HomeMy WebLinkAboutBuilding Permit #937-15 - 197 INGALLS STREET 5/19/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date'lssued:
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
LXne family
0 Addition
0 Two or more family
11 Industrial
11 Alteration
No. of units:
0 Commercial
0 Others:
>Aepair, replacement
0 Assessory Bldg
11 Demolition
0 Other
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Identification Please Type or Print Clearly)
OWNER: Name: .44AT1,14AI Phone: (�7
Address: 19 7, A,' J 4 N s- 5 T- A-) 0 -IL/-r/4 A.- 'a I/ R -L
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A,RCHITECT/ENGI NEER
Address:
Phone:
Reg. No.
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FEE SCHEDULE: BULDING PERMIT: $1Z00 PER $1000.00 OF THE TOTAL ESi1kATED COST BASED ON $125.00 PER SA
Total Project Cost: $ q6) q00 FEE:
Check No.: Receipt No.:
NOTE: - Persons contr�cAnt�ith unregistered contractors do not have a
cce;s 'to —the'g—uarantyfund
pure OjAgtnvowner A, i
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'4�V: - Fa din r 7177-
Permit No#:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
16
0 -0.
co .1-9
Print 100 Year StrUcture yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes, no
TYPE OF IMPROVEMENT
PROPOSEDUSE
Residential
Non- Residential
El New Building
El Addition
El Alteration
0 One family
El Two or more family
No. of units:
El Industrial
El Commercial
El Repair, replacement
El Demolition
0 Assessory Bldg
0 Other
0 Others:
�nW SEWN
J�
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
E-mail:
Address:
Supervisor's Construction License: Exp. Date'.
Home Improvement License: Exp. Date:
ARCH ITECT/ENGI NEE
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDINGPERMIT.- $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.,
Total Project Cost: $ FEE: $
-4
Check No.: Receipt No.:
440TE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Plans Submitted 0 Plans Waived 0 Certified Plot Plan F1 Stamped Plans
OF SEWERAGE DISPOSAL
FTYPE
_ _ Sevver
P h
ublieSevver
Tanning(Massage/Body Art El
Swiluming Pools 0
well El
'I
Tobacco Sales El
Food Packaging/Sales 0
Private (septic tank, etc. El
Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HI�ALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes
Planning Board Decision:
3
Comments
Conservation Decision: Comments
Water & Sewer Connectioni Permit
DPW Town Engineer: Signature:
— I -- Located 384 Osgood Street
H rrn
1�j'q iy'
7 'R-
E
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
Ll Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
M
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
,�6 Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4. Building Permit Application
4; 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
OTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
10TE: 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
Doe: Building Permit Revised 2014
Location
Date
No.
Check # /Ovy
9 T
2 8 7 9 S
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee
TOTAL $
""—ruilding Inspector
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t%ORTH TOWN OF NORTH ANDOVER
OFFICE OF
0
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 0 1845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE:—
JOB LOCATION: 197 1 Iv,,9,4 L 1- 5 5 r
Number Street Address Map/Lot
HOMEOWNER C49-131'Ple- b14& -F1_9+,-1 7? 3 3,5�- oi�q. 6
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 3? Vitlije R,9 _*�(09_
00 le +OA/ MA 0 1 N�
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 c-ompliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies tIR he/she understands the Town of North Andover Building Department
minimum inspection procedures and requilp ents and that he/she will comply with said procedures and
requirements. '1�1 , i
HOMEOWNERS SIGNA
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
Department of IndustrialAceidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affldavit: Builders/Contractoi-s/FIectricians/Plumbers.
TO BE FILED WITH THE PEPJvffl'MG AUTHORITY.
Aipplicant Information Please Print Legibl
NaMeO3usiness/Organization/Individual): 41L t 1, 9
Address: -38 VIIIA54e go
City/State/Zip: M I p.o)e, *tov M A. 0 1qq hone #: '17 F- 3�� - 0 6 '76
Are you an employer? Check the appropriate box:
I.F1 I am a employer -with employees (full and/or part-time).*
2. [—] I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.X1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
Those sub -contractors have employees and have workers' comp. insurance.1
6. We are a corporation and its officers have exercised their right oflexemption per MGL c.
152, § 1(4), and we have no, employees. [No workers' comp. insurance required.]
Type of project (required):
7. El New construction
8—kRernodeling;
9. El Demolition
10 n Building addition
ME] Electrical repairs or additions
12. n Plumbing repairs or additions
13. E] Roof repairs
14, [:] Other
*Any applicant that checks box # I 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.
tContractors 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 employeas, they must provide their workers' comp. policy number.
Iam air employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company
Policy # or Self -ins. Lic.
Job Site Address:—
Attach R copy of the workers'
Expiration Date:
City/State/Zip:
policy declaration page (showing the policy number and expiration date).
Failure to secze �covers required under MGL c, 152, §25A is a criminal violation punishable by a fine up to $1,500.00
r s
ri
and/or one -yea risonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day agaMsf 'th—e violator. A copy of this statement may be forwarded to the Office of Investigatio* ns of the DIA for insurance
I do hereby certM derthepai andj?enalfies ofpetyury that the information provided above is trite and correct.
Signatt Date -
I
Official use only. Do trot 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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