HomeMy WebLinkAboutBuilding Permit #801 - 125 OLD VILLAGE LANE 5/7/2012 BUILDING PERMITof NORTy
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received
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Date Issued:
IMPORTANT Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition or more.family Industrial
No. of units: Commercial
Re air, re lacem t Assessory Bldg Others:
Demolition Other
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DESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Type Tr Print Clea ) +
OWNER: Name: O 'D OJ Phone: 'I— G ?5-d
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Address l�,� A-b V'/ L Lx4i!�ir_ ,4 ILIA-
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ARCHITECT/ENGINEER- �1 �- Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BA D ON$125.00 PER S.F.
Total Project Cost: $ glt�0&0. FEE: $
Check No.: c; C P Recei t No.:
NOTE: con t" with unregistered contractors do net have ss t e b and
_ef�Agent/ wgnafurecoa�
Plans Submitted Pians 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
C 0MlVIEN T S
HEALTH Reviewed on Signature
0.
COMMENTS
i
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
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Conservation Decision: Comments
Water $ Sewer Connection/Snature Date Driveway Permit
DPW Town Engineer: Signature:
ocated 384 Os ood Street
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xLocatedf � 9ain Scree# s
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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 - Date
Doc.Building Permit Revised 2010
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 PP Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ "lass 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
❑ Ce i feu r^ropo ; , 11
se❑ Poo- 1-1 a,,
❑ 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
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 2008
Location i �1���// �—•
No Date 5- 9
• - TOWN OF NORTH ANDOVER
•
� Certificate of Occupancy
beBuilding/Frame Permit Fee $
Foundation Permit Fee '
n,�
Other Permit Fee $
TOTAL $
Check#-Owlp
25274 Building Inspector
The Commonwealth oflMlassachusetts . -
Department offndustriglAccidents
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 Legibiy
Name,(Business/Organization/Jndividual): �'�/� l:///-f71a/o17
Address:_ l Z� Q�� lei
city/state/zip:_ _ 4700 Ve-1- 44 D 1 R5l _phone#: 47P &ff-6YNV
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/orpart time)* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.z 7• ❑Remodeling
ship and.have no employees These sub-contractors have 8. ❑Demolition
weking forme in any capacity. workers'comp.insurance. g, ❑Building addition
[N workers'comp,insurance 5. F, We are a corporation and its 10.[]Electrical repairs or additions
` required.] officers have exercised their
3. ` I amt a homeowner doing all work right of exemption per MGL 11.❑Plumbing.repairs or additions
yself.[No workers'comp, c.152,§1(4),and we,have no 12.❑Roofrepairs
insurance required.]t employees.[No workers'
comp,insurance required.] 13.❑Other
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they 9ie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
X am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:.
Policy 4 or S elf-ins.Lic.4: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation-policy 8eclaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 civilpenalties 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 maybe forwarded to the Office of
Investigations of the DIA for insurance age verification.
Ido reby c rte nd zep s enaldes ofperjury that the information provided above is true and correct. -
x Si atur Date: /Z
FOther
only. Do not write in fids area,to be completed by city or town official.
n:. Permit/Ucense 0
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
- - -
son: Phone 0:
TOWN OF NORTH
ANDOVER •
OFFICE OF
BUILDING DEPARTMENT
AL io P^ " . 1600 Osgood Street Building 20,-Suite 2-36
fy�ssq14usc�5 North Andover,Massachusetts 01845
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings
HOAMOWNER'LICENSE EXEMPTION Fax (978)688-9542
GUIDING PERMIT APPLICATION
Please print
DATE: 6 7 20/z
JOB LOCATION: l2� (9Le Z,+Alr 416 �(0
Number Street Address
Map/'Lot
HOMEOWNER /,)0 Al C6 P/0/t �'t?,7 laf-S 0
Name Home Phone c
Work Phone
PRESENT MAILING ADDRESS 5t47`((L
/M'1
City Town AV I
S*w*e
Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units-or less and
to allow such homPot.,1-jers to engage un 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 unders the Town of North Andover Building Department
minimum inspection procedures and requirements anda/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 688-9530
HEALTH 688-9540 PLANNING 688-9535