HomeMy WebLinkAboutBuilding Permit #92-16 - 20 EMPIRE DRIVE 7/23/2015�i�ll < "�a" 4 UT --
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:
Date Issued:
IMPORTANT: ADDlicant must
Date Received
all items on this
t%OR
LOCATION 20 eroplip-E- _P12. 'A toop--r�+ A&)Dpv-e:e— HA of"Sr—
Print
PROPERTYOWNER P-po VA�Jyrwpe- \rtT-((-)t-
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes ( no
TYPE OF IMPROVEMENT
0
Residential
LOCATION 20 eroplip-E- _P12. 'A toop--r�+ A&)Dpv-e:e— HA of"Sr—
Print
PROPERTYOWNER P-po VA�Jyrwpe- \rtT-((-)t-
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes ( no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
0 Addition
El Two or more family
0 Industrial
0 Alteration
No. of units:
0 Commercial
0 Repair, replacement
0 Assessory Bldg
1) Others:
0 Demolition
0 Other
D Septic D Well
0 Floodplain. 0 Wetlands
D Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
f5 AS C -t -AG P -a
C9 k C- P
Id
OWNER: Name:
Address:
Contractor Name:
Email:
Address:
qHcef kocv- -&- CAP -PE -r- .
-r y -.I- y 101 'r 9- -
�E� Please Type or Print Clearly
Supervisor's Construction License:
Home Improvement License:
Phone:)
Exp. Date:
Date:
ARCHITECT/ENGI NEER Phone:
Address:
. No
FEE SCHEDULE. BULDINGPERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 10i 00c) FEE: $ 12-0
Check No.: Receipt No.: C �tl=
NOTE: Persons contracting with unregistered contractors do not have access to the ivarantyfund
Location L)v
No. Date
Check
-95092
7. ,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $ / I 0�" I
Foundation, Permit Fee $
Other Permit Fee $
TOTAL $
'--'Building Inspector
Dimension
Number of Stories:. Total square feet'of floor area, based on Exterior dimensions. -
0
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANG po 7nK1F= I ITFRATURE: Yes No,
MGL Chapter 166 Section 21A —I- and G min.$100-$l 000 fine
Doc.Building Permit Revised 2014
in
th
M1
Plans Submitted F1
Plans Waived 11
Certified Plot Plan 11 Stamped Plans 11
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature—
COMMENTS
CONSERVATION
COMMENTS
I-iEALTH
COMMENTS
Reviewed on j �'D 5) 1'1 — Si
Reviewed on Signature
.01
S
. lZoning Board of Appeals: Variance, Petition No: 7oning Decision/receipt submitted yes
it
.- Planning Board Decision: Comm
1j
Conservation Decision: Comments
Water & Sewer Connectionisignature & Date nrivPw2v r"
DPW Town Engineer:.Signature: Located 384 Osgood Street
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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
OTE: 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/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
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
OORTH
TOWN OF NORTH ANDOVER
OFFICE OF
0
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
SACHU
North Andover, Massachusetts 0 1845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOYvrNER LICENSE EXEMPTION
Please print
DATE: 07 -
JOB LOCATION: 2 C) emplac
Number Street Address
N - AtODOLIGe-
Map/Lot
HOMEOWNER 2- 0 erY)P1R_F P -e . 41J - AA)Dr.)v-&e_1
Name Home Phone 20' Work Phone
PRESENT MAILING ADDRESS 9,0 C_ ro P I je Cc -0 e- -
^.) - PY rJD 0 VC- e -
City Town
state
H e r-> I " �.r
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" assurrics 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 ofNorth Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 689-9530 1 IFALTI 1688-9540 PLANNING 688-9535
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FOUNDATION L OCA TION
CLIENT: ORCHARD VILLAGE, LLC
THIS CERTIFICATION ISMADEANDLIMITED TO THEABOVECLIENT
LOCATION. -20 EMPIRE DR. NORTH ANDOVERMA.
DATE -511112 SCALEIJ'�--30'
�� N\- 12'
LOT3
MICHAEL
0 J.
SERG( m
0 4
N..33191 I
ss
8 u
THISDRAKING SHALL NOTBEUSED BYTHECLIENTFORANY
PURPOSEOTHER THAN THATOURINED ABOVEEXCEPT WITH
THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC
FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY
OFCHRISTIANSEN& SERGI INC. ANDANY UNAUTHORIZED USEIS
PROHIBITED. CHRIS77ANSEN &SERGI TAKES NORESPONSIBILITY
FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY
INFORM4TION CONTAINED HEREON.
BASED ON SCALED DATA ONt r THE PRIMARYSTRUCrURE
SHOWN IS NOT LOCA TED IN A FLOOD H42ARO ZONE AS SHOWN
ONFEMA FLOOD INSURANCE RATE MAP. COMMUNITY NO.: 250098
0008C DATE.61VI993 ZONE X
PROFESSIONAL ENGINEERS & LAND SURVEYORS
CHRISTIANSEN & SERGI, INC.
160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830
WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX. 978-372-3960
�rl
DWG.NO.:06029.001.047
The Comimaiturealth of fillassachmvetts
Departinent of IndustrialAccidents
I Congress Street, Suite 100
Bostoit, MA 02114-2017
wwiv.mas.,;.gov1d1a
Workers' Compensation Insurance Affidavit: Btii1derviContractors/Flectricians/Plumbers.
TO UE FILED WF111THE PERNH'ITING AUTHORITY.
Avolicant Information Please Print Lepjibl V, 04t— c)
Name (liusiiirssfOrf,�,tnizatioivindividuni): eAzesHpAe- igno vk)yy_Fw.v.,!z1
Address: P I R a _D9
C> I ax L4
city/state/zip: M-AfJ0V'&P_ M4 Phone#:
Are you nit employer? ('bctk The appropriate box:
Type of project (required):
JQ I all, a employer with _..._cmployms (full and/or part-time).*
7. New conslruction
2.rl 1 am a solo proprietor or partnership and have no employees working for me in
8. Remodeling
any capacity. lNo workers* comp. insurance required.)
9. El Demolition
ri-In a honnowner doing all work mysclf (No wiuke"* camp insuiame required.]
10 n Building addition
1 am a honicowncr iind will he hiring contractors to cond-t nit work an my property, I will
ensure that all contractors either have ivofktas'comperisation insuninct: or are sole
I l.n Electrical repairs Oradditions
propfictom with no employees.
12.n Plumbing repairs or additions
s 0 1 am a genefal conuacAtur and I hive hiied the sub -contractors listed on the attached sheet,
13, [] Roof repa i rs
Tlw,sc sub-cotuniclors have employees and have workers'comp, insurance)
6,n we are a corporation and its afficcrs have exercised their tight ofeiteruption per MG1. c.
152, § 1 (4), and we linve no emplayces. (No workers'comp. insurance rcquircd
Any applicant that checks box #1 must also fill (nit this section below showing their workets'comper=tionpolicy information.
I Tom"owne" NvIni submit this affidavit indicating they am doing all work and then hire outside contractors must submit a nevv affidavit indicating such.
te(unlactors thit check this box must attached an additional sheet showing the no= ofthe sub�coransctms and staic whether or act those entities have
employees Ifthe sub-contractias love employees, dicy must provide their wcAtrs* camp. policy rumiliec
Iii))iaii(,,Pytplo),eriliall,vproi,idiiigii,oi*er.v'conipe,tisatiotilitsitrartceforntyeipiployce,s. Beloit, is thepolicy andjob site
b rination.
I itsurance Company Natne: L1&E4Z_rY F-4010P)L- _ I——
Policy # or Self -ins. Lic. It; _- 'Th -C /C�:) li /
.piration Date: 0
Job Site Address; City/State(Zip:,
Attach a copy ofthe workers'compensition policy decloration page (showing the policy numbe r and expiration date)
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine ofup to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office ofInvestigations of the DIA for insurance
coverage verification.
I do hereby certtfy under fie)iains anelp M -saflietiryffinilth information pro vided abope Is true and correct
Date. 0
Offirial rise only. Do not write in this area, to be conipleted by city or town qfjkfal,
City orTown:
Perinit/License
Issuing Autbority (circle one);
1. Board of Health 2, Building Departinent 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: — Phone
M I tj 0 je- CH
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