HomeMy WebLinkAboutBuilding Permit #545-13 - 200 SUTTON STREET 1/29/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit N0: b—� Date Received
Date Issued: I,— L`1 ,
t " IMP'6RTANT: Applicant
must complete all items on this page
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❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial,
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
demolition
❑ Other
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial,
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
demolition
❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
ntificati n Please Type or Print Clearly)
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OWNER: Name: � // ll Phone:
Address:
CONTTRACTOR
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�`A'ddress
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$upervisorzs�;ConstructiontLicense_,`�i __T zExp tDafe:_ d o �' _.0
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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: $, FEE: $
Check No.: �� �� Receipt No.:
NOTE: Persons contracts ith unregis ere contractors do not have access to the guaranty fu d
Signature of Agent/Owner : ature.of contractor,:
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
ti.
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑Swimming
Tanning/MassageBody Art ❑
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
711
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
4
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comm
Conservation Decision: Com
Water & Sewer Connection/Signature & Date Driveway Permit
IDPH' Towp- Engineer: Signature:
EIRE DEPARTMENT - Temp Dumpster on site
Located at :124 Main'Stre6t:. .
Fire Depai-tmert signatureldate
.COMMENTS
Located 3M Usgooa btreei
yet.-
COMMENTS
es.
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
i
Doc.Building Permit Revised 2010
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
if—Workers Comp Affidavit
❑ Photo Copy d/Cd"r SQL. LI enses
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)
o 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. subm:¢ted with the building application
Doc: Doc.Building Permit Revised 2012
Location p ✓�PZ
No. Date
)34f
Check #
26128
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee .$ 41
Foundation Permit Fee $ �t
Other Permit Fee $
TOTAL $
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
$ 31500.00
m
$ -
$
42.00
Plumbing Fee
$
5.25
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
5.25
Total fees collected
$
152.50
200 Sutton Street Suite 412
545-13 on 2/1/13
Demo of 200 sq. ft. exisitin suite
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Massachuselts - Bepm*tment of Public Sdet%
Board of Building,; Regmiat ons and Standm As
Construction Supervisor License
License: CS 5712
STEVEN C MATSES
202 SUTTON ST
N ANDOVER, MA 01845
( E�mmi�nirmcr
Expiration: 10/23/2013
Tr#: 5888
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
U www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Mk-&, 7 U4/9`1744��-t—MIV Z419MPkAV 7 / /l G -
Address:
City/State/Zip: (, &Vj) A1i1 k &9K Phone #: 9 Y
►re ou an employer? Check the appropriate box:
I am a employer with_ 1;9—
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
❑ I am a sole proprietor or partner-
listed on the attached sheet. t
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
❑ 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. Vemolition
9. ❑ Building addition
1011 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Ly applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
w irn employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
�rmation.
urance Company Narne: nl DKM- N l-rV I�D kJ P%N y`
icy # or Self -ins. Lid. #: XC gV-6 -- Gl k OP A4, -,q 4�- Expiration Date: 3
Site Address: -2� -`5 46'�'-'29N -ST
City/State/Zip: A(, 4 -AID Z, "14 0 / 91y
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
astigations of the DIA for insurance coverage verification.
o hereby certo�ynrlel flie pains ani penalkies VpeVury that the information provided above Vrue and correct.
?k1cial use only. Do not write in this area, to be completer) by city or town official.
:ity or Town:
Permit/License #
ssuing Authority (circle one):
. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Other
`.nntart Parenn• Phnna #-