HomeMy WebLinkAboutBuilding Permit #810-14 - 19 CANDLESTICK ROAD 5/9/2014i
BUILDING PERMIT �? -�` °'
TOWN OF NORTH ANDOVER
Q_l APPLICATION FOR PLAN EXAMINATION " - -
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Permit NO: Date Received
AroD
Date Issued:
I �9SSACMUS�t�
IMPORTANT: Applicant must complete all items on this Daize
LOCATION l ( Caod 0 7cLc, PDaa 0 mot, Ah20&zV_
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PROPERTY OWNER W, /%f C. A"!5
Print
MAP NO:PARCEL: i5 ZONING DISTRICT: Historic District yesnno
Machine Shoia Village ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
SeRepair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
0 Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
1 r � � ° rI � c` � � � � 1 ••/il
Identification Please Type or Print Clearly)
OWNER: Name: I,( k ff1 aAM5 Phone- q% -&s5 - q l;2
Address: iq C�}7Gk P-Ocao( yY?brqti AlidAi<oir W VI'8)g5
CONTRACTOR Name: Phone:
Address 111r_ "t—
Supervisor's Construction License: t " , Exp. Dale:
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: $, enry FEE: $ -F-0
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2
Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
must complete all items on this p,
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PROPOSED USE
IMPORTANT: A plican
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
' IR, 0,10
❑ Industrial
-
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eyes
1-.0
❑ Assessory Bldg
❑ Others:
MAPINO
RCEL ZONING
must complete all items on this p,
57 �HtT
'rin`t �100_Yea Old Stru
)ISTRICTJH storit-astnct.
• f I^MachinP�Shnn
.TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
no:••
❑ Industrial
' �
ture yes
eyes
1-.0
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
.R tics Well
.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
.R tics Well
lanF Nel
odpA
tSe
r
5Water/5ewer
tP F
s,
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
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.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Ovvner "` .Signature of contractor �.:
Plans Submitted Plans Waived ❑ Certified Plot Plan R Stmmnprl Plans ❑
CONTRACTO.RName: 0
IP,hone�
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�R
A'dtlfe'ss
iSu e}rvlsor'sConstructo I - z ^
n License
ExpD ate
tP F
1
HomerlmprovementLLleense?Exp.
05te.
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.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Ovvner "` .Signature of contractor �.:
Plans Submitted Plans Waived ❑ Certified Plot Plan R Stmmnprl Plans ❑
Plans Submitted -,PlansW-aived L. :..Certified Plot Plan ❑ Stamped Plans-
TYPE-OF
lans
TYPE OI ::SEWERAGEDISP_OSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
Swimming Pools ❑
Well ❑
_Tobacco.Sales ❑
Food Packaging/Sales ❑
-Private(septic tank, ete:_ . ❑. -> ._ .
`permanent Dinpster on Site ❑
._ -THE_FO.LLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE, -APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
ONSERVATION Reviewed on
COMMENTS
HEALTH
COMMENTS
►s wl`,^100`
r AYsrL'1ae.iv-?��
c,J J ►� r c:b wj
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comments
j I Conservation Decision: Comments
k
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tovv2 Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTM:ENT -.Temp Dumpster on site ` Yes: no
Located -at 124 Mair, Street
--Fire Departrner-It signature/date
COMMENTS
Dirnenslon
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
_Total land area; sq. ft.;
ELECTRICAL: Movement of Meter. l.ocatFon-, mast or ser vice drop requires approval of
.:Electrical inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL.Chapterl66.Section 21A --F and G min.$100=$1000.fine
NOTES and DATA - (For department use
D Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
he r'oli avuing is a' list of the requlred.forms to be -filled ouf#or:the. appropriate permit to`be obtained.
Roofivg, Siding, Interior Rehabilitation Permits
❑ . B,iailding Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/OrrG.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
❑ 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 apu•,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Bui?ding permit Revised 2012
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TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: 9-TQl✓' Est. Cost
Address of Work 0 Ca cd0+1 lc. &Ooaa
Owner Name: �14A 4� U),I. A awS
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law Permit No.
Job under $1,000 Date
Building not owner -occupied
✓ Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND LINER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date
Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
51%11
Dat
15115'" "4C 674W5
Owner Name
Gerald A. Brown
Inspector of Buildings
Please print
DATE:
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Telephone (978) 688-9545
Fax (978)688-9542
JOB LOCATION: 0 (_GriNe7(&X iGk 110( ,
Number r Street Address Map/Lot
HOMEOWNER CIISik4L V)&& &PPK q1 ? 13,R 1401,5
Name Home Phone Work Phone
PRESENT MAILING ADDRESS l q Caodu - &_ )eo( .
_ 79!11 4006V&- 114 61&V5
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
Revised 10.2005
Form Homeowners Exemption
IN
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Print Form
' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Et%so� W1I`1 S
Address: lot CCjydiQ 41 t,L CQ ,
/State/Zip: I'AA4 ► Ano(w-0-, 10 OtM5 Phone #: 6g5" aql V
Are you an employer? Check the appropriate box:
L ❑ 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance.+
required.]
5. ❑ We are a corporation and its
3. I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
insurance required.] t
right of exemption per MGL
c. 152, § 1(4), and we have no
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.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.M Other r ��
ft 0�t5f 444. 9f
*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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am 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. Lic. #:
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties o perjury that the information provided above is true and correct.
Phone #. 9071J - lo$ 5 - o2 `f I -,;?, '
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 #: