HomeMy WebLinkAboutBuilding Permit #297-2012 - 111 HICKORY HILL ROAD 10/15/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ��- z) Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER sag&� Unit#
Print
MAP NO:a�0�' PARCEL: a lj ZONING DISTRICT: ( Historic District yes Q
t Machine Shop Village yes Q
100 year-old structure yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 4 One family
�n ❑Two or more family ❑ Industrial j
a Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
® Sepfc ®Weill ti (]tFloodplama �WatershedlDistrict
fiWater/S ewer
DESCRIPTION OF WORK TO BE�ERFORMED:
'C k 'S oay , sec
'ro�
i
(Identification Please Type or Print Clearly)
OWNER: Name: e -�'(e,i S Yidn�m Phone: fly—63 _ - a
Address: M �A<Gyof�/ �y�� �a
CONTRACTOR Name: M�� ��(1n Phone: _919--590 ++12-03
Address: W 0 (7s Dos
Supervisor's Construction License: 6 Exp. Date: I IZ q (I
Home Improvement License: 3 ('iy Exp. Date: I12_1 11,14-
ARC HITECT/ENG I NEER
Phone:
Address: •
Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92,00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 2;79P r FEE: $_
Check No.: �� Receipt No.: A` i r_74
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ter;.
Cnnafi iranftOricri�/(lWni:i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
I
Ems_RAGE DISPOSAL
ublic Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
i
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 4
• 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 h
it
Doc:.Building Permit Revised 2011 June/mi
Building Department
I '
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
o 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 Permi
Addition or Decks
❑ Building Permit Application
-o' 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
i
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
o EngineeringAffidavits 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: Doc.Building Permit Revised 2008mi
,
Location ��� d 0,1112/ f'� �� ��`•
No. � Date �10/ -/_2
of HORTN TOWN OF NORTH ANDOVER
p
a �o Certificate of Occupancy $
CNUsEt� Building/Frame Permit Fee $ �d
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Ch
eck #
24672 Building Inspector
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COC MIC ME WICK �
d�oRA T E D BOARD OF HEALTH
lv ` Food/Kitchen
PERMIT T D
Septic System
BUILDING INSPECTOR
��:/............ . .................................................
THIS CERTIFIES THAT...................f' .......�. Foundation
has permission to erect........................................ buildings on ......... .....� ........................... Rough
to be occupied as..................................... y '-r Ti ti` chimney
.. ' '/ ......�................................................. ......... ..:..........................:.......:...................
provided that the person accepting this per4h shall in every respect confdrm 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 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ARTS Rough
05
e.
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.
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Mi msachusetts- Department of Public ', etr
Board of Building Re¢ulatioa*and Stab! rt14
Construction Supervisor incense
License: CS 72146
Restrictedlo. 00
MICHAEL P' RYAN
880 OSG06D ST
41
N ANDOVER, MA 01845
►�- Expiration: 10129f2bl
£'.Rn�ntiieaner Tr#: 9050
i
I
Office of Consumer Affairs R Business Reg, a t Lifre or registration Valid for;ii►divtd " 'Ose oniy:
• s HOME IMPROVEMENT CONTRACTOR i efre.the expirk"date. 1f found"return to:.
Registration '143164 'fyp3 �, Ofilee of Consumer Affairs and Business Regulation
Expiration; 6/211.2012 DBA _ 10 Park Plaza=Suite 5170
s 'BOton,MA 02116
RYAN BUILDERS
Vj
MICHAEL RYAN
880 OSGOOD ST -
N.ANDOVER,MA 0186 *Not .._. .Undersecretary signature
_.. _ u__- . ...........
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual): • M I he,
Address: M0 05gooN
City/State/Zip: P o t More, , KA Phone#: 91 g-5 9 0- 7 Z03
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 1 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. t 7. ❑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 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3. ❑ 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.❑Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.el f P Other fA Vo'C 1 1�.
*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 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 certi y nder t e pains andpenalties of perjury that the information provided abov is true and correct.
Si nature:
Date:
Phone#: 1
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#: