HomeMy WebLinkAboutBuilding Permit #330-11 - 104 MIDDLESEX STREET 10/20/2010 t%ORTH
BUILDING PERMIT OFS�LED
y6•.1f v_'4 �6
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION '-
1;
Date Received /10 ��04AT¢o P? A
Permit NO:
gSSAC HUS�C
Date Issued: '
IMPORTANT:Applicant must complete all items on this page
LOCATION
t
PRQPERTY.OWNER
Print
MAP 210 PARCEL:. . . ZONING DISTRIET° HistoncDistrict. yes. rn
.
/ Machine Shop.Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No, of units: ❑ Commercial
. epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
�.
0.Septic p VI/ell p Floodplain El Wetlarids ❑ 1Nate'rst ed Distn t
❑-.Water/Sewer.
DESCRIPTIOF WORK TO BE PERFORMED:
Ide tific on Ple se Typeri t Clearly)
OWNER: Name:
Phone: 5'7d:b&o- Oab 7
Address:
[.A
ONTRACTOR Name: Phone: :.
ddress:. ..
`Super visoris.Construction License: Exp: Date:..:
Home.lmprovement LicenseEp. Date:. f
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: $=--�- Ar00 FEE: $ �-
Receipt No.:
Check No.:
NOTE: Persons contracting 'th unregistered contractors do not have access to the guaranty fund
Signature of contractor
Signature of Agent/Owner _
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
MOTE: 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 Co
of H.I.C.
Copy 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
DOTE: 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg P errnit
Xxi all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
One copy and proof of recording
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds.
must be submitted with the building application
Doc:Building Permit Revised 2008
Pi
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
FPublic
WERAGE DISPOSAL
❑ Tanning/MassageBody Art ❑ Swimming Pools❑ Tobacco Sales ❑ Food Packaging/Sales 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 iii Date Driveway Permit
.>IDJPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dui-npster on site yes no-
Located at 124 Main Street
Fire Department signatureldate
COMMENTS..
I
Dimension
Number of
Stories: Total square feet of floor area, based on Exterior dimensions.
. _—
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mastor 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
I
® Notified for pickup - Date
—
i
Doc.Building Permit Revised 2010/October
I .
I
Location
No. "' Date ^�
N'50 TOWN OF NORTH ANDOVER
pMIT
w
9
Certificate of Occupancy $
Building/Frame/Frame Permit Fee $ L3
sACMust 9
Foundation Permit Fee $ _
Other Permit Fee $
TOTAL $ T
Check #
23578
Building Inspector
ORTH
ToVM Of And
- -;=-
_ LAJKE O dover, Mass., 0 - 2 • ly
COCHICKEWICK
ADRATED
SS BOARD OF HEALTH
Food/Kitchen
.PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.7_7_ 0.��........
"""""""""' Foundation
has permission to ec re .................. buildings on .......� �
........... !4.�... .... g
............. Rough
to be occupied as 1 ' J�GL� c7�iv S Chimney
..1......................................................... .....".s.d
provided that the person accepting this permit shall in every respect co form 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
PERMIT EXPIRES IN.:6" ONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUC ST S Rough
....................................:. Service
BUILDING INSPECTOR
Final '
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the- Premises — Do Not Remove RoughFinal
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.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA. 0211.1
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name(Business/Organization/Individual): Q�"
lee
S� ,
Address: •z l
City/State/Zip: P•A • Phone#: F 71 , 660 -000:,7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I 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• E]Remodeling .
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9• ❑Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
KI
officers have exercised their 10.❑Electrical repairs or additions
�
3.LJ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 1311 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I 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 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 he eby cert'y un r the ins andpenalties ofperjury that the information provided above is true and correct.
Simature: Date: to40. to
Phone#: ��• (0DG
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 CIerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
C ontact Person: Phone#:
F AORTH TOWN OF NORTH ANDOVER
020`t? @� � OFFICE OF
s BUILDING DEPARTMENT
*� 1600 Osgood Street Building 20, Suite 2-36
"yes
cHus
CH "�t5 North Andover,Massachusetts 01845
Sa '� .
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please Print
DATE: I D • 0 ( U
JOB LOCATION: j t A r lep r S4
Number Street Address Map/Lot
HOMEOWNER 0%0 IM "'b X; I W I/, TV &60•QW '7
Name Home Phone Work Phone
PRESENT MAILING ADDRESS S7 )A?je&r S�
N,AN6, ul . pia %(5:
City Town Qtan LP 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) .
DEFTNITION 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 constructs 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 re uirements 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 ION 688-9530
HEALTH 688-9540 PLANNING 688-9535