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Home My WebLink AboutBuilding Permit #237-15 - 12 BARCO LANE 9/4/2014 BUILDING PERMIT o`"°eT 6� ti TOWN OF NORTH ANDOVER 3� y 0 APPLICATION FOR PLAN EXAMINATION Permit No Date Received R"�gITEO gSSiC HU`�� Date Issued: l IMPORTANT: Applicant must complete all items on this page LOCATION P PROPERTY OWNER �j�')') 1 ti Print 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District yes kno Lor Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial R , replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: identification- Plea Ty r P ' t Clearly OWNER: Name: �C�'!'1/� s �� J Phone: �Zr- ��'-O� Address: Contractor Name:4&,tS�0YQ✓ Cone: 77y - c24? - Address: _ `S7 /V-7 1 Supervisor's Construction License: U2`t*03 Exp. Date: /Home Improvement License: /5Z9!5N-)7 _ Exp. Date: it ARCHITECT/ENGINEER Phone: i' Address:_ ZZ Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. /1? K Total Project Cost: $ / � 7'(-r-4 _FEE: $ Check No.: Receipt No.: NOTE: Persons contrac ing with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor T __ Location [r� l_ lit No. Date J t I . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ t.LG Foundation Permit Fee $ I(( Other Permit Fee $ TOTAL $ 4 Check# f i _ -) . `: '� �' O 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r 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 Call Email I Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/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) o 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) o 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 Doe:Building Permit Revised 2014 Town of tAndover . O ". - "t No. T - oh ver, Mass, coc"Ic"t—C.. y1' A0R� S V BOARD OF HEALTH PERM I-T,, T LD Food/Kitchen Septic System THIS CERTIFIES THAT ..� '^....I..........•• OJ�v :5BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ......�.�........ ........a.... ................................. Rough • to be occupied as . Chimney . .. . ...��......... .................... ............................................................... provided that the person accepting is permit shall in every res ct conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONS T Rough Service .......................... .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. s µ q Ac'o CERTIFICATE OF LIABILITY�--� TY INSURANCE "Tor 03-122014 THIS CEFiTXjp OC IS f9SUED AS A MATTER Aw OF►NFOfIhiAVON ONLY AND DONFR6 NO RIGHTS t1pON TNH CERiiF7CA7E HOLDER. gy GL"I poLiATH DOES NOT w FVVJA71VELY 69 N64A7WffLY MAENO� BXIEND DR ALTER THE EITn AQte AFFORDED BY THE POL►p�4 g�Oyy,. CIFiURCATS OF INSURANCE DOFS NOT CONBTD OR ATM THE 9 THP R`rAN ti ithe 99MMwk AUTHORD�D RS7RE$wTATIYE all PRODUCER,AND THE CERTtRCAT 6 HOLDER "I N i�iF eet to K the ce►Bilrahi)bider is M ADOU16M- INSURED the atlbjeettafhatermsandonelklassrifthepoky, ' powws)nnaTt6sendme(L Ifm OCk47I0Nt3WA VW, not carder tights 10 fit W"cate holder fi hV o1 w or k the an estdoreweA A rde}en al an this cor oasts doeii PRooucot MARKEnNG ASSOC IN8 AGCY coNrAer 150 WELLS AVE,Irl AIONa FAX NEWrOAk MA 02458 E y� 1NeURenIS1AiWAD0000VERA0B . Nem A: EAWRONNeURANCI CWPAW NAIQI VAWEZ WIL90N 02A MASTER ROOF IN✓�lRFA 0 r lA UNIEIWLOUS-MA ung e PO BOX 83. MILFORD.MA 01787 DIWRFR 0 r ' IMeur♦ER C r iNmR61 F t THIS IS TO CgFMFY THAT 7T4E POUdE3 OF i - I ' CO A90YNTRACT OTRHE P0.1CY PERIOD INDlCA7Eb. NOTYVITy�'MDI BELOW HAVE SEEN TS TER TO THE INSURED NAMED MURANCR AF FWED ByyWr TT i �41iH RESPBQi W}10H THiB OERTIFICCATfiI MA S6r MUED OR ON ITION OF P;NY 'ni5 CaIDiT10NS OF SUCH POLIGTES LJM �OWH MAY HAVE ISRSIEEN W SLJaED Bey pTO A1D ALL T. SMS' EXCLUSIONS AMO t 7YPlDI<plillaAnef � �,��, POuerra>Msp1 crei* ra1Ic1•e� C011MEROtAr.0CN61W 11MUrY EAGtOCCURRENCQ Down i 0 ane i A001 MIX as P aA0YY1AlfrY A? COX EWE r lu"N E1LABLBY l� PRdit - A6fi i AR1'AU1D AUTOS_ NEDtn Gff ` I UMfr eDOi.YvuUaY ht p'.oe0 i H 6Dtl1 AUfpS 0LIM= 9DDpYlltrt>:tYlF.reea0nq UYORARLALM6 OOCUR i EMMUAY OLA W10& FACFiGIxuRnBlpC = D� RFiFMrpNi AORRQ6ATB s _ AtVe9llOY8RSW0i�rtY C AWPR°PArirpyr N M X W-STAooftTU. pn�, PAWS lrirp+smoccw6o? Y N/A n7AYLitRi Eq X574 43 l6 2d14 09.152015 1100,000: F-" '�� 1100,000. Er.DD A91-A% vr.Dsr 000' li0NOf0i'ERA1tOMi/LOCA7{pIy/yt;�gIPYAc11ACM 1p(, . 1 hQ world DD tiOrtp°Bq dDEi not A�onaltieerh�W►.Mae*Ansae IS r POLICY AAD iTS UMiTED OTHER STATES ds covar0g,r firrVAlDt7 WILE L THE INSURED 8 MA WORKERS OGMPe4SA110M TME 04SUREOB MA EbpL01'EbB INSTATES CITFtHR THAFi S THE PAYM2tYr OF SENeATS FOR CLAIMS MADE.BY 81AYPS OTHER THAN MA IF THE tNBLtRED HI AVTHORMTION iS GIVEN TO PAY CLAJKS FOR PRO"'04 COVERAGg"ANY STATE O'1T•IERkTi."j A. '+NREO EMPLOYEES O(l=E OF hK 7M18 POUC;Y OOp38 NOT tN LOWE'S 001APAAOES INC - &HOUTA ANY OFTHB ABO S ATTN: a�SURAIJCE t 0�LLwED�BEFORE THE DE5CR1gED PO tXX 1111 004RATION DATE T�F hL s90R0,nIC 28ASB pOLiCY PIIOVISOf E-IYERED IN AOCORDANCE WfM TH 'u'► AseR�rrAmtr ACORO zs 1yp10 .aray.r��„ The AQORD same and 46 are rtQieter +�of ACORD rl The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations Epp Washington Street Boston,MA 02111 .:�,v- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricibers PleasPrint Leidmbi . Applicant Information Name (Business/Organization/Individual): � —" Address: YN0475-hone#: City/State/Z ? t Are you employer? Check thpappropriate box: Type of project(required): 1. 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 listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g, ❑Demolition ship and have no employees employees and have workers' Working for me in any capacity. t 9. ❑Building addition o workers' comp. insurance comp.ar t o corporation [N p� 10.❑Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3,❑ I required.] a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12 Roof repairs insurance required.] t c. 152,§1(4),and we have no 13.❑ Other employees.[No workers' 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. tContraetors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'co enation insurance for my employees. Below is the policy and job site information. r Insurance Company Name: Policy#or Self-ins.Lic.#: v S^ 5`�5 Expiration Date: 3l�S 1 _ Job Site Address: 9 City/Stalc/Zil- . Attach a copy of the workers' compensation p liey declaration page(showing the policy number a...�xpiratioa u>iz:,. 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 certify under the pains and)pen'al�ties ofRerjury t i-thnform ' n provided above is '*ue and correct. � 2 Si ture: ,tt f/J�Y%yl ate: _ Phone#: Official use only. Do not write in this area,to be ebmpleted by city or town offcciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector.5.plumbiltg Inspector 6. Other Contact Person: Phone#: