HomeMy WebLinkAboutBuilding Permit #439-11 - 1004 SALEM STREET 11/22/2010 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ' Date Received
Date Issued: 'Z Z ^�
IMPORTANT:Applicant must complete all items on this page
LOCATION /00 � T� a
Print .•� ��
PROPERTY OWNERQA-C_ac.E,u
Print _
MAP NO:/O ,A PARCELQa 3/ ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ZOne family
❑Addition ❑Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
® Sep ic4 0 Well# ®Floodpla ® Wetlands Waters edDstrt ``
.t
DESCRIPTION OF WORK TO BE PERFORMED:
G MC) �oA44/F- f /?aoF f CCE /,` i0 - 1asFal( AIEw paUl-' � //l Ccr
Aro Luy �,- ke 44L sk.-e_ as &4±6*e_
SPA-; �� 2� v1�c�JE-ck1 � } .I-n G��v,rr� >. �'% Sv. w�`'N� i ,.�
Identificati6n Please Type or Print Clearly)
OWNER: Name: Pho
Address:
CONTRACTOR Name: t e Phone:
Address: iko 7 l _ _.l l — /
Supervisor's Construction License: __)Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER N-A A Y 4 �a Nth Phone: Gb'
Address: RAI r� s+ w �b- U 16r6 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: $ � . 'goFEE: $ �
Check No.: Receipt No.:_-a �
NOTE: Persons co tract* with unregistered contractors do not have access to the guaranty fund
Signa F-7-of�Agent/O Signature ofcontractor
Building Department
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
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ 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
❑ 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)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
fat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
lust be submitted with the building application
Doc: Doc.Building permit Revised 2008mi
Plans S ❑
ubmitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming 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 ❑ ❑ I �� I
COMMENTS
CONSERVATION Reviewed on III 6j 1-0Si nature
COMMENTS
HEALTH Reviewed on Si nature/
/'/',
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wates' & Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories:_Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
o re
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
U Notified for pickup - Date
L
Doc:.Building Permit Revised 2008
Location��allG �S
No. Date Z z`d
Of NORTH TOWN OF NORTH ANDOVER
9
°> Certificate of Occupancy $
.�::.. —
;�s
Must Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2371
Building Inspector
ORTH
0over�:
...... . .....
}(0
C, - -o dover, Mass.,
T Q = LAKE
COCHICKEWICK
7�ADf?ATED
BOARD OF HEALTH
Food/Kitchen
PERM IT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.......�i ........ .. ... .K..!'!-..1....f?..Q..:rl. _z z.................:.
................................................ Foundation
has permission to erect........................................ buildings on t.Q.04........sa. . ....... .....:......................... Rough
to be occupied as....1'��WI��!!'.4- (�--�.a.. lZe-- �'u!'!'t ,�........1 .. ' �Od.✓L.....t#�............... Chimney
........... ..... ................ .... ... .
provided that the person accepting this perm' hall in every respect conform to the terms of the application on file in Final
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
SSD PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUC S ELECTRICAL INSPECTOR
Rough
........................................... Service
. . ..... .... .... .
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA. 02111
�„ sy www.mass.gov/dia
'workers' Compensation Insurance Affidavit: Builders/Contractors/FIeclricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): C Ap m to t',A , E/((,Q 1`C�Z_ L,) /�f Z-
Address: loo SA 6E M �� '
City/State/Zip: 6 LJ,Q �• Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.I 7<Remodeling .
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. g, ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
' officers have exercised their 10.❑Electrical repairs or additions
required.] o
1 I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing.repairs or additions
myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs
insurance �ired.re q uemployees.[No workers'
13.❑Other
comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
I 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 sub-contractors and their workers'comp.policy information.
X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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 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
Investigations of the DIA for insurance coverage verification.
X do hereby certi e pains andpena ies ofperjury that the information provided above is true and correct.
Si afore:
`� Z. Date: ill7 // /C)
Phone# �r
Official use only. Do not write in this area,to be 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
Contact Person: Phone#:
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HARRY ALLAN
RESVENCE 64 MAIN STREET WESTFORD, MA 0186ro
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1004 STREET - • 508-183-1111 • - S
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HARRY ALLAN
RESIDENCE 64 MAIN STREET WESTFORD, MA 01886
1004 SALEM STREET PHONE: 508-183-1111 FAX: 918-496-1526
110. ANDOYER,1"IA email- harryallangcomcast.net
PAGE *:
ALL MEASUREMENT TO BE CHECKED ON SITE DRAWN BY: HARRY EXISTING
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE,
- SCALE: 1/5 = 1 FT.
DETAILED INFORMATION.
DATE. November 05, 2010 BAS 1"1 1�1T FLAN
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RESIDENCE HARRY ALLAN
64 MAIN STREET WESTFORD, MA 01886
�OO4 % ALEM STREET PHONE: 508-183-1111 FAX: 918-49ro-1526
email- harryallanwcomcast.net
NO, ANDOVER,MA
PAGE
ALL MEASUREMENT TO BE CHECKED ON SITE DRAWN 1': HARRY ATTIC LEVEL
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE SCALE: 1/4 = 1'FT_ A-3
DETAILED INFORMATION_ DATE: November 1-7, 2010 UNF I N I SHED
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HARRY ALLAN
RESIDENCE 64 MAIN STREET WESTFORD, MA 01886
1004 SALEM STREET PHONE: 506-183-1111 FAX: 918-496-1526
Nemail- harryallanwcomcast.net
O. ANDOVERMA
PAGE
ALL MEASUREMENT TO BE CHECKED ON SITE AWN Y: HARRY NEW CEILING
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE
DETAILED INFORMATION. SCALE: 1/8 = 1 FT. RAM INCA PIAN
DATE: November 05, 2010
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RESIDENCE 64 MAIN STREET WESTFORD, MA 01886
1004 SALEM STREET PHONE: 508-183-1111 FAX: 9*18-496-1526
email- harryaIlanecomcast.net
NO. ANDOYER,MA
PAGE *:
ALL MEASUREMENT TO BE CHECKED ON SITE AWN 1': HARRY NEW ATTIC CEILING/
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE E:
DETAILED INFORMATION. SCALE: O/O = 1 FT. COLLAR TIES
DATE: November 05, 2010
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RESIDENCE
64 MAIN STREET WESTFORD, MA 01886
1004 SALEM STREET PHONE: 508-183-1111 FAX: 9-18-496-1526
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email- harryallanscomcast.net
NO. ANDOYER,MA
PAGE
ALL MEASUREMENT TO BE CHECKED ON SITEVSCALE:
Y: HARRY
- CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE
DETAILED INFORMATION. O/O = VFT. ROOD FRAMING PLAN
DATE: November 05, 2010
RIDGE VENT
EXISTING CHIMENY J THIS AREA 2ND LEVEL
TO BE EXTENDED 5
ABOVE RIDG TO CODE1211 0 ALL NEW
TYPICAL ROOF 12 If ,
ASHPHALT SHINGLES O
OVER 15" FELT PAPER
MIN, 3 FT. ICE/WATER R- 38 BATT INSULATION
ON EDGE,VALL*8,,GHEE<S
RAFTERS Iro" O.G.
x (-_tz1L1Na JV15T5 16 O.C. ON ALL NEW
TYPICAL SECOND FLOOR EXTERIOR WALLS
HURRCANE STRAP PER _ FINISH FLOOR ON TYPICAL 2x6 SIDING EXTERIOR WALL:
CONNECTION SIMPSON TYP.H.2 7 5/8" T4G PLYWOOD SUBFLOOR �� SIDING
RAFTER AND CEILING JOIST �� EWER 4 GLUED l/16" PLYWOOD SHEATHING
NAIL WITH 8-16d N LS -ZScI�FLOOR JOISTS o 16" o.c, w/ 2x6 STUDS s 16" c.c.
2x2 CROSS BRIDGING R20 BATT INSULATION
5/8" CEILING BOARD 6 mil POLY V.B.
TAPED 4 SANDED 1/2" DRYWALL
TAPED 4 SANDED
1 A kAJOISTS 16" o.c.
p MAIN SCOPE OF WORK IS
r_ OUTLINED. ADDITIONAL WORK
EXISTING EXTERIOR WALL REPLACE SIDING ON COMPLETE HOUSE.
REPLACE OR REPAIR EXIT. DECKS.
EXISTING FIRST FLOOFZ_ � �'
Gc � --REPLACE ANY WINDOWS THAT NEED TO
BE REPLACED.
WALL AND LALLY POSTS
UNDER FRAMED WALL
EXISTING BLOCK FOUNDATION
TO STAT' IN PLACE �
RESIDENCE HARRY ALLAN
�o4 MAIN STREET WESTFORD, MA 01886
1004 SALEM STREET PHONE: 508-183-1111 FAX: 918-496-1526
I email- harryallanocomcast.net
NO. ANDOVER,MA
PACE
ALL MEASUREMENT TO BE CHECKED ON SITE AWN Y: HARRY NEW SECOND
S
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE o4-4-1
DETAILED INFORMATION. SCALE: O/O = 1 FT. LEVEL ADDITION
DATE. November 05, 2010
GENERAL CONSTRUCTION NOTES
FRAMING PLANS ROOFING PLANS
FOUNDATION PLAN 1, LUMBER SPRUCE,FIR,PINE NO. 2 1. 1/2" PLYWOOD NAILED TO MANUFACTURER SPECS.
1, WALL FOOTING 2ro"X 12" DEEP OR BETTER. 2. 5" METAL DRIP EDGE ON ALL EXPOSED EDGES.
WITH KEY WAY,STEEL REBAR IN 2. STUD WALLS Iro" O-C SINGLE 3. ICE AND WATER/SHIELD 3'FT WIDE ON ALL
WALLS,STEP FOOTINGS 3,000LB. BOTTOM PLATE, DOUBLE TOP PLATE EXPOSED EDGES, CHEEKS OR DORMER,BALANCE
CONCRETE ON SOLID MATERIAL. 3. JOISTS AND HEADERS 1-1/2" BEARING OF SHEATHING USE 15Ib.FELT PAPER.
LALLY FOOTING 26"X26"X12" DEEP MIN. ON WOOD OR METAL OR WERE NOTED FLASH ALL PROTRUSION THROUGH ROOF/EXTERIOR WALL.
2. WALLS io" POURED CONCRETE 4, NOTCHING TOP OR BOTTOM OF JOISTS 4. FULL RIDGE VENT ON RIDGE LINE,SOFFIT VENT STRIP
WITH 2 ROWS OF "5 REBAR SPACED SHALL NOT EXCEED 1/6TH.DEPTH OF JOISTS CONTINUOUS IN SOFFIT UNRESTRICTED FOR AIR FLOW,
IN WALLAET OVER FOOTING KEY WAY. IN THE ENDS, 1/3RD. FROM ENDS.
3. SILL ANCHOR -J- BOLTS IN DOUBLED JOISTS UNDER LOAD BEARING PARTITIONS
TOP OF WALL SPACED MIN. 6'FT. AND
VFT FROM CONNERS. 5. MAXIMUM CLEAR SPANS FOR JOISTS, RAFTERS, FIRE/SMOKE STOPPING AND ALARMS
4. DAMP PROOF EXT. WALLS BELOW AND HEADERS SEE SPAN TABLES PAGE [ A-4-2 Z 1. ALL OPENINGS AND PENETRATION BETWEEN
FINISH GRADE, 6. ALL STRUCTURAL MATERIALS SHALL BE CLEAR FLOORS TO BE FILLED WITH BLOCKING AND/OR
5. DRAIN PIPE [4"] AROUND PERIMETER OF ANY DEFECTS THAT MAY DIMINISH CAPACITY NON COMBUSTIBLE MATERIAL.
OFF FOOTING WITH STONE COVERING PIPE TO FUNCTION IN AN ADEQUATE MANNER, STRUCTURAL 2. AT ANY CONCEALED SPACES, STAIR STRINGERS
WITH FABRIC PAPER TO STOP SILTATION. ENGINEERING OR ANY OTHER PROFESSIONAL TOP AND BOTTOM OF WALLS.
6. BACKFILL FOUNDATION WITH SUITABLE SERVICES THAT MAY BE REQUIRED SHELL BE BY 3. SMOKE DETECTORS TO BE PHOTOELECTRIC DETECTORS
MATERIAL FOR DRAINAGE. OTHERS, NEAR BATH AND KITCHEN AREA LOCATED IN ALL BEDROOMS
NEAR ENTRY DOORS, IN BEDROOM AREA HALLWAY,
CONCRETE FLOORS BLOCKING AND BRIDGING IN ALL STAIR WAY AREAS TOP AND BOTTOM.
1. COMPACT SUITABLE GRAVEL IN 6" LIFTS 1. BRIDGING BETWEEN JOISTS NOT TO 4. ONE SMOKE DETECTORS REQUIRE FOR EVERY 1,200 SQ, FT
2, INSTALL 6 MILL POLY WITH ro" OVER LAP EXCEED S'FT.INTERVALS, I"X 3" STRAPPING OF FLOOR AREA.PER LEVEL INCLUDING BASEMENT AREA.
AND UP INSIDE OF WALL ro", STRAPPING DIAGONAL OR SOLID BLOCKING 5, CARBON MONOXIDE DETECTORS IN BEDROOM AREA,
3. MIN. 4" THICK POURED CONCRETE 2. JOISTS SHOULD BE ATTACHED OR BLOCKED 6, HEAT DETECTORS IN GARAGE AND VAULTED CEILINGS.
(GARAGE FLOOR ADD WIRE OR FIBER MESH.) AT BOTH ENDS.
4. CONCRETE SLABS 30'FT. IN ANY DIRECTION 3. SHEATHING SEAM SHOULD BE AT LEAST ro"
ARE REQUIRED TO HAVE I"IN.DEEP CONTROL JOINT BEYOND WERE JOISTS OVER LAP OR USE
AND OR METAL MESH IN CONCRETE SLAB. METAL STRAPPING.
SILL PLATE ALL BEARING WALLS TO HAVE DOUBLE JOISTS
1. MIN. P-T 2"X ro" + 2"X (o" K-D LAGGED DOWN UNDER PARALLEL WALLS.
ON TOP OF 1/4" SILL SEAL WITH FOUNDATION LAGS.
HARRY ALLAN
RESIDENCE 64 MAIN STREET WESTFORD, MA 01886
1004 SALEM (STREET PHONE: 508-183-1111 FAX: 9-18-496-1526
email- harryallangcomcast.net
110. ,4ND0uER,MA
PAGE :
ALL MEASUREMENT TO BE CHECKED ON SITE AWN B`I': HARRY GENERAL
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE A-4-2
DETAILED INFORMATION. SCALE: O/O = 1 FT. CONSTRUCTION NOTES
- DATE: November 05, 2010
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' HARRY ALLAN
RESIDENCE 64 MAIN STREET WESTFORD, MA 01886
1004 SALEM STREET PHONE: 508-183-1111 FAX: 9-T8-496-1526
NO. ,4NDOYER,1" email- harryallanscomcaatanet
PAGE *:
-�� ALL MEASUREMENT TO BE CHECKED ON SITE DRAWN BY: HARRY
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE
DETAILED INFORMATION. SCALE: O/O = VFT. FRONT ELEVATION
DATE: November 05, 2010
12'-0"
4'-O"
2'-4" x 4'-9" 2'-4" x 4' " _
cn _ C Q�oS Kl
Ll
x
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CA t N Q
PEI
V ' pl
2'4" x 2'-I I" 2'-8" x 2'-II" 2'- " x 3'-
2'-6'
32'-2" A
= r-
`� - BEDROOM *2 _
x
BATH O
C,4 EN �' N
EXISTING FLOOR PLAN _
Q2'-4,. 2'-8 4-8 2'-
WORK PROPOSED 4 cm 2'-411
REPLACE CEILING JOISTS `"
SEE FRAMING PLAN 5-1 0 15'-1 " '
S CONVERT TO BEDROOM*-3
x � R40
1 21'-8" 15'-6" KITCHEN
HAVE ALL SMOKE-CO. TIED IN. w BEDROOM *I LIVI G ROO '
SOME WINDOWS WILL BE REPLACED.
_ 10_u x - I5,X4 i - r
DECK AND STAIRS TO BE REPAIRED
OR REPLACED.
4'-O" 1-6" 4'-6' 8'-2" 8'-4"
53'-0"
HARRY ALLAN
RESIDENCE 64 MAIN STREET WESTFORD, MA 01886
1004 SALEM STREET PHONE: 508-183-1111 FAX: 918-496-1526
email- harryallanecomcast.net
NO. ,ANDOVERM>'A
PAGE *:
ALL MEASUREMENT TO BE CHECKED ON SITE
CHECK DETAIL SHEETS A-4-1, A-4-2 FOR MORE DRAWN BY. HARRYEXISTING
DETAILED INFORMATION. SCALE: 1/8 = i'FT. -2
DATE: November 05, 2010 MAIN FLOOR PLAN
of "ORT" TOWN OF NORTH ANDOVER
ti �4e a°�O fi OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover,Massachusetts 01845
SAGHUS
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: 10
JOB LOCATION: 1 CX)
Number Street Address Map/Lot
UOMEOWNER A® r
Name Home Phone Work Phone
PRESENT MAILING ADDRESS AM U�2_
City To,�-,n Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
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 familystructures. A person w
p who constructs more that one home -
m a two-year period shall not be
considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the 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
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS
APPENDICES
Construction Checklist
f Single-&Two Family Dwellings
If required by the building official,this form shall be submitted at the completion of the work,prior to the issuance of a certificate of
occupancy or completion,by the licensed construction supervisor;registered professional or homeowner(responsible party),as
applicable,the municipal and/or state building official in verification that,to the best of his/her knowledge,the work has been
executed in accordance with the provisions of the applicable state building code(code)and reference standards. The date shall
indicate the date on which the responsible party viewed the building activity to ensure compliance with the code and/or reference
standards. This date may or may not correspond to the date on which the activity was inspected for compliance by the municipal
and/or state building official.
Note any deficiencies that were discovered(if any)and corrective action
Activity Date taken to ensure compliance with the code and/or reference standards
Foundation
a. Location/excavation'
b. Preparation of bearing soil
c. Placement of forms/reinforcing
d. Placement of Concrete
e. Setting weather protection methods
f. Installation of water/dampproofing
g. Placement of backfill
Structural Frame
a. Floor
b. Walls
c. Roof/ceilings
d. Masonry or other structural system
Energy Conservation
a. Insulation/vapor and air infiltration
barriers
b. NFRC rated window
c. HVAC equipment with proper
efficiencies
Fire Protection
a. Smoke
b. Heat
c. Carbon Monoxide
d. I Other
Special Construction
a. Chimneys
b. Retaining Walls
c. Other'
1. If encountered in excavating for foundation placement,the responsible party shall report the presence of groundwater
to the building official and shall submit a report detailing methods of remediation.
2.Frame shall include the installation of all joists,trusses and other structural members and sheathing materials to
verify size,species and grad,spacing and attachment methods. The responsible party shall ensure that any cutting or
notching of structural members is performed in accordance with the requirements of this code.
3.The building official may require the responsible party to be present on site at other points during the construction,
reconstruction,alteration,removal or demolition work as he/she deems appropriate.
12/28/07 (Effective 111/08) 780 CMR-Seventh Edition 1045
I
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS
THE MASSACHUSETTS STATE BUILDING CODE
NOTES
t
In signing this form,the licensed construction supervisor,registered professional or homeowner(responsible party),as applicable
attests to the fact that,to the best of his/her knowledge,the work as described on the referenced permit number and associated
plans and specifications has been executed in accordance with the provisions of the applicable state building code(code)and
reference standards.
Name of Responsible Party Signature of Responsible Patty
t
Construction Home Improvement Registered Registered
Supervisor License Contractor Registration Professional Engineer Architect
Number xpiradon Date Number Expiration Date Number Expiration Date Number Expiration Date
This form is submitted for the following project
Permit
Number Property Address
1046 780 CMR-Seventh Edition 12/28/07 (Effective 1/1/08)