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Home My WebLink AboutBuilding Permit #107 - 240 STEVENS STREET 1/24/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NOU Date Received Date Issued: F _ _ IWORTANT:Applicant must complete all items on this page LOCATION go e v an Print flo PROPERTY OWNER t print MAP . (�PAR E G ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential ��Resi tial ❑ Ne�rz, ding ❑Addition [ITwo or more family ❑Industrial ❑Alteration No. of units: ❑ Commercial ' ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other - � / ,DESCRIPTION OF WORK/TO BE PERFORMED: �n 5 Ttr. 11 h or C c n c�� 'l .-�c a 4 Crfb��N c - VA- C ( 'CA # Pee M • Identification Please Type or Print Clearly) OWNER: Name: Phond: - Address: p / CONTRACTOR Name: d M (4eaf1Yl q C. Phone: 781- 316 C 3 il-3 Address: /L/ . a 17/(- Supervisor's 7/bSupervisor's Construction License: a `l L g 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 COS7BASED ONS 00 PER S.F. Total Project Cost: $ /` �O FE Check No.: w Receipt No.: G �� NOTE: Persons contracting with unregistered contractors do not have a cess to the guaranty fund ,— Sign. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art El Swimming Pools ❑ WeII ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY - INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on. Signature COMMENTS i a HEALTH Reviewed on Signature COMMENTS } y Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connertion/Signature&Date Driveway Permit DPW Town]Engineer: Signature: FIRE DEPARTMENT - Temp Dempster on site yes Located 384 Osgood Streetno Located at 124 Main Street Fire Department signature/date COV:II MNTS 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 Revised 2008 Doc:.Etuldmg?oruut R i C Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, S' •� 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 u 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 o 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 . OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals it the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording ist be submitted with the building application Doe: Doc.Building permit Revised 2008mi y` 107 Date./. e--,-��(�. i r r ,�ORTIy TOWN OF NORTH ANDOVER of ,tio PERMIT FOR MECHANICAL INSTALLATION f f 9 h �.Is I sACNUSE This certifies that . .,l.f. . . ./.!l. . f . . . . has permission for mecha/ni'cal installation . . . . r' / � in the buildings of . . . /l i? :. . '.`. . . . . . . . . . . . . . . . at .` . . .� �.�'.�!�� ';� . . , North Andover, Mass. Fee. Lic. No. GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer The Commonwealth of Massachusetts Department of IndustrialAceidents Office of Investigations 600 Washington Street Boston,MA. 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/iElectricians)Plumbers Applicant Information b �^ Please Print Legily NaMe(Business/Organization/Individual): ( 'a(�,C,, l,�c A CMM(►�0- L .Lc Address: M b MtA&4,,i✓ City/State/Zip: rel ap$p d-�17 6 Phone#:-I ( ja Tg Are y an empIoyex?Check the appropriate box: Type of project(required): 1.RI am a employer with-e,�) — 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/orpart-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.r 7. ❑Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, auilding addition [No workers'comp.insurance 5. Ee are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[]Plumbing-repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 1311 Other comp.insurance required.] ?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 a new 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 insurancefor 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify uncle the pains dpe alties ofperjury that the information provided above is true and torr ect. Signature: Date: f Phone#: ELM e only. Do not write in this area,to be completed by city or town official wn: Permit/License# thority(circle one): Health 2.Building Department 3.City/Town Clerk 4.EIectricaI Inspector 5.PIumbing Inspector rson: Phone#: