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Home My WebLink AboutBuilding Permit #693 - 15 COMMONWEALTH AVENUE 5/23/2008 BUILDING PERMIT OFyORTF/ tt�eo ,bgti 1-?t yt ,' •6 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION b Permit NO: Date Received74p�R�i.o �SSACHU`-+�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION COrnmonwea i Ave Print PROPERTY OWNER C,t►'1 + , U I t e Q n K e r`S 1 e\.J Print MAP:NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Re air, re lacement Assessory Bldg Others: Demolition Other Sepbc Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: rt� Ind Co Identification Please Type or Print Clearly) OWNER: Name: Ry�j►r) -r IainKersi-e4 Phone: -8D�^IggLl Address: IS CO rrry ()n jen 144--) P\V2 CONTRACTOR Name: Fey(-e_� U n 1t m 1 �td Phone: 603 - 557 0 555 Address: a Ind 1811 W 1 Od haM �J P 0 a OR Z Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PERK(: 1,J$1000.00 OF THE TOTAL ESTIMATED COST B SED ON$125.00 PER S.F. Total Project Cost: $ �/ FEE: $ � J� Check No.: �/s�� Receipt No.: �!/ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owna l 1 Signature of contractor 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 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 FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location No. ` Date J av MORTq TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ �'�s'•^•',t'�' Building/Frame Permit Fee $ Mus Foundation Permit Fee $ Other Permit Fee $ tJ TOTAL $ Check # I 21 r 60 Building Inspector 3 fl lot ^r _ K � if f i The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations d 600 Washington Street et. Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorOndividual): �U�i-e, —F( ,n kzr i e Address: Co rYl W)Un1 ea.I -I--h A' City/State/Zip: P- t21Cnd0,jC r Phone.#: s (p 8 Li Are you an employer? Check the appropriate box: Type of ' re uired . I am a general contractor and I p roJect( q j': 1.F-1 I am a employer with ' 4 � g 6. E]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. 7. .0 Remodeling ship and have no employees These sub-contractors have g• Demolition working for me in any capacity. employees and have workers' co insurance.$ 9. Building addition [No workers' comp.insurance comp. ' required.] 5. We are a corporation and its 10..0 Electrical repairs or additions 3 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself: [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 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. *Contrctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot 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 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 I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: // Date: S a 3 Q Phone#: ��47(� la Ll 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact.Person: Phone#: N0 R.TH Town of 6jAkndAL nover 0 .in.V.u..H..� ti;,4• No. b 9� ~ _ - C% i== o �` dover, Mass., 3 01S I� A. COC MIC MLAKE WICK V 7�ADRATED O'P�,`�� S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System lBUILDING.INSPECTOR THIS CERTIFIES THAT....... .... ... .............. ....Q.�.. ��. ............ ..................................... ... ••••••• Foundation has permission to erect........................................ buildings on ...1. . . .!n!!.1!h..Q.l!� .................. Rough to be occupied as......& I ........:. .............................................................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 1 UNLESS CONSTRUT ARTS 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. SEE REVERSE SIDE Smoke Det.