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HomeMy WebLinkAboutBuilding Permit #8-12 - 166 SALEM STREET 7/5/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received_ 5 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION A.L V N/1 ` r,� Pr t PROPERTY OWNER 5A�n S _ Y� (ru-c S Unit # Print v MAP NO: OZ 1 d PARCEL: -ZONING DISTRICT: . Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ephc We11T D Floodplain ❑.Wetlands; p Watershed District 0 Water7Sewer, ESCRIPTION OF WORK TO BE PERFORMED: , e v DLhce 1900 s 4� t -- .3 51 us 5, jiAJ E-3 To JCA t ,p�AAJ , 4 PO (Identification Please Type or Print Clearly) OWNER: Name: �naN P. (fA&A+LL, Phone:%7s�_OI!o Address: I ep G SALf M Ati<,0100�� CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Home Improvement License: ARCHITECT/ENGINEER Exp. Date: Exp. Date: Phone: Address: Reg. No. FEE SCHEDULE: BULD/NG PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAS D ON $125.00 PER S.F. Total Project Cost: $ 5W0 FEE: $ Check No.: / b� Receipt No.: NOTE: Persons cohtracting,with unregisterAd contractors do not have access ipht/nwnPri� IN `Gw� Siar, ature,oticontractor, '-)F-x­� r, -C V_ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ • - �t ti 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 ❑ J i 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 - �j 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 C 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 NU I t5 and DATA — (For department use ❑ Notified for pickup_- Date Doc:.Building Permit Revised 2011 June/mi 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 ❑ 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 o 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 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: Doc.Building Permit Revised 2008mi Location 2 leln No. _ ` )Y Date. !� NORTN TOWN OF NORTH ANDOVER _ s s Certificate of Occupancy $ O 4 J'K�Us Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # 244 i Building Inspector f µORTH TOWN OF NORTH ANDOVER ,.° OL OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BLUDINGPERIVIIT APPLICATION Please print DATE: _� U ov oR O ) JOB LOCATION: lfi L Number BOMEOWNER 5 AL� �W -04�'� Street Address CAWLL Name Home Phone 76- c`�e(-OII PRESENT MAILING ADDRESS 6 16 SAC15M S 1" N 0110 37 Map/Lot Work Phone e Zn -k AND©o vi MA Ol 9 y g, E -111y 1 own . St�tw. . 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 gwns 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 wi requirements; t said procedures and e 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 UFDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 021X1 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information Please Print Lezibiy Name (Business/Organization/Individual):_ _ _ A OV4 &4 CA, l4 I LL. Address: 110fo -5ALrILA ST City/State/Zip: i� m-nA ANDoy (5A Phone #:_ Axe you an employer? Check the appropriate box: .1 -El I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).' have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4);, and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. El Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. I 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 foamy employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Job Site Expiration Date: 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 certif nde thepain and en ties of perjury that the information provided above is true and correct. Signature: �'V -( - --- - _ Date: O� O to — ®1 1 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 m m m m m v m y d C � yCD I �••� n Z CO) CD O CL r. ? O CL = CO) > C c v CD a`� o Q CD Sr CD 0 CD °DCD• CL. O CO) O co O CD S- CO) O 1 Z CD O CD O CD K; n O V J I C 0 G 5-R® QD dy Sc. 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