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Home My WebLink AboutBuilding Permit #338 - 0 PLEASANT STREET 10/31/2007 BUILDING PERMIT NORTh�o ,bgti TOWN OF NORTH ANDOVER 0 - - APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �9SSACHU Date Issued: 16 IMPORTANT Applicant must complete all items on this page LOCATION LIAKt i t, 1G Lam , Print PROPERTY OWNER Print MAP NO: PARCEL: 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 Industria Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer - DESCRIPTION OF WORK TO BE PREFORM: m -�� Identification Please Type or Print Clearly) (� D F or c7 OWNER: N A Name: /(9 n � �"I�- 1'�"� v�,2 M 5s Phone: Address: S'T S') s CONTRACTOR Name: Phone: 1-(o03-qN— W-97 t Address:_ j e9,6? Y, 04 dry Supervisor's Construction License: C's Exp. Date� X610 Home Improvement License: N/A Exp. Date: ARCHITECT/ENGINEER We�kOM 5y4y-hpS0J Phone: t -na - 777-ok\o Address:_ (� tvn"�,� ar:.)C- qco\xc�A MM&CW—�.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: $ FEE: $ N/^ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acceto he guaranty fund ignature of Agent/Owner Signature of contractor " i Building Department j 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 o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan { ❑ Workers Comp Affidavit o 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 , o 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) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products i 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer iJ//- Tanning/Massage/Body Art fS Swimming Pools Well tl/A Tobacco Sales N/. Food Packaging/Sales N/.rs 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 /w P;+,.&— . 0aa. L -4he. -� 'EJECTED DATE APPROVED % CONSERVATIONS COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpsteron site yes no Located at 124 Main Street' Fire Department signature/date COMMENTS Dimension Number of Stories: f-� Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: Nom„ ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No '-� DANGER ZONE LITERATURE: Yes Nom MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA- For department use �I i El Notified for pickup - Date Doc.Building Permit Revised 2007 Location `3� No. `33 69 Date �oRTM TOWN OF NORTH ANDOVER Certificate of Occupancy $ -_. 1SACNUS t� Building/Frame Permit Fee $ -1-1— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 20751 Building 0751Building Inspector ; The Commonwealth of Massachusetts Department of Industrial Accidents Office of In vestigations 600 Washington Street by Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Name(Business/Organization/Individual): Please Print LeQibty��—,v-vZ�t,s� J�v mar=: Address: Ja i pr; City/State/Zip: ,A ,- i Phone.#: bz) ++ Are you an employer?Check the appropriate boa: 1.❑ I am a employer with 4. ❑ I am a gen7exercisedtheir actor and I Type of project(required):. employees(full and/or part-time).* have hired contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on thd sheet. 7. ❑Remodeling ship and have no employees These sub- rs have working for me in any capacity. employees e workers' 8' E]Demolition [No workers'comp,insurance comp.insur9. ❑Building addition required.] 5.0 We are a con and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers haysed their myself. 11•❑plumbing repairs or additions y [No workers'comp, right of exemption per MGL insurance required.]t c. 152,§1(4),and we have no 12,C]Roof repairs employees.[No workers' 1 j: Other.= i t comp. insurance required.] (5k�� , cS(vi CA •Any applicant that checks box#1 must also fill out the section below showing their workers'cornpensa4on policy infomration. t Homeowners who submit this 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 subcontractors and state whether or not those entities have employees. If the subconbutors have employees,they must provide their workers'co mp.Policy number. 1 am an employer that rs providing workers I — insurance for my employees Below is the poli andjob site information. cy Insurance Company Name:_ 7`� Policy#or Self-ins.Lic.#: -� Expiration Date:_I;Z• sf , Q Job Site Address. 1P Y, S Attach a copy of the workers'compensation policy declaration page(showinri ttthepolic � g p y y number an 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-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. Be advised that a copy of this statement may be forwarded to the Office of ITPhone Memd :2,Mcp ers a verification. nalties ofperfury that the information provided above is true and correct Date• � — Offlcial useonly. Do not write in this area,to be Completed—FY city or town offlclaL 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#: Board of Buid{ng ReguinYions and Standards Construction Supervisor License L-ic#@m'. CS 96542 `_ 1/1972 1. tnF x,12010 Tr# 96542 t { i J f CHRISTOPHER c 4 TWIN STREET WINDHAM, NH 03087 Commissioner 4