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Home My WebLink AboutBuilding Permit # 2/9/2016 -1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:e2�41 � Date Received tO ..2-0, l r Date Issued: IMPORTANT:Applicant must complete all items on this age q � "4 " LOCATION ) A q,. RROPERTY OWNED h , Print o tri ' �n 7 00 Ysar; Id S cfure yes � MAP ICI: . µ �m. PARCEL. ZC7NING DISTRICT Hifstoric ,1 rict yes Nlachirie Shc p Village yds ri-. TYPE OF IMPROVEMENT PROPOSED USE -T-- Resi ential Non- Residential ❑ New Building - 17ne family _. ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units. El Commercial El Repair, replacement ElAssessory Bldg ❑ Others: ❑ Demolition ❑ Other CI Septic F1Well u Floodplain El Wetlands ❑ Watershed District a Water/Sewer, - DESCRIPTION OF WORK TO BE PERFORMED: o i,2 174 OWNER: Name: Identification PleaseType 61-jni Orly) Phone: <. _m Address: 0 r7 'ez) CONTRACTOR Name: Phone: Address: Supervisor's Construction License. Exp. Date: I=lome Improvement License: . . Exp Date: - . ARCHITECT/ENGINEER Phone: Address: _ Reg. No. c ase FEE SCHEDULE:BULDING PERMIT.,$12.00 PER,$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Oast. $�� ''�� "�� FEE: Check No.: Receipt No.: , NO'rE: Persons contracting with unregistered contractors do not have access to the guaranty fund g..i rra .. __ ._ .--. .. Sl nfiractor ueo Plans Submitted : P4 ans Jaived ❑ Certified Plot Plan ❑ Stamped Plans El Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OF'SEwERAGE DISPOSAT Public Sewer ❑ Svdun i.ng Pools ❑ Ta -,i,g/MassageBody AA ❑ .. well Tobacco Sales 0 Food Packaging/Sales ❑ Private(septic tanl�, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY TMENTAL SIGN OFF - U FORM. D TE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ i COMMENTS CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionfreceipt submitted yes •- Planning Board Decision: omments vation Decision: omments �, Water & Sewer Connect!on/s, nature Dat Drivewa Permit I)PW Town Engineer: Signature: \�\\ A Located 384 Osgood Street_ FERE:DtPARTMk--NT -Temp Dumpster on site yes no Located-at'124 Mair}`Street- Fire DepairtinefA!§ignatutb/date COMMENTS . ............ VtORT Town of Andover No. �_ � � _ ver, Mass, 0 U BOARD OF HEALTH Food/Kitchen PE �RMIT T LD Septic System . .1BUILDING INSPECTOR THIS CERTIFIES THAT ... .!;A.VN.10440%........VA .'LOFop .........4..................................... Foundation has permission to erect .......................... buildings on ........T..I.......... ................. Rough .... to be occupied as .............. ......... ....... JN..... ...aoter Chimney P rovided that the person accepting this permit shall in every 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC N ST T Rough Service ................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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. .............. .. ........ Enter construction cost for fee cal - North Andover"Fee Calculation l Construction Cost 5,000.00 m $ _ $ 60.00 Plumbing Fee $ 7.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 7.50 Total fees collected $ 175.00 i I i 81 Linden Ave 767-2017 on 2/9/17 112 bath in existing closet I ir 7 1 v LL" w _- - T 'r 5 s l 1 I { , I UP `lie b �91 ' E 9 Y f t f P t 1 �- The Commonwealth of Massachusetts Department offildustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-20-17 WWW.Mass.gov1dia worl,,ers,compensation insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FMEID WITH THE PERMITTING AUTHORITY. Please Print Legibly Applicant Information Name (Basiness/0rganizatiOD/Individual): Adch-ess: Phoile, _) "S City/State/Zip: Are you an employer?Check the appiopriate box: Type of project(Tequired): LF]I am.a employer-with , .-.-,employees(full and/or part-time).* 7.- U New consti action [J I am a sole proprietor or partnership and have no employees working for me in S. Jaemodeling 3.[/capacity.[No wo�kcrs'comp.insurance required.]an capad .9. El Demolition am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.0 1 am a homeowner and will be hiring contractors to conduct all work on my property. 1will ensure that all contractors either have workers'compensation insurance or are sole 11.F]Electri.cal repairs or additions proprietors with no employees. 0.Q Plumbing repairs or additions 5. 1 am a general contractor and I have hired the sub-contractors listed an the attached sheet. 13. hoof repairs Thes'e sub-contractors have employees and have workers'comp.Misurance'l 6.[:]We are a corporation'and its officers. have exercised their right ofoxemption porMCYL c. 14.0 Other 152,§1(4),and we havee yes.[No workers,comp.insurance required] 7 - , I *Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy inform"ation. ars who submif this aff indicating they are doing all workand then hire outside,contra I idavit , ctors must submit a new affidavit indicating such. Homeownp tConfractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-couiractnrs have employees,&y must provide their worke&comp.policy number. y o Iam an employer tliatisp�6vidiiigwoilceis'coml)ensatioiz insurance formy employees.' Below sthe poic and d jbsite information, Insurance Company Policy#or Self-ins,Lic. Expiration Date:_____ fob Site City/State/7,ip:_.__,_-.-- Attach a copy of the workers' compensation ompensation 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. d above is true and correct. I do her certify opider the pains aqdpenaltles ofpeijtny that the information prOVide i Date: atur _7do Si5j h( iatur - PhoneJ�. (\ -9- �V -9: Official use only. Do not write in this area,to he 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 Phone 4: Contact %%ORTM TOWN Or NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 120 Main Street North Andover,Massachusetts 01845 S 5 I Telephone(.978) 688-9545 Donald Belanger -- Fax (978)688-9542 Inspector of Buildings HOMEOWNE LICENSE EXEMP'T'ION Buildin Permit Application Please print 1 DATE; ,... JOB LOCATION: Number Street Address Map/Lot HOMEOWNER Name Horne Phone Work Phone pRESEN'r MAILING ADDRESS -_- w' i J, V, - City Town State Lip 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 far hire who does not passes a license, rp OVicied, that the owner acts as su ez_v_isor. 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 accessary 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 11 0.85,1.2) 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 miniinum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE .. APPROVAL OF BUILDING OFFI Revised 9/16 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535