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Home My WebLink AboutBuilding Permit #556 - 104 BLUE RIDGE ROAD 4/24/2009 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * ,� Permit NO: S Date Received a�' 'lf4A°44rED {� �SSACHUS�� Date Issue "6 PORTANT:Applicant must complete all items on this page LOCATION U ` f t° 6t-t'c4e— k Print PROPERTY OWNER n Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes MachineShopVillage yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building amilyAddition JWLne o or more family Industrial Alteration No. of units: Commercial air placement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: �{VkCLce_ son, e o� �4 o bob c S� �. na P�c k-e r-. v r'' ntification Please Typeo Print Clearly) OWNER: Name: rQ u `cam S Phone: Address: I O CONTRACTOR Name: Phone: Address: Supervisor's Construction diense: Exp. Date: Home 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 S.F. Total Project Cost: $ O U FEE: $ Check No.:_T Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of Agent/Owner gnature of contractor Location / Xlk No. Date /�Z i MaRT� TOWN OF NORTH ANDOVER Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #16 6 2 ► : 5 / Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body 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 COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 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 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.: 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 ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 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 2.2008 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 If,ashington Street Boston, MA 02111 1 www_mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information. Please Print Legibly Nanie (Business/organization/individual) a„ � �, Address: u City/State/Zip: �• �, JY4,� � I k �l Phone#:_�� S �D � Are you an employer?Check the appropriate box: Type of prefect(required):1.13I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am.a:sole proprietorr or partner- listed on the attached sheet 2 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 -required.] officers have exercised their 10•0 Electrical repairs or additions 3. I am a h;7Zner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. rkers'comp, c. 152, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs q ] .employees. [No workers' camp. insurance required] t 3.❑Other l'4 j �?C 'Any applicant that checks bob#l must also ftll out the section below showing their workers'compensation policy information. / Homeowners who submit this affidavit indicating they are doing all worts and then him outside contractor;must submit a new affidavit indicating such. 4contractors that check this box_must a_ffached an additional sheat showing the name of the subcontractors and their workers'cor.:p.polis;information. I am an employer that is.providuig:workers'compensation insurance for my employees; Below it the policy a�td job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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. I do hereby cert u �theins and penalti of perjury that the information provided above is true and correct Si tire: Date. / Phone =Other only. Do not write in this area,to bee%mpleted by city or town officio[ n: _Permit/License# hority(circle one): Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector son• Phone#. x4ORTH Town ' of t 4Andover No. #.,r4o 1 W4 dover, Mass., T 1 - LAK �• COCHICHEWICK VOF71 �d AORAT E C ,.? �5 `s BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System /� �AA � BUILDING INSPECTOR THIS CERTIFIES THAT ..............�`� ..... ..... .... _ Foundation .. .... .. .. . .. .... has permission to erect......... .............................. buildings on ....A0. ............... .. Rough tobe occupied as.... � I....... .......... ...... ./r .......... ...................................................................... ............ Chimney provided that the person acceptiflg this per d shall 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 3� woom PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR STARTS 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. SEE REVERSE SIDE Smoke Det. NORTH TOWN OF NORTH ANDOVER' ID •• OFFICE OF A BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 �.,'°�•...s'° North Andover'Massachusetts 01845 Sswc►a5'�t Gerald A Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please pript DATE: JOB LOCATION: 104 C� n rl f umber Street Address MaPILot HOMEOWNER n I I pet 6ro-A Name Home Phone Work Phone PRESENT MAILING ADDRESS �( `/ City Town State 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 (Cade 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 family structures. A person who constricts more that one home in 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 1sr6wd 10.2005 Foam Homwwam Eamon TIOARD OF \PPEA1.S 6R8,T5 11 CONSERV.VFIQ\689-9530 HE.U.,Tli 688-9540 PL.L\,NI\G 698_9535