HomeMy WebLinkAboutBuilding Permit #514 - 21 WEYLAND CIRCLE 1/3/2011Permit NO: 15-1114 '
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this pate
LOCATION oil W(-Y(AA 1 aft CLE
Print
PROPERTY OWNER 0 ff-Z
Print
MAP NO: �r PARCEL: 3 S'ZONING DISTRICT: Historic District yes
Machine Shop Village yes a
TYPE OF IMPROVEMENT
PROPOSED USE
Residential .
Non- Residential
❑ New Building
§(One family
❑ Addition
❑ Two or more family
❑ Industrial
Pkteration
-No: of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other -
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DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly) /
OWNER: Name: y19- tP<,a,aslt z Phone:vNy3
Address: 91 V, rl( _
CONTRACTOR Name: ,.i h t+ ( - Phone:
Address:
Supervisor's Construction License:
Home Improvement License:
Exp. Date:
Exp. Date:
ARCHITECT/ENGINEER Phone:
Address:
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: $ -:1S 0 0 FEE: $_'S 0,,.,576
Check No.: CP Receipt No.: c 3
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ l Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer V
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
s
COMMENTS '
CONSERVATION Reviewed on Signature
COMMENTS -
HEALTH Reviewed on Signature
COMMENTS
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: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp 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
U 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
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
❑ Certified 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
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
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ Mass check Energy Compliance Report
a 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
:hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
oust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Location % 1 (A y 4 l4 14
No. _ << Date �T
TOWN OF NORTH ANDOVER
" w
o Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2384 8
Building Inspector
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The Commonwealth of Massachusetts
Department of Industrial,Accid'ents
Ofjlce of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/JE+ lectriciansfPlumbers
.Applicant Information Please Print Legibly
Name (Business/organization/Individual): Y/O1 KJ_ o��Vr
Address: ' i al,_v %w� Ci 6C ( �,
City/State/Zip: lJoi(f \ /q,-Joyy /4,4 Phone #: 911-Od -34fC-'
Axe you an employer? Check the appropriate box:
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
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
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
f 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.] t
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
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box 41 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 anew affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam 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. Lic.
Job Site Address:
Expiration Date:
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 ofthis statementmaybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the painsapdpenaldes ofperjury that the information provided above is true and correct.
Phone #• 5 -kA - 6; -Yf c'
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
PermitUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
tiORTH
TOWN OF NORTH ANDOVER
OF ,S�eo 6'S4,
°L
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
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:_ 1a-1 2-31 1 D
JOB LOCATION: 4g i
Number Street Address Map/Lot
HOMEOWNER Y46L— V,0009fi 313 -6 Qj 65. U 512 -a04 -ot4Lr- .
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
14-
Caty Town Sf�t� . Zip Cede
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. 1
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 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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