�stnct yes no _ Machiri`e Shop Village Y�.S no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building M One family ❑Addition ❑ Two or more family ❑ Industrial )(Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition Other R.. Sok ❑ Septtc ❑Well 0 Flooclpfain El-Wet Iajnds ❑ .Watershed District. - I1 Water/Sewer CRIP ION OF WORK TO BE PERFORMED: r Identification Please Type or Print Clearly) OWNER: Name: ; Phone: j Address: � � '� c CONTRACTOR Name. Phone.; . Address: Supervisor's ons rue License Exp Date. Horne Improvement License. Exp 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 SX_ Total Project Cost- $ 0 ,;�� FEE: $ -a Check No.: Receipt No.:� NOTE: Persons contracting tivi h nregist ped contractors do not have access to the guaranty fund .. St nature.of A en Owner Jc ri Signa#ufe of canfiractor g.. --._ g _ _ . - Plans Submitted Plans 6ived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Piot Plan ❑ Stamped Plans ❑ TYPE-OF-SEWERAGE DISPOSAL Public Sewer Tanning/MassageMody Art ❑... Swirilning 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 TP r7 Si nature COMMENTSCaLl'21k- c oning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments 'mater & Sewer ConnectioniSignature& Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT" - Temp Dumpster on site yes no Located at 124 Mair Street Fire Departrnerit giginatui� Idate COMMENTS ................ ........... ......... ...................... ................ ...... r—mr-4 tkORTH d ' town of 0 . No. h - Ver, Mass, a 0 BOARD OF HEALTH FAF- Food/Kitchen off— E AN F= RM. IT I Lmftmwo"' Septic System THIS CERTIFIES THAT ..... ................................. ... .. ....... BUILDING INSPECTOR Foundation has permission to erect ............... buildings on .. ........ ........... Rough to be occupied as ..........;V.... .. . . . .... .. ................................................... Chimney provided that the person acceptilihis permit s ffalFilnevery respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTDR: UNLESS CONST TI Rough 0 Service Final BUILDING INS CTOR GAS INSPECTOR OccupancF Permit Required t® Occuuildin Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. • 'The Commonwealth of Massachusetts . Department of lndustrialAccidents 1 Congress Street, Suite 100 s Boston,MA 02114-.20.17 ��`. SQ'�gyK www mass.go�7dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH TIS PERNiIIIING AUTHORITY. Applicant Information /t Please Print Le0b NaMepiisiness/Orga-nization/fndividual} — Address: � �C3 City/State/Zip: �t� �/ � t` �Pho4 Cz- cic(q,VD- 2=:7ca Are you an employer?Check the ap}iopriate box: Type of project(required): 1.❑lama employer with employees(full and/or part-time).* 7,. ❑New construction 2,n I am a sola proprietor or partnership and have no employees working for me in $, [1 Remo delirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition I❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.W 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 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors hale employees and have workers'comp.insu€ance T , 6.0 We are a corporation and its officers have exercised their right of 1memption per MGL c. 1 �` Y t}l�l 152,§1(4),and we have no employees.[PTo workers'comp.insurance required.] -Any applicant that checks box##1 must also full out the section below showing their workers'compensation policy information. t homeowners who subrriif Ws 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-cbdractors have employees,hioy must provide their workers'comp.policy number. Iam an employer that ispMvidingivor/rers'compensation insurance for my employees.'Beloiv is thepolicy andjoh site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: /Job Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expirations date). 'lure to secure coverage as required under MGL a. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 anal/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violas r.A copy of �s statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verlficati I do hereby c if u d r't/ poi s and penalties of perjury that the information provided above is true and correct Signature: / - Date: C7 h37! Phone#: 1'r Official use only. Do not-write in this area,to be completed by city or torvn official, City or Town: Permit/License# Issuing Authority(circle ane): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 5.Other Contact Persons: Phone#: ............. ............ ............... 00 r,l i-�. !r- e ••{' Fri+. Y€ �Y,��!i.\-1%F F.{r.��;~, 7. @7, ----------- ------------------- .............. IF 13 .......... ------------------------------------................. --------------------