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HomeMy WebLinkAboutBuilding Permit #521-11 - 20 FULLER MEADOW ROAD 1/4/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N — l ( Date Received Date Issued:I '— V IMPORTANT: icant must complete all items on this Print PROPERTY OWNER —,nda 1 Print MAP NO: I U Y PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Se tic ®Well �' �❑f �Floodplairi `m°Wetland's,`"� ?'VVatershed}District' (/(?R— Identification Please Type or Print Clearly) OWNER: Name: Phone: M• CONTRACTOR Name: Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. Phone: FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: $ 5 ��v FEE: $_ 6� Receipt No.: �� a 3,� Check No.: � p NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund agent/O �er - _ _- _.4:Signafure. of:confractor :i: �� .;-:� Locatiorc)> tV �I t.L_. �iCG[�DV✓ �yl No. 521 Date NaRTh TOWN OF NORTH ANDOVER 3 � F w 9 yk } �o Certificate of Occupancy $ CMUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # l 23b -,)S Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ f / TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ~- } i -❑ 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 = ; PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Sign_ ature: r --; Located 384 Osgood Street FIRE DEPARTMENT �= Tehip Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 0 Notified for pickup - Date Doc:.Building Permit Revised 2008 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) ❑ Muss 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit a all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording . Lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi The Commonwealth of Massachusetts Department of IndustrialAccid'ents Office of -Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contiactors/JEieci ricians/Plumbers .ApipHeant Information Please Print Legibly Name (B.usiness/Organizatior�/Individual):� 4—�5�0,�/pt?r /�t.'%a (r Address: City/State/Zip: /4/1 X„Co VAF Phone #: / D (Y 6 F 69fc 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.1 ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepaixs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeoviners 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 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 Policy # or Self -ins. Lie. #: Expiration Date: Sob Site Address: 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 flue 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby certif9y under• t pains and penaltiesgfperjury that the informationprovided'above is ue and corn ect. Si afore: Date: Phone #: 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. Cit3ffown Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other C ontactPerson: Phone F tiORTH TOWN OF NORTH ANDOVER Ott�eu 6'5.1.0 ° 6 o OFFICE OF BUILDING DEPARTMENT e� + 1600 Osgood Street Building 20, Suite 2-36 pq mcwww:�c North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: / /r// % JOB LOCATION: a Lz fig-/7� w ZT Number Street AddressMap/Lot HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State _ Zip Code a 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. 61 HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 _R 10651 Date... /v. .": .... ...... NORTq TOWN OF NORTH ANDOVER PERMIT FOR WIRING I,- APIPOR—W SSACMU t'� This certifies that '....�..............��. has permission to perform ................./..4.1.. f.. ...................... wiring in the building of ..................`'.....1.'!.................................. � D..v67 Z at .............orth Andover, Mass. � 00 Fee . � ....-----Lic. No. E CTRICAL INSP &ORS' Check # Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ( EC , 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I City or Town of. NORTH ANDOVER To the Inspeclorlof Wires: By this application the undersigned gives notice o is . r her intention to j]performAelectricall work described below. Location (Street &Number) 2(' �J''�j?y( %%�,/jdU!✓ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Telephone No. No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: . f jyjfa ti� l -r Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. of Emergency Lighting Battery Units No. of Receptacle Outlets S No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. (� of Gas Burners No. of Detection and Initiatin Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons J.KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ns'pections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equiv7ei t. T e undersigned certifies that such coverage is in force, and has exhibited proof of same to the pe it i ui� office.,, // I CHECK ONE: INSURANCE W BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury that the in rniation on thi application is true h�trYcompl FIRMNAME: u /f LIC. NO.: �i Licensee: (> Signature LIC. NO.: (Ifapplicable, e " xe in the license number ' je Bus. Tel. No.: Address: {L Alt. Tel. No.: *Per M.G.L c. 147, S. 57-61, security wor requires Departure of Public Safety "S" License: Lic. No. fAr OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance co age ormally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent P ERMIT FEE. $ ©D Signature Telephone No. 5 p6l-�q &k r. 1 sl 70M c c ID c C H or - C.3 C. G3C) cm a � ca c .= o o CD Ea CDC o a N 3 ,o m v' V c O `1 Ci s! 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