HomeMy WebLinkAboutBuilding Permit #616-2017 - 1755 OSGOOD STREET 12/7/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION,
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Permit NO: �6 I Date Received �-^ 1p
°� SSACHUSf
Date Issued: ' 1 (o
IMPORTANT• Applicant must complete all items on this page
LOCATION
�— Print
PROPERTY OWNER
Print
'MA'P-'NO: PARCEL: :: ZONING DISTRICT: —Historic District yes In
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
Aew Building
addition
ne family
[two or more family
Nndustrial
alteration
No. of units:
mmercial
F0 epair, replacementLo'
ssessory Bldg
`Others: Sl
11 emolition
1'^ they
t8 Fepiic ell
loodplain etlands
atershed District
Nater/Sewer
Identification Please Type or Print Clearly)
OWNER: Name:
t cz1
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ Ioa FEE: $
Check No.: Receipt No.: 3 13 a
NOTE: Persons contracting with unregistered contractors do not have access to the paranty fund
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Plans Submitted ❑
Plans Waived 01 Certified Plot Plan ❑ Stamped Plans ❑
-TYPE'OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassagemoO Art ❑
Swim,-,inPools ❑
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
PLANNING & DEVELOPMENT Reviewed On
�17elffliffilr�9�r7+
Signatu
CONSERVATION Reviewed on Signature
7
COMMENTS
HEALTH
COMMENTS
Reviewed on
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Commen
Conservation Decision: Co
nature
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Locatea Jb4 Usgood Street
yes no
-)imension
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
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
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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/Cross Section/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)
D Building Permit Application
❑ Certified Proposed Plot Plan
o 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
DOTE: 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: Building Permit Revised 2014
Location G- oo
No. -(DI(D - 41�0 I Date /;L/ -71(9 6
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector --T
Plans Submitted I�qI Plans Waived L.°Q2-1Certified Plot Plan E� Stamped Plans 0'
TYPE OF SEWERAGE DISPOSAL
FE 07 Public Sewer 40
Tanning/massage/Body Art FE 17
Swimming Pools 04
n0
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00
Well
nnE4
LaJ
Tobacco Sales
10111
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
NING & DEVELOPMENT
DATE REJECTED
ai
DATEAPPROVED
GUS 1zl / IWIY�
E it
CONSERVATION `"' 1 -VI
COMMENTS
DATE REJECTED DATE APPROVED
E0 np
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Located at 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site
1L-jdated at' 124:'Main Street
Fire Department signature/date
COMMENTS
yes no
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SIGN PERMIT APPLICATION
�t �j, 1600 Osgood Street - Building 20, Suite 2035 / �O
Mapk_Parcel U / TOWN OF NORTH ANDOVER �� 7 ! /
DATE SUTBAUTTED
Site Owner _ Applicant e �C�l
L�YGM � s— . ►'� a � _gp�(.
Site Address 61 Size of Proposed Sign,
MTERNALL•YILLUMMATEDSIGN PROMBrUD' `�,��IiVlRN65�Ul1�S
How attached: a) Against the wall �F'CI
Roof .__ Illumination: a Not illuminate
C) Ground ��-���-5 b) Externally illuminated ]�
d) Other --I )L I ,x ` - I
Proposed Colors: Background
Lettering
Border N� MIkA
Recquixed Attachments*
ttachments J
Photographs ofding
Material sample/
Color sample
Site or Plot Plan (Required fo; all freo-standing signs)
Drawings of proposed sign
Other, spay
Will sign overhang any public road or wallcway Yes ( ) No 1
If Yes, Name of Agency who will provide liability insurance:
Materials: V kLu �v
ji(Q� `►1lL (j� iYV14V151 - UJ0.�R
No )ermanent/teroporary sign shall be erected, or enlarged until an
application on the appropriate form famished by the Sign Office has been
filed with the Sign Officer containing such information including
photographs, plans and scale drawings, as he may require, and apermit
for such erection, alteration, or enlargement has been issued by him.
Such permit shall be issued only of the Sign Officer determines that the
sign complies or will comply with all applicable provisions of the By -
Law.
AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED
t�J= 61 L�Jlv?
DATEFILED: CnC,I � l l�l�o
NATURE OF
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builder-,%/Contractors/Electricians/Plume rers
pleaseApplicant Information
Name (Business/Organization/individual):
Address:
City/State/Zip:
#: k 2—
A ou an employer? Check a appropriate box:
4. ❑ I am a general contractor and I
lI am a employer with
have hired the sub -contractors
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
t
listed on the attached sheet.These
ship and have no employees
sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5• ❑ We are a corporation and its
[No workers' comp. insurance
officers have exercised their
required.]
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
employees. [No workers'
insurance required.] t
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
131, Other --
*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.
:Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. I I_ 1 (\ 3;. l; ,,, 0
Insurance Company
Policy # or Self -ins. Lie. #:XV�)
Expiration Date: (012(a t Z C-�
Job Site Address:. Ila 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 MGI, 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 certify der th pains an penal es of perjury that the Information provided above is true and corrector
f u� _J -= Date: Lai [ l
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 #:
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