HomeMy WebLinkAboutBuilding Permit #757-2017 - 205 BRENTWOOD CIRCLE 2/3/2017►� �I CSNBUILDING PERMIT
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINATION " -
Permit 140: 257 7 " P-61? Date Received
C US
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION `� /Z V f W d 0'0
Print
PROPERTY OWNER it/1 a l� (� L v / �✓
Print ; Cr
MAP NO: PARC
EL: ZONING DISTRICT: Historic District yes
Machine Shoo Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
^e ew Building
Nddition
ne family
Ewo or more family
„': Ei
ndustrial
&Iteration
No. of units:
E? ^, ommercial
LoJZepair, replacement
E ssessory Bldg
E'� Others:
of emolition
08 ther
-
�a ptic ell
e
..;.Ery. ..
plain � etlands
En
atershed District
dEo r
ilater/Sewer
_.
'k6)a*\ %rfj7 / a � pi d 6 6 (-
OWNER: Name
Address: 0 S
Addressd
s=
SupeN or:'s Con
Identification Please Type or Print Clearly)
Tl ivi o,r/- Y C—a Ly iy Phone:
6 fi 0LI-r w opt) C/1iGCc POP-- -1
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.: 1, °T' Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
4-q..-AlIq C?Ca (BUILDING PERMIToiL TOWN OF NORTH ANDOVER I.
�) APPLICATION FOR PLAN EXAMINATION «
Permit NO: 775% " of /* "
Date Received
qp
Date Issued: 9SSwc►wSEt
IMPORTANT: Applicant must complete all items on this paee
LOCATION 0 S I J lL Eli/ 1 'w d 0 b C 1 k� L ��
PROPERTY OWNER Tim % il y Print C, -A L - v IJ
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Villaae ves n;ol
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
U' ew Building
Wne family
0o ddition
qa wo or more family
Andustrial
Alteration
No. of units:
^i ommercial
�9epair, replacement
-Z ssessory Bldg
o8 Others:
0o emolition
n& ther
a. eptic .o ell
o. loodplain Netlands
L --Watershed District
ater/Sewer
1)td0&\
OWNER: Name:
Address: 9,C15-
TIMOTHY
,dS
(J -f / aomm6c-
Identification Please Type or Print Clearly)
TIMGTHY C—q L V 1 y Phone:
[3 h,ETlL/y" w 00t) C1fi&C I P09714 A1-1f)6>VCC
CONTRACTOR Name:
Address:
Supervisor's Construction License:
Home Improvement License:
ARCHITECT/ENGINEE
Address:
Phone:
Exp. Date:
Exp. Date:
Phone:
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: $ 0 Q 0 FEE: $ 0
Check No.: /,?(o Receipt No.:
NOTE: Persons ntracting with unregistered contractors do not have access to the guarantyfund
Signature_ of Agent/Owne � yignature of contractor
Location 0 Q
,0S 6re✓44,,,600 (filL
No. 7S 7 - gyo /'? Date �z 7
Check# 1-707
31499
TOWN OF NORTH ANDOVER
Certificate of occupancy
Building/Frame Permit Fee $e'- 410
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
h
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE APPROVED
Reviewed on Signature
Reviewed on 3 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
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.$10041000 fine
NOTES and DATA — (For department use
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
No
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
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulil
Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
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
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
Doc I\SPECrIo\,\L SERVICES DEP MTNIEN'r:UPF0RN115
Parc 4 of -1
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 209000.00
m
$ -
$
240.00
Plumbing Fee
$
30.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
30.00
Total fees collected
$
400.00
205 Brentwood Circle
757-2017 on 2/3/2017
bathroom remodel
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NORTN
S�1CFtt15
Gerald A. Brown
Inspector of Buildings
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Telephone (978) 688-9545
Fax (978) 688-9542
Please print
DATE: (� /
JOB LOCATION: 2-05 f' Z e k W.9 0,9 Cl 6q
Number Street Address Map/Lot
HOMEOWNER M a TI -Q' i C— A L V i fV , 7 t/, �f -;d6 i q 79' - P
Name
PRESENT MAILING ADDRESS
LJ,MTti Akl& eek
City Town
Home Phone '
;-0 S' ij %Z F1v%wo60
J41 4r
State
Work Phone
C//G C L (-
of 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" 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 STGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
'., Tlie Commonwealth of Massachusetts
Department of Industrial Accidents
X Congress Street, Suite 100
Boston, MA 0.2114-2017
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractois/Electricians/PIumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Ledbl
-� y
Name (BusineWOrganization/Individual): / L V / t�
Address:—�- 0 S 6 tl6ILI V 7d I k C (_
City/State/Zip: W IL I -f AV /i 0V
#: q -7? --3(y—000?
Are you an employer? Check the npproprinte box:
LE] 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.]
3gI am a homeowner doing all work myself. [No workers' comp. insurance required.) t
4.❑ 1 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. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.)
Type of project (required):
7. ❑ New construction
8- Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.❑ Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13. ❑ Roof repairs
14. ❑ Other
*Any applicant that checks box iil must also fill out tho 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 employees, they must provide their workers' comp. policy number.
I ant an ernployer tliat is providing workers' eonlpeirsodorr iilsruailce for iiiy er»ployees. Below is the policy and job site
inforirration.
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 MGL c. 1.52, §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 of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify r der thepains mr penalties ofper jury that the irrforniation provided above is trlre ird correct
Si nature: -7 Date: / 7
Phone #: q-7 l � Oy 1
Official use only. Do not sprite 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 Cleric 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone M
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M
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6656 3044
MASTER BEDROOM
605 sq ft
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