HomeMy WebLinkAboutBuilding Permit #532-11 - 171 LACONIA CIRCLE 1/7/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: —L—
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Date Issued ^
IWORTANT:
Date Received
must complete all items on this
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MAP NO: 0 . PARCEL: -7kZONING DISTRICT: Historic District yes no
Machine Shop Village 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
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DESCRIPTION OF WORK TO BE P
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Identification Please Type or Print CIearly)
OWNER: Name: 1A \M ASSA-0 131-1 ATN AG A -;Z Phone:q"7C—�9-3--96&q
Address: `� 1 LocIrk' L .N, A -v, V-eii F
CONTRACTOR Name:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No
Phone:
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
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Total Project Cost: $ FEE:
Check No.: 2 Receipt No.:
NOTE: Persons contracting with unr4iskOfontractors do not have access to the guaranty fund
Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Well ❑
Private (septic tank, etc. ❑
Tanning/MassageMody Art ❑ Swimming Pools ❑
Tobacco Sales ❑ Food Packaging/Sales ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comm
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
COMNMNTS
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
U Notified for pickup - Date
Doc:.Building Permit Revised 2008
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
❑ 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
o Engineering Affidavits for Engineered products
d®TE: 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
hat 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
Doc: Doc -Building Permit Revised 2008mi
Location G 1 Uaw 114 C, dz— -
No. S&IZ Date
NORTq
TOWN OF NORTH ANDOVER
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Certificate of Occupancy
$
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Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
23648 uilding Inspector
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�aRTH TOWN OF NORTH ANDOVER
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RtteO
0 OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover Massachusetts 01845
Y q�no �e 9
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: f -7 J
JOB LOC TION:[ � C0 1\J /
Number
IJOMEOWNER M
Name
Address
�''_L _
Home Phone
CjkC.CF-
17AY C,
Map/Lot
9?9-683-868"?
Work Phone ?
PRESENT MAILING ADDRESS / �S
�, c�
City Town c +w . Zip Cede
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 NAndo er Building Department
minimum inspection procedures an r quirements and yea he/she will comply�*th sat rocedures and
requirements. \ j
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 ofMaassachusetts
Department of Inclustrial.Acculents
Office oflnvestigations
600 Washington Street
Boston, MA 0.2111
www.mass.gov1dia
Workers' Compensation Insuranoe.Affidavit: Biiilders/Contractors/JElectricians/Plumbers
Applicant Information Please Print LegibX�
Name (Business/Organization/Individual): l inti Lint. V> �y
Address: 1-7 I
City/Stale/Zip: N , �k q % 97— b g 3
9
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet. z
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. ❑ I 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
I1.❑ Plumbing repairs or additions
12.❑ Roofrepairs
13.❑ Other
*Any applicant that checks box #I 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.
lContractors 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 isproviding workers' compensation insurancefor my employees Below is the policy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lie.
rob Site Address:
Expiration Date:
City/State/Zip.-
Attach
ity/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 i a 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage ve i�tion.
Ido, hereby �Art f under the PRPs and
that the information provided above is true and correct.
,/ / t
Phone #: % $ — cS3 _ g i5
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
C ontactPerson:
Phone #:
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