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Home My WebLink AboutBuilding Permit #744-13 - 133 CAMPBELL ROAD 5/9/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: j Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION r' r . PROPERTY OWNER hh Print 100 Year OId.Structure yes ' MAP NO: PARCEL ZONING. DISTRICT: Historic District yes rim Machine Shop Village yes 917 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial El Alteration No. of units: ElCommercial Repair, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other Septic: 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District` ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 4 Identifica 'on lease Type or Print Clearly) OWNER: Name: f-2,v�� Phone: Address: 33 F-C CONTRACTOR Name: e, Phone: l O ! Address: Supervisor's Construction License: C'S 07 Z( Exp. Date: `f' 7,9 ` 2� Home Improvement License: 2� 23 Exp. Date: f Zb ' 15- ARCH ITECT/ENGI NEER jSARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ASED ON$ 5.00 PER S.F. Total Project Cost: $ Z� 3'[ ��' FEE: $ �" Check No.: .1 Receipt No.: NOTE: Persons contra ting with unregistered contractors do not have access tot a guaranty Signature of Agent/Ovvne. Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ tamped ns ❑ Location h` A Y' No. L Date s a - TOWN OF NORTH ANDOVER 4' r , F Certificate of Occupancy $ 4 Building/Frame Permit Fee $��001 01 Foundation Permit Fee $ Other Permit Fee $ ti TOTAL $ Check# I /K 26371 Building Inspector J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF'SEWERAGE DISPOSAL ' El Pools Public Sewer ❑ Tanning/MassageBodyArt ❑ 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 COMMENTS //t l ` I ` HE LTH 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 DPW Tow ]Engineer: Signature: Located 384 Osgood Street FIRE:.DEPAR-*f.ME-NT Temp Dumpater on site yes no Located at'124:Main'Street-. : Fire Depa&h'ent-sigriatdtb/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 1 Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine MOTES and DATA— For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 R Building Department The foliawin is a list of the required forms to be filled out for the appropriate permit to be obtained. 9 q Roofing, Siding, Interior Rehabilitation Permits u Building Permit Application o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses u Copy of Contract u Floor Plan Or Proposed Interior Work Li 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 o Certified Surveyed Plot Plan u Workers Comp Affidavit o Photo Copy. of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) Li 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) :Q Building Permit Application Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 app;al 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.Buil Jing permit Revised 2012 SECTION 4-WORKERS COMPENSATION(M G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ T7ddition ❑ Accessory Bldg. ❑ Demolition ❑ Other Specify ' Brief Description of Proposed Work,,,,,0419 (4 ` ' .. , Q 2✓� �� r�r/CA v C✓! (:'tn &J SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be dFCI�USE"ONi:Y Completed bV permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbingBuilding Permit fee(a)X (b) 4 Mechanical HVAC) 5 Fire Protection 6 Total 1+2+3+4f5 Check Number SECTION 7a OW AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT 6R CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. i Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, �C t//t-7) 'c as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief c l/r� Print Name s- Si ature of Owriei/A e Dat INIM IN— NO. OF STORIES' SIZE BASEMENT OR SLAB, SIZE OF FLOOR TINMERS I 2ND 3 FLD SPAN DIlVIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE P921 e, U>arrurrear6e ea �d�C�/G�ataac�ccteCCi. - - Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ey egistration: 162123 Type: Office of Consumer Affairs and Business Regulation xpiration: :1/20/2015- Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 K&R CONTRACTORS;;-_INC. KENNETH ROY 1 CAMPBELL RD. _ N.ANDOVER,MA 01845 a ` Undersecretary Not validVsignature Massachusetts- Department of Public Safety Board of Buildin ; Rc;ulatioirs and Standards Construction Supervisor License License: CS 80721 KENNETH R ROY - 1 CAMPBELL RD i N ANDOVER, MA 01845.%° Expiration;: 4/2912013 ('�atntgiisvi�»ter Tri#: 16891 NORTH ve" 'o C, 'hver, Mass, COCHICKIWICH I-1' A�4ATEO ►P�,`�(5 S U BOARD OF HEALTH M -T T D Food/Kitchen Septic System PER I THIS CERTIFIES THATr- , „ , . ............................................... BUILDING INSPECTOR .. has permission to erect .......................... buildings on � _Ca . 2A Foundation Rough tobe occupied as ...... .................:...................................... Chimney provided that the person accepting this permit Miall in every respect 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT N SARTS Rough Service ........................................................:.:..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display ina' 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. SEE REVERSE SIDE The Commonwealth ofiMassachusetts Department oflndustriglAccWnts 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 Le 'bl Name(Business/Organization/Individual): Address: City/State/Zip: NA")so vR-- " A Ak D f %Y__Phone#: q 7'6 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. El 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. [1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition p -, working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We area corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 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 ]re uired. v employees.[No workers' 13.❑Other a ' q comp.insurance required.] —� 'Any applicant-that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit anew 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. lam 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.Lie.#: 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 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 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 Hereby cert! rider the pains a naldes ofperjury that the information provided above is true and correct. Sip-nature: Date: Phone#• OL 7 Z 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#: