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HomeMy WebLinkAboutBuilding Permit #138 - 19 MEADOWOOD ROAD 8/21/2007 pORTF/ BUILDING PERMIT OFtAOR H TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 70 "0' Permit NO: Date Received /`� /o 7 �'qSs R%ren U Date Issued: '`� IMPORTANT:Applicant must complete all items on this page LOCATION ./ G 00W 4Of a /�' t Dyc. ', 0_1 Pq'S' Print PROPERTY OWNER Apt 1)0,V Print MAP NO: PARCEL: ZONING 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 A No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: /7/autE TE Sid ems/) Identification Please Type or Print Clearly) OWNER: Name: 5 Ao.,) Cgtz bode Phone: Address: /? �CffAoal ����= �.vaJuC•c �cl o,�ys CONTRACTOR Name: _ 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 BASED ON$125.00 PER S.F. Total Project Cost: $ 6110 a FEE: $ 1 O 3 Check No.: 3L( 51__ Receipt No.: NOTE: Persons contrac ng . ith unregistered contractors do not have access to the guaranty fund ignature of Agent/Own'-, Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans i 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 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS ZonMg Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature&Date Drivewav Permit Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate 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 NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Locationl /(� � No. l Date �!� MORTM TOWN OF NORTH ANDOVER 10. � 9 s a Certificate of Occupancy $ ;7b'••°'''<� MusE Building/Frame(Frame Permit Fee $ O ss�c Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 205 '15 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): M At C41f b o s✓L Address: / &� r,+o a L✓ 14,A.-J t City/State/Zip: A,,i oay c'x-,1-0 oit vs- Phone #: Oe- /,?7-S6 7y Are you an employer? Check the appropriates box: Type of project(required): 1.❑ I am a employer with 4. , I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. JR Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.;X I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also till 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. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: /�� /`�XOow ZAAIC-. /j,CI ANyove-,< of�y 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 andpenalties ofperjury that the information provided above is true and correct Signature: "7 L,0J4::J Date: � -��A7 Phone#: $7 7v- ro P ?- Si� 7 jV 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#: NORTIO TOWN OF NORTH ANDOVER ° "•" '•1"o OFFICE OF F p BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 1ss�caus�� Gerald A Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please gdm DATE: 4p/ to 7 JOB LOCATION: / ./`,e A 0a t v 'G4'v 6- a 4/ &'*C �.t l� 10 i 4P `/-r Number Street Address Map/Lot HOMEOWNER �N�u C A,c.60ti C-"- 9'�a - e 7 - Name Home Phone Work Phone PRESENT MAILING ADDRESS / ✓'���JaHe � �. ,4•v cin ��-�- �,¢ ��8�/S 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 hetshe 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 requirenients. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Foam Homeow m Exemption 130ARDOF \PPEAJ-5688-9511 CU.\SERV.1' ON 688-9530 IIE.u,'rif688-95.10 PL.L\VING688-9535 �.IORTIy Town of No. o dower Mass., �''wit - o -- T O LAKE COCHICHEWICK Aof?ATED P ,�5 `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System `�' ` BUILDING INSPECTOR THIS CERTIFIES THAT.......�, .�^�....���o�.............................................. .......................................... Foundation has permission to er buildings on I� fir#* p •...................... g1. ..... .................................. Rough to be occupied as.2141.1-101 1. 1. 1.�1�.. ............................................................................................................................ Chimney provided that the person accepting this P1. shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 0 PE MrF EXPIRES IN 6 MONTHS Final 7 g�g ELECTRICAL INSPECTOR UNLESS�I . LESS CO A T�I STR�J . .... . S Rough ...... ............... Service .. .... .... BUILDING Final Occupancy Permit Required to Occupy Building . GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — .Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. NOFdTM Town 0 ove No. �- _ A K E O � dover, Mass., �''v�t• o co ORATED 1"9 C7 7 BOARD OF HEALTH PERMIT. T D Food/Kitchen Septic System THIS CERTIFIES THAT......., .�^N....��.�..�.r�d!!` ........................................... BUILDING INSPECTOR "" Foundation has permission to er r ' p ................•...................... buildings on 1� ......................... Rough .... ...... .... ............................... to be occupied as..?, 1.11�.. ..........................................-conform.............. ................................................................... chimney provided that the person accepting this pe�it shall in everyrespect to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERF EXPIRES I1 6 MONTHS Final 7T �g- T ELECTRICAL INSPECTOR. UNLESS�I LESS COy� S A R S Rough ..................... Service BUILDING Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — .Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.