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Home My WebLink AboutBuilding Permit #268-15 - 125 BLUE RIDGE ROAD 9/16/2014 NORT11 Ofuao ,6 Ah BUILDING PERMIT 4°fir. TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: ��SSACHUS IMPORTANT:Applicant must complete all items on this page LOCATION • 1 L�> fUt �Z PROPERTY OWNER �t Of4k �_ Print,,`C_, \ Print MAP NCt��PARCEL Og ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building R16ne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer Identi1fication Please Type or Print Clearly) OWNER: Name: "�4+sra K mat 1 Phone: °� `� '&XI Address: CONTRACTOR Name: Phone: q 7�- - � y3s' Address: School ?e/ Mg. 0151.72 Supervisor's Construction License: Exp. Date: CS-D8�060 J--.z 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: $ FEE: $ Check No.: Receipt No.: 0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner ( Signature of contractor 4l� I 1. NORTH BUILDING PERMIT 0 tvEo 16;9tio TOWN OF NORTH ANDOVER 3? ry,-A. . _ °L APPLICATION FOR PLAN EXAMINATION * ,� Permit No#: Date Received �SSAAr CHus��y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER - Print 100 Year structure yes no MAP _.PARCEL: _ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Address: Supervisor's Construction License: _ _ _ Exp. Date:_ Home Improvement License: d . �, _ 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature 0 f Agent/Owner Signature of contractor Location l No. "' Date e TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ a Foundation Permit Feejr $ s Other Permit Fee $ TOTAL $ Check# :!5 2 'U' 6 21 uilding Inspector Location J�;,S— No. � Date o - TOWN OF NORTH ANDOVER e �D ' Certificate of Occupancy $ Building/Frame Permit Fee =$ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# jr—(�r 28021 'Building Inspector i 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 r 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) i ❑ Notified for pickup Call Email 3 Date Time Contact Name l Doc.Building Permit Revised 2014 i` 4 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I 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) i ❑ 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 j 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:Building Permit Revised 2014 ~k. �..� 4 ti r -- `�. �, �- • - _ w � � �' 'd `, •y � µORT1.r Town o s_E : ., Andover No. t _ YY T ro h ver, Mass, 14 coc»ic"IWIC,c 1 7.95°R�reo ►`P� �(5 U BOARD OF HEALTH PERMIT T Food/Kitchen ........... . LD Septic System THIS CERTIFIES THAT ................... ... .. . ...,,,,,.,,, „(,r,,, „ BUILDING INSPECTOR lira . .. ..... ........................... has permission to erect ... Foundation ....................... buildings on 6)'S......... ,. . ��..X . ..... ............... Rough to be occupied' sS�.......aa&oT........ —Tv ,,,,,,1h, Chimney ... ..... ... . .... .. ........ ...... provided that the perso accepting this permit shall in every respect conform to the terms o e application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final 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 CONSTRUCTIOXVr 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, Smoke Det. (�;9� W0MWMMVea&'A Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 174702 - Type: Individual Expiration: 3/11/2015 Tr# 236987 BRIAN R. YOUNG BRIAN YOUNG " 44 GROTON SCHOOL RD AYER, MA 01432 _ Update Address and return card.Mark reason for change. Address ❑ Renewal Ej Employment E] Lost Card SCA 1 0 20M-05/11 tD C��tra:ac�uaelld Office of Consumer Affairs&Business Regulation License or registration valid for individul use only -- OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 174702 Type: Office of Consumer Affairs and Business Regulation xpiration: 3/11/2015 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 BRIAN R.YOUNG BRIAN YOUNG 44 GROTON SCHOOL RD AYER,MA 01432 Undersecretary Not valid wit ut sign ture Massachusetts C o; Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS4)87060 f- R .1-' . °, , 1114 BRIAN YOUNG = ' 43 GROTON S6fOOL1k0 AYER MA 0143E Expiration Commissioner 05/29/2015 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Y Boston,MA 02114-2017 s� www massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):— /7r,112-4 yQ cm,� Address: "/,/ �i^4�]`aa SCGI City/State/Zip: & • � A,1 67 J Z Phone#: Y7�' 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 employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. EJ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 employees. [No workers' 13 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 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'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Li c. 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. Ido herebycertif under the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: Phone#: Y�y— 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#: