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HomeMy WebLinkAboutBuilding Permit #729-15 - 21 LINCOLN STREET 3/23/2015BUILDING PERMIT TOWN OF NORTH -ANDOVER':: APPLICATION FOR PLAN EXAM INA-f"ION' Permit No#: / Date:Receiveci t Date Issued:��� IMPORTANT: Applicant nUf9t complefe alI%i#ernsi on this.`page ��P�"rn�'�`Y spa � �. - v iPR®PE,R�Tr�P OWNER_,.- `� ,�,. •` - Print° X00}YSFuetu a eyes i �IVIAP4.' +PAFtCEZONtNGa®IS7 RIOT 1Histonc®:tstTict Yyes ono - k ... fN1ar..hifiP l hnn^ lanei ViaE, 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 ❑'S�e et c ©r'q k 1 T j� ®Floodplain t3^i❑ Vlfetlandse" Y � p Wa shed. God - M ;, t � Water/SeW9 --- i DESCRIPTION OF WORK TO BE PERFORMED':. �- `�J Identification - Please Type or -Print' Clearly' OWNER: Name: k 211n V (A\ L;^rn\k C1— rvr)(--k A„ A_., -r - me: lCk A q-1 ) K' /AI i► A 6 d t i. -- Address: ... _ - -- - u . . i — - s \C;z -V-• . j r • I t -r v l P 7 5 'Contract®r[fa_7 ��Address: p Supervisors EC�onstr�uction iLlcense _.t �IHorne�[Irnprou�_t1Lic-erase__ _ �„�p� ,ja�e,�e � �,. ARCH ITECT/ENGINEE Phone: Address: Reg -N6:,:-. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE'TOTAL ESTIMATED COST`BASED ON $125.00 PER S.F. Total Project Cost: $ �a 1 qo() Check No.: /AGO � eceipt'"N.o,'�.- . �• L NOTE: Persons contractinghvith u> We ed contractors-do._fiot:have,access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -rypF-Z)F 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 Reviewed On . Signature Reviewed on Signature Reviewed on Signature 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 Town Engineer: -Signa F�,IREDEPARTME T Tern f®um a sten ®nE sitees ca a n© o sgooree Skocatetlkat 024iMainStreef° F; ireDepartments`ia -- -- --- - gnatur�e/d�te Dimension Number of Stories: Total square feet of,.flcaor. area,::.based on;:�Exte io.r dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mastor'servid&dr'op'requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No' 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 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/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 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 a 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 VOTE: 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 Doc: Building Permit Revised 2014 Location UC Yl L` dy, S No. 1 ` Date3) 2,3 1J TOWN OF NORTH ANDOVER Certificate of Occupancy $1 1A Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r, Check # 28581 Building Inspector O V v ui (L U) CL °: z 'oo p 0 : J_ N V Q 8 o to � - 0 z O O O (� L 5 V N G CL Cc w Lu - t/1 ,: ea V N a z N a c X O LU ' 1 �- E O cc U �• -i:_: N O 0)N O O � '> 2�2_�� CL -1; a• Q m 0 ) 0 c =c a L ev .o o �n CL «. Cl)w 7 oo IL N O O N 'M O F- Ns O '� '� - z W va v V Q 0-0cc H t .0.. Q- O Ci -5 tea. ry V O s 2 v E d i O Z N O = N0 �E m m i d O �1 d L) O L- m O C. Q. Q OM _ v_ J .Q O .� � Z � V CL CL ca � U B I x Q W x LL O D cr O mO w \ O t, E N U CL Ln cr W d z Z m C "O O LL L O W C U to LL 0 W 0. Z t7 Z m J d L j d' co LL W N Z Q U J W L CC Ut >m Ln LL oc O U LLI Z N cr ca LL Z W Q LLIa 5 LL N m +' N N N O 0 N O V v ui (L U) CL °: z 'oo p 0 : J_ N V Q 8 o to � - 0 z O O O (� L 5 V N G CL Cc w Lu - t/1 ,: ea V N a z N a c X O LU ' 1 �- E O cc U �• -i:_: N O 0)N O O � '> 2�2_�� CL -1; a• Q m 0 ) 0 c =c a L ev .o o �n CL «. Cl)w 7 oo IL N O O N 'M O F- Ns O '� '� - z W va v V Q 0-0cc H t .0.. Q- O Ci -5 tea. ry V O s 2 v E d i O Z N O = N0 �E m m i d O �1 d L) O L- m O C. Q. Q OM _ v_ J .Q O .� � Z � V CL CL ca � U B I The Commonwealth of Massachusetts Department of Industrial Accidents a _ , 1 Congress Street, Suite 100 Boston, MA 02114-2017; www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information I `, Please Print Legibly Name (Business/OrganizationAndividual): KQ rvA-K (_/�b+l jcyl 5 Address: of 1 L ' r�, &o 1 r\. Sr ` City/State/Zip: N �� ��-L (_1 Pr Pone # Are you an employer? Check the appropriate box: 1. ❑ 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 an acity. [No workers' comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I 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.t 6. ❑ We are a corporatiofficers on and its ocers 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. F1 Remodeling 9. ❑ Demolition 10 0 Building addition 11.0 Electrical repairs or additions 12.0 Plumbing repairs or additions 13. RRoof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the 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. #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-contraciors 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. Lie. 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. 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 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. I do hereby cer under the ains andpenalties ofperjury that the information provided above is true and correct Si nature: /�Date: 3 Phone #: nl g "' `1 7 /J — D,5— y 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 Phone TOWN OF NORTH ANDOVEi. BuffiDING DEPART • ' a X600 0sgooaStrOctBtuldin 2 ?g6 r 7- sa�� n •4"` y Nbrih Au.dovex� Massaeh u etis 01845 SRC}It15� • Gerald A. Brown Telephone (978) 688-9545 1nspectorofBi ldings Fax (978) 689-9542 . HOMEOWNER.•LICENSEEXEMPTION ' - BMD)NG PFMT A!PLZCAT10N Pleas-- ey ._riot DATE:- -B LOCATION: a l - L ► �� (� 5 ��� �- a PFK t9AZoVer Number SireetAddress Map/Lot I50MEOWNER PI(M L4(t�Jee-s • IN .. Home Phone Workmone -PRE-SENT MAIiRG ADDRESS a �; ° S }• - • . City d StEk • 7p 7Li.�i%-ter The current exemption for "-homeow_n_ers" was extended to i aolucie owner occupied 10 allow su- ,h homao; rdivellugs to two units -ox li�Ss anduem to engage aa?-raViaual•forhire, -rho does notpossess a license, provided that the owner acts as supervisor). StateDuilding (Code Section DEMITION OFROMEOWNER Persons) who awns aparcel ofla. bed on which. helshe. resides or iutends to reside, on Which there is, or is intended to ' , a one ortwo fbzaUYstzuctures. Aperson.who constroctsmorethat-onehome in.atwoyearpeiiodshah ztotbe considered a homeowner. The undersigned "homedwner°' assumes responsibility forcompliances with the State Duilding Code and other .Applicable codes, by-laws, rules andxegalations. • The undersigned "homeowner' cez ties that he/she understands the Town of North Andover Building D e&rtment minimum inspection procedures and re ' ements and that helshe will comply with,said procedures and requirements, - IIOAMDWNI3RS SIGNATURE .A.PPR.OVAL OF BUILDMG OFFICIAL Revised 7.2009 )FOnn Homeowners J3x&nption •23OARb OFAPPEAYS 688-9541 CO3\SF-RVATI0N 688-9530 HEALPIi 688-9540 PL&NNING 688 9535