HomeMy WebLinkAboutBuilding Permit #148-12 - 148 WAVERLY ROAD 8/7/2013 TOWN OF NORTH ANDOVER
�l APPLICATION FOR PLAN EXAMINATION
Permit NO: 2— Date Received
Date Issued:`:- -Z3
IMPORTANT:Applicant must complete all items on this page
LOCATION �.wL . CLci
Print
PROPERTY OWNER S _ VAI
Print 100 Year Old Structure y no
MAP NO: PARCEL-: ZONING DISTRICT: Historic District esno
Machine Shop Village es no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building D One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well p Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
�l Y tom, L i---i cA 1.e<c te�
Identification Please Type or Print Clearly)
OWNER: Name:_O6,,orSa ^ onPjz eC • 7— Phone:
Address:
CONTRACTOR Name: P-e-lo-yf L) Phone:
—T
Address: �Lv'1►� /�-y �� .v I �~ b (&U.
Supervisor's Construction License: .62112- L/ Exp. Date:
Home Improvement License: _ Exp. Date:
4
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 of Agent/Owner Signature of contractor. .(� '
Plans Submitted 01lans Waived 6 Certified Plot Plan ❑ tamped Plan ❑
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH p Reviewed on Signature
COMMENTS
I
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 DEPARTMENT -Temp p
Dum ster on site yes no
Located at 124 Mair, 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
A
El Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The foli'owing is a list of the required forms to be filled out for the appropriate permit to be obtained.
i
i
Roofirag, 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/Crossection/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)
❑ 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm:tted with the building application
Doc: Doc.Bui?ging Permit Revised 2012 .
Location/ �/
No. Date
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy, $
Building/Frame Permit Fee $
Foundation Permit Fee . $
Other Permit Fee
$
tai s�te'' TOTAL (o/?A47,L L $
Check#! s`
26707 Building Inspector