HomeMy WebLinkAboutBuilding Permit #46 - 193 CORTLAND DRIVE 7/15/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued: S %)
v ttyc.. �6• ryO
IMPORTANT: Applicant must complete all items on this page
LOCATION__L1 1 3 j tltv i T ?-! K) - A4&4 ,%+�1,,,7
Print
PROPERTY OWNERAM
Print
MAP NO: U PARCEL: ZONING DISTRICT: ' _Historic District yes
Machine Shop Village yesno
TYPE OF. IMPROVEMENT
PROPOSED USE
Res'
Non- Residential
� gOne
f '
Addition
wo or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Se tic Well
Floodplain Wetlands
Watershed District
ter/Sew
DESC IPTION O
OWNER: Name: Q nn
Address:
PREFOrMELD:/� /M C/41
Please Type or Print Clearly)
IR
J
CONTRACTOR Name:
r,
Address: /S_
tt
Supervisor's Construction License: r% Exp. Date:-7�
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No. /
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED CAST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ • V-LV-IAJ G Nz'�r
I
Check No.: 8 Receipt No.: Olza \I Z
NOTE: Persons contracting with tp4jegistered tractors do not have access to the gyprantyh4d
;signature of Agent/OwnecS Z4 Signature of contractor
Location
No. Date
NORT1y TOWN OF NORTH ANDOVER
41
N? • • G9
4 Certificate of Occupancy $
s''^°' tt� Building/Frame Permit Fee $ '
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # L 04 -Z'7-
2 2 2 1
2
222+
� C?=== -
Building Inspector
3
Plans Submit d
Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
u is ewe.Tanning/MassageBody
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 N 1,.A
CONSERVATION
COMMENTS
HCALTH
COMMENTS
Reviewed on
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _
Planning Board Decision: N / Comments
Conservation Decision: Z� Z ` 1 Comm
c
Water & Sewer Connection/Sianature & Dated
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp DumpstWjon site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
no
D,
Dimension
Number of Stories
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions. / fZ,5�7
3�6.2
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No �(
DANGER ZONE LITERATURE: Yes
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 2008
No
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 2.2008
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`'s \ The CommonWeaft ofMassachusetts
f De Wftenrt of Industrial Accidents
t Office of Investigations
, a 600 NrashhTton Street
Boston, MA 02111
r www MWS gov/din .
Workers' Compensation insurance Affidavit: Builders/Contracfors/Eieefricia�s/P
�uiliit t Information . lumbers
i arae (ausincssldrgaoization/Individual): _71S
Address:
R
City/State/ZiF raP� %�� Q % Phone k .
7,Afreyouemployer? Cheekthe appropriate •box:
mployer with 4. ❑ I am a . TYPe of project• (require):
gametal contractor and tees (fu(1 and/orpart-time):* have Dred the sub -cont actors 6: awcona�truction
20I am a:sole proprietor or partner. listed on the attached sheet t 7: ❑ Remodeling
ship and have no employees These sub -contractors have
working forme a; any capacity. workers' comp. insurance. 8. Q I}emoiition
[No wotiters' oomp. insm�arsce 5. ❑ We arc a corporation. and its 9. ❑ Building addition
'��d.] officers ' have exercised their 10.❑ Electrical repairs or additions
3. ❑ I cin a homeowner doing all work right of erxcinption pa MOL 11.
m self ❑ Plumbing repair$ or additions
Y [No workers' comp. c, 152, § 1(4),•and-we have no
insurance -required.) .t employees [No Workers,
12.❑ Roof repairs
'AnYappticarrtU,ar �P• insurance required.] 13•❑.Other
checks boZ p l must also f'[i i out the section beiow ahow.iog their;wor taus' bornpeasetiori policy infomiahon
t iiomeownasT who submit this d idzvit indjcathi theyare dein en
�Coitractors that check this box must 8 wo'* end than hie outside contractors must submit n naw 6firdavft ,ndioa* such.
an a d'tioasi sheet siwwirrg• the name of the w
b-aioactors and their woridss' ce�np. POU -1 ' h;an.
I arn.art eloper tFa� islerx�rieiutg:rsarl�s' compensatiori nsuraace or
infonnafiom sf nr enPloyem. Brjow is IhePoNzy andyob site .
Insurance Company Name: '
Policy # or Self -ins. Lie. #:
Expiratim Dale.
Job Site Address;
Attach a copy of the workers' wmpensatfon policy deeiaratioo page (showing the nn
Failure to satin a covers c as P° cy' wirer and expiration date}. .
g required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of 2,
fine up to $1,500,00 and/or one-year imprisonment; as as civil penalties in the form of a S'317P WORK CJ}ZpER anu a fine
of up to $250.00 a day against the violator. Be advised s e of this statement
Investigations of the DIA for insurance coverage vend 'on, copy 3' be forwarded to the Office of
I do hereby certify under the
IPP&and penaida
9 797— 4S %
rnat tae utfornmatian Provi'la above ' true and neared
rred
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094ci& use only. Do not write in this area, to he p, l4ted by , or town. ofTrio[
City or Town. Permit/Licease #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town -Clerk 4. Electrical Inspector 5. Plumbing Ins
6. Other g pec%r
Contact Person:
-
Phone #:
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