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Home My WebLink AboutBuilding Permit #161-14 - 202 LACY STREET 8/15/2013 ,AO RrFf BUILDING PERMIT 0r°4 TOWN OF NORTH ANDOVER ►- l� p� , APPLICATION FOR PLAN EXAMINATION Permit NO. Date Received 4,4"'�,..o►•"'`c`�* Date Issued: _ t 9SSAc►+US�t IMPORTANT: Applicant must complete all items on this page 1 LOCATION C20 ^1\t4 Print PROPERTY OWNERt �U��N�o� j Print MAP NO: / PARCEL: ZONING DISTRICT: Historic District yes no l Machine Shop Village yes no 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 0 Others: ❑ Demolition ❑ Other Septic Well ❑ Floodplain ❑Wetlands 0 Watershed District ❑Water/Sewer. t�tF oc- \AOu5 . Identification Please Type or Print Clearly) I OWNER: Name: Phone: Address: CONTRACTOR Name: G Phone: v i' Address: Supervisor's Construction License: Exp Date: Home Improvement License: Exp. Date:: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING 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 contrac ing with unregistered contractors do not have acs o th anty fund Signature of Agent/OwnerSignature of corgi;Tactor TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain 0 Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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 contracting with xinregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Sigiature of contractor Plans Submitted ❑ Plans Waived, Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OF`.SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMKiIENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes - Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow;: Engineer: Signature: Located 384 Osgood Street FIRE DEPARTME-NT - Temp Dempster on site yes no Located at 124 Mair, Street Fire Departmerit signature.1date f 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 U Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The foLowing is-:a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Bailding 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 apu.zal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 I Locations �.i' r No.�(11 Date ' • - TOWN OF NORTH ANDOVER • Certificate of Occupancy _ $ Building/Frame Permit Fee Foundation Permit Fee '$ Other Permit Fee $ TOTAL $ Check# D 26753 Building Inspector Ir - NORTH _ s E nc .c ve: 0 No. 161 — l * - h , ver, Mass, • coc Nlc Newlc" y1. S U BOARD OF HEALTH Food/Kitchen PER ITT % LD Septic System THIS CERTIFIES THAT AlawT....0 ....11�kL!!1.Is.1 1. BUILDING INSPECTOR has permission to erect Foundation p .......................... buildings on , .�........ ��irl�......�><..�'�....................... _ 1 Rough to be occupied as .&&..Ito � �.sA dft&.'L. '�' �. Chimney .... ..... . ....... ..... ....... ............... provided that the person accepting permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING'INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU SN S Rough (Soho .......... . .... ................... .............................. Service Fina BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Foam The Commonwealth of Massachusetts Print _ Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ryis-Evc Address: 202 l.W Y SIT- City/State/Zip: 04 5 Phone #: 97$ '&S 5, 12471 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp, insurance.$ required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.[l Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job 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 fine 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiQ under the pains andpenalties o er'u that the in ormation provided above is true and correct. � tX13 Signature: — " - Date:. zS ®��1 Phone#: A78 -&T56- 14*71 (,g Q78 - Q`73 .4109 (Cou ) 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: e ttoRTH TOWN OF NORTH ANDOVER OFFICE OF ° , p BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 �ssncHu5 � Telephone(978)688-9545 Gerald A.Brown Fax (978)688-9542 Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Please print DATE: �S I q 1 ZU 13 JOB LOCATION: 2w 't t uy Sz Number Street Address Map/Lot HOMEOWNER`Tb� C_Z�\Gk\WSoa 6f>s -14h q79-Ct73.4109 Name Home Phone Work Phone .O . 1 PRESENT MAILING ADDRESS -P mon333 �c�A43ooy V\A 019 6 t 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 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. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535