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HomeMy WebLinkAboutBuilding Permit #162-12 - 116 HIGH STREET 5/1/2018 ■ TOWN OF NORTH ANDOVER . APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IWORTANT:Applicant must com lete all items on this page LOCATIO f 6 Print PROPERTY OWNER rf,L!I V D le Print MAP NO:_6;3_PARCELZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEME�JRe ROPOSED USE sidential Non- Residential ❑ New Building ❑ One f ily- ❑Addition o or more family ❑Industrial ❑Alt tion No. of units: ❑Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition r ❑-Other - _ �� c—rte+r Sec, l7 Well ,' „ I1: p ami f gu(]tWetlan_s4, ' ;; '�(] jWatersfied ptDistrict + 7 __ ry E: •1�e � t i .._--------------- � ter,- � ��a_ a a DES CR 11 TION O' WORK TO BE -LRE 0 D: � v © fin ( i-) /T kin (n ) WOO n i (Identification Please Type or Print Clearly) OWNER: Name: 4Z L u D I (L Phone: T786PQ(/ l Address: CONTRACTOR Name: Phone: Address: v Supervisor's Construction License: )3xp. Date: Home improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg, No. FEESCHEDULE.B ULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PERS F C� FEE:� ' Total Project Coit: $ 0 � Check No.: 7/OReceipt No.: I C� NOTE: Persons contracting wzth unregistered contractors do nothave access to theguaranty fund �Si natureof�Ageri�l0wn___- - - ---- - g=- -•-=-- —==-=r---- -- - --- - _ -- ;a IN Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Pians ❑ 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 CO-NSERVA T ION Reviewed on Sionature COMMENTS HEALTH Reviewed on Signature COMMENTS r Zoning Board of Appeals:Variance, Petition No: Zoning Decision/recelpt submitted yes Planning Board'Decision: Comments Conservation Decision: Comments Water& Sevier Connectlon/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP.A_RThENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Deparhnent signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. t.. P ELECTRICAL: Movement of Dieter location, mast or service drop requires approval or 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 de artment use ® Notified for pickup - Date Doc:.BuRding Permit Revised 2008mi ■ 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 Comb 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 Li Building Permit Application - ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ® Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Con ract ❑ Floor/Crossectiion/Elevation Plan Of Proposed Work With Sprinkler Plan AI�d 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 INIOTE: 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.BuildingPermit Revised 2008mi Location S No. Date i N°^TM TOWN OF NORTH ANDOVER F � {�e Certificate of Occupancy $ ,SSACHUSE�� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # +cz 2 4 " ! 0 Building Inspector NpRTH Town 0 _ Andover - . ,.. No. - dover, Mass., o T O� +-' LAKE I\, COCHICHEWICK �! A0RA T E o BOARD OF HEALTH qS Food/Kitchen PERMI Septic System BUILDING INSPECTOR � / Foundation THIS CERTIFIES THAT,................. ' ............. ...�... . .'fir'...................... . ,/ r Rough S on ....... (� J has permission to erect.. .... ...........,................ . buildingil n 4� f s Chimney �i ....�f........ to be occupied as.................. ... application on file in Final provided that the person acce ting this permit shall in every respect conform to the ter Alteration at on aConstruction of this office, and to the provisions of the Codes and By-Laws relating to the Inspection, PLUMBING INSPECTOR Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final JV PERMIT E 1 tES MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ARTS Rough - — Service ............... ................ ..................... ................................ BUILDING INSPECT Final GAS INSPECTOR Occupancy Permit Required to Occupy Bui�ing Rough Dis la in a Conspicuous Place on the Premises — Do Not Remove Final Py No Lathing Or Dry Wall To Be Done FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner P Street No. Smoke Det. SEE REVERSE SIDE r r • The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street t Boston,MA 02111 www mass gov1dia Workers' Compensation Insurance davit: Builders/Contiractors/JElectritcians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): mq� ( _-� Address: 116 di ig 5�'T Ci /StatelZip•.A/�O 6LY &O DOOP-2 Phone#: �-2 8 �a6 ty 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(frill and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# 7. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition wFuired.] for me m an ca aci workers' comp.insurance. Y P tY 9. ❑Building addition [Nkexs' comp.insurance 5. ❑ We are a corporation and its '' r officers have exercised their 10.❑Electrical repairs or additions 3.1Y1 am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.F1 Roofrepairs insurance required.] employees.No workers' comp.insurance required.] 13.0 other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 7 Homeowers 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. lam an employer that is providing workers'compensation insurance f or my employees. Below is the policy and job site information. Insurance Company Name: Policy 4 or Self-ins.Lic.4: 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 certify under th ains an enaldes ofperjury that the information provided above is true and correct. Simature: Date: Phone#: d, ! 7� [FOfIfil,clagI only. Do not write in this area,to be complefedby city or town official n: Permit/License 0 hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone 4: of N°aT ti- TOWN OF NORTH ANDOVER ,,ORT , �s °� OFFICE OF BUILDING DEPAR TMENT '1600 Osgood Street Building 20, Suite 2-36 oq^nD'Pa�.y �S S E�� North Andover,Massachusetts 01845 SA�1{U Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE:_ JOB LOCATION: 11g Number Street Address Map/Lot HOMEOWNER_ q I - f,V l P Name Home Phone FV Work Phone PRESENT MAILING ADDRESS "•' o (2/� City Town fcrarte. 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 9wns 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 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 685-9530 HEALTH 688-9540 PLANNING 685-9535