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HomeMy WebLinkAboutBuilding Permit #395-2011 - 1547 GREAT POND ROAD 11/9/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION f� ` Permit NO:.5 JS?o`/ Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION < 7 �WLA� P Print j/ PROPERTY OWNER �`/ �7"' L �-S Print MAP NO: 9,;.20 PARCEL: Oe77ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE R t ential Non- Residential ❑ New Building A One family ❑Addition ❑Two or more family ❑ Industrial �KrAlteration No. of units: ❑ Commercial []'Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other e, I- ®i�W,ellx�� ®Floodplain ®Wetlands} Jj Watershed District - _ 12f DESCRIPTION OF WORK TO BE PERFORMED: dow Ye,,Place-,t ,if 3A Identificationlease Tyr or Print Clearly) ffo 2 97�-7.�5- 2 570 OWNER: Name: ase � o�� Phone: �'��� 6117 907-a i33 Address: /5y7 6 tc�2 1 0�tj KCJ CONTRACTOR Name: w✓�e t' Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. 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: $ / ®° ® FEE: Check No.: y�2 Receipt No.: ��3 NOTE: Persons contractin with nr iste ed actors do not have access to the guaranty fund f Signature_of+Agent/Owie'r : Signature:ofcontractor { Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody 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 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.$10041000 fine NOTES and DATA— For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2008 i i Building Department I 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 ❑ Copy of Contract 1 ❑ 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 g Permlt Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Co V of H.I py .C. And C.S.L. Licenses ❑ COPY Of Contract E3 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 p d Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Two Sets of Building Plans � g (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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals fiat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording iust be submitted with the building application Doe: Doc.Building Permit Revised 2008mi Location /r4 No. o// Date NpRTq TOWN OF NORTH ANDOVER 0 w a Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s.KMusE 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # f 2 3 6 r! _---1/g Inspector A uit din g p ORTiy Town of y. .:; :_ Andover Noj Q Z- LAKE `o dover, Mass., , COCHICHEWICK y�. �d ORATED SS BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... 45 �—'. ..... . ..�1i ................................................................................................ Foundation has permission to erect.................:....................... buildings on .1. .7......6z Gqo! �'"...'�................... Rough P -� � � t0 be OCCu ied as �.. . L!(ll........ ,......,, llGE -'� 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 UNLESS CONSTRUCTION STARTS Rough c ....... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. F NORrH TOWN OF NORTH ANDOVER 2 ° OFFICE OF BUILDING DEPARTMENT o 1600 Osgood Street Building 20, Suite 2-36 �y.4 p'e+no••^'`.� North Andover,Massachusetts 01 845 5 sgc►+use Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: 15'17 Number Street Address Map/Lot HOMEOWNER 7a67- 2570 Cell 6/7 90/a�33 Name' Home Phone Work Phone PRESENT MAILING ADDRESS City Town State. Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an 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 owns 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 understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/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 The Commonwealth of Massachusetts Department f IndustrialAccirlents a rtment o Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers Applicant InformationPlease]Print Legibly Name(Business/Organization/Individual): S e A-11+011C l ff/( S Address: -5 V7 ,^C2 r 60ond a2(, 2 d City/State/Zip: d(-4 Phone#: 9 4- — 7.;?s_ 7 O 7- ZVI 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.? 7• ❑Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp,insurance 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3. 1 am 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.❑Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 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 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 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. Ido hereby ce 'y uncle the ndpe aal perjury that the information provided above is true and correct. Simature: Phone#: UHJ16� 47F- 7aS-a57© 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#: