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HomeMy WebLinkAboutBuilding Permit #73 - 18 PENNI LANE 7/27/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 75 Date Issued: I _dz_4 _(1 Date Received IMPORTANT: Applicant must complete all items on this page LOCATION % oI Print PROPERTY OWNER SCD7 Unit # Print MAP NO: () q PARCEL: 9�' ZONING DISTRICT: Historic District yes no Machine Shop Village yes 100 year-old structure yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial 'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other s FS-6--p-OWe11 Floodplau0< Wetlands ® Watershed District= r_ K n DESCRIPTION OF WORK TO BE PERFORMED: @`e IQ(In �C_ exi,S1'%n!2 3/y _1�91-ti % 21-he2 5-1nle a(' 2oOnA. c�PllS ��,�ro5� _bP4roo00 (9Xyx1d1Jv,4115 ), Al,sv creile- n �CJU 't` >L� Oy S/X l/r`I �'�DSG'l�• PDX'i i90A ifu derr10 eC15fir,c, 1,)(a1i5 An. (Identification Please Type or Print Clearly) OWNER: Name: SOD -17- Phone: /EL30`l -fao l Address: �enIi r` 614n e_ , 1021/i Irlo p18Y5� r CONTRACTOR Name: �M,,7,-'79 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 SETY$125.00 PER S.F. Total Project Cost: $ /S60,00 FEE: $ Check No.: S2 g Receipt No.: CJ NOTE: Persons contracting�vith unregistery contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ ' 4 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 PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED 0 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature QOMMENTS •t. Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Com 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 r DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES 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 (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Addition or Decks ❑ Building Permit Application I ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o 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 o 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 ❑ Engineering Affidavits for Engineered products f 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: Doe.Building Permit Revised 2008mi e Location No. -""' ��---- Date J�/� MORTh TOWN OF NORTH ANDOVER - p _ Certificate of Occupancy $ _;.. Building/Frame /Frame Permit Fee $ s�cMust 9 Foundation Permit Fee $ _+y. Other Permit Fee TOTAL Check it 24410 Building Inspector g NORTH TOWN OF NORTH ANDOVER °0 OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 pPAArta �'�`� � North Andover, Massachusetts 01845 Gerald A. Brown Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Please print DATE: July 26,2011 JOB LOCATION: 18 Penni Lane Telephone (978) 688-9545 Fax (978)688-9542 Number Street Address Map/Lot HOMEOWNER Scott Briley 978-685-7474 978-304-9001 Name Home Phone PRESENT MAILING ADDRESS 18 Penni Lane North Andover Ma City Town State Work Phone 01845 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 compl with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 FIEAL'17H 688-9540 PLANNING 688-9535 The Commonwealth ofHassachusetts Department of Industrial,Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www massgov/d'ia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): sap // Address: L r�n e City/State/Zip: AWk Ntn&pe i Ma, W66 Phone #: 97y —,3e cl -,060 ( Are you an employer? Check the appropriate box: 1. ❑ 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. I 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.] 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. F1 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. 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 isproviding workers' compensation insurancefor my employees. Below is thepolicy andjoh site information. Insurance Company Name:, Policy 4 or Self -ins. Lie. #: Job Site Address: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify uryler the pains and�ties ofperjury that the information provided above is true and correct. Phone #: 117J7 ~ 31 y Official use only. Do not write in this area, to he completed by city or town offzciaZ City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone .05e exf_s" kilelmd 094, Y�i n C°C'1 if nc``-/� E)et(-,C lc 10rc) I+s. T d445 on ClIz <5: ...' _ st I " t ?A .- _ .. .. _ - - °v e C' �C! y , Rte. t� 1•- yrs 1©Cft{�an� � ,�' a. ... / ♦ 4.0 WiT JR I 11Y x ll v� z s•: C� oj b. o w u v Cf) O A as g b o x o w a U � ir. 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