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Home My WebLink AboutBuilding Permit #686-15 - 134 CROSSBOW LANE 3/2/2015 BUILDING PERMIT o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o Permit No# Date Received' �q 2 SSACHUS� Date Issued: 7 2 IMPORTANT: Applicant must complete all items on this: ..age LOCATION z/ C /R 05 5 UO w �JK Print PROPERTY OWNER S4-ev-e Print i Oar Year.Structure yes - no MAP ID&.A PARCEL: ZONING DISTRICT: Historic District yes no 6 Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building R One family 0 Addition ❑Two or more family ❑ Industrial [9--Alteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: 0 Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: c/o se L't"4cr)c/ /.�1,9 J/ Identification- Please Type or Print Clearly OWNER: Name: � °tien , i,��. ).r,'A Phone: y7P tial - Address: G-y Y2 c J't _- Contractor Name: Phone: 7 �;o Address: Z. q 4-119 Supervisor's Construction License: U 9 F3 Y-fS Exp. `Date:. Home Improvement License: f .2-� E3 5_ Exp. h: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: $ b s-00 ,moo FEE: $ 36 Check No.: a�Receipt-No : � NOTE: Persons contracting with unregistered contractors do not have.acom to the guaranty wind ignature of Agent/Owner Signature of contractor '" Location lN U- ,2y" No. Date_ . - TOWN OF NORTH ANDOVER f . Certificate of Occupancy $_- i Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $' TOTAL $ Check# Q 35 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPF':"F SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ s Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM lPLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 1 CONSERVATION Reviewed on Signature COMMENTS HEALTH 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 Town Engineer: Signature: Located 384 Osgood Street FIREDEPARTMENT 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 I ❑ Notified for pickup Call Email 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 r ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work I ❑ 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) ❑ 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 Doc:Building Permit Revised 2014 " r - ' NORTH c ver O - M No. • * `� - h ver, Mass, cocHicnew�cK 1 V BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THISCERTIFIES THAT ....... ....... .. ................................. ..... ..................................................... >............ Foundation has permission to erect buildings on .%.244. Rough tobe occupied as ........... .OJ400.......W.WrTr1wr.............. ......................................................... Chimney provided that the person accepting this permit shall 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 ®D UNLESS CONSTRUCTIO PS S 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. j 110 Ssa� l d W �i�e�esti SRp94 a on t o f pli� . IC �LCS98S4�r Sahastan ac7fet Y�, .4� jo i O HISS Jt tft id� ��\ C m � on�,r Og23l2p0 1 S 1 The Commonwealth of Massachusetts Department of IndustrialAccidents a d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ® Please Print Leizib Qly Name (Business/Organization/Individual): ,)1*l// 41'yl �If- Address: -- _�— Cl .c"�`e-e V, 7 City/State/Zip: ��-C 7� � 9 rj/! ?oPhone#: rf 7i?) ly 6) e) ay r Are you an employer?Check the appropriate box: Type of project(required): 1.F-1 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.I 0 I am a sole proprietor or partnership and have no employees working for me in $, �7e modeling any capacity.[No workers'comp.insurance required.] L' 9. ❑Demolition 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] IL *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.Lic.#: 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 0 00— if Official use only. Do not write in this area,to be completed by city or town official. i City or Town: Permit/License# j 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#: