HomeMy WebLinkAboutBuilding Permit #283-2017 - 241 MASSACHUSETTS AVENUE 9/16/2016 1 �p O� NORth q
BUILDING PERMIT
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1 m TOWN OF NORTH ANDOVER � p
�J, APPLICATION FOR PLAN EXAMINATION «
Permit N0: " -Nj Date Received '� �•�'" °"+
Date Issued:
�9SSACHUS
IMP RTANT: Applicant must complete all items on this page
LOCATION-241 -d--xki✓er- �4,4•
Print
PROPERTY OWNERcQ-E t i k 14 c,*Inpr
/ Print
MAP NO: b t PARCEL: 661S DISTRICT: Historic District yes no
Machine Shop Village yes o
i
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alt ation No. of units: ❑ Commercial
w1tepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic ❑Well Floodplain ❑Wetlands Watershed District
Water/Sewer
Identification Please Type or Print Clearly)
OWNER: Name: Ju ;h .. �Ae -A�ne-c- C,; Phone• R7S-C L-)1--( 0'-{ I
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement L'
p t icense:
Exp. Date: i
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: $ OCA FEE: $ Cao - p 0
Check No.: Receipt No.: Q C
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ignature of Agent/Owner Signature of contractor
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OF NORTH y
BUILDING PERMIT �.0-ED 116
TOWN OF NORTH ANDOVER n
APPLICATION FOR PLAN EXAMINATION
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Permit No#• Date Received °R�reD
..SSRCHus�t
Date Issued,
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT-.—Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
[IAddition ❑ Two or more family ❑ Industrial
❑Alteration
No. of units: ❑ Commercial
ssessor Bld ❑
Others:
p
❑ Repair, replacement ❑A Y g
❑ Demolition ❑ Other
Septic ®W .1 –-- ® 'Fbo plaint »1lUef.la rn s, L71 1111st ser pied'U tal l
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: - Exp. Date:
Home Improvement License: _-Exp. Date:
ARCHITECT/ENGINEER Phone:
1
Address: Reg. No.
FEE SCHEDULE.BULD/NG PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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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
OTE: 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
ISIOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
I
Building Permit Application
Certified Proposed Plot Plan l
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
2012 I ECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
then get this recorded at the Registry of Deeds. One copy and proof of recording
that the appeal period is over. The applicant must
must be submitted with the building application
Doc:Building Permit Revised 2014
I
1
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 ❑
N
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Si
qnature
4
COMMENTS
WEALTH 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& ®ate Driveway Permit
DPW Town Engineer: Siannature:
Located 384 Osgood Street
FIRE DEPARTMEIVl° - Temp.Dumpsfer,on-site ,yes,
Located af,124iMain Street .,
Fi'r'eRDepartment signafiiare/date
e
COMMENTS
_ qtr;• ,:�.t.,
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.$10041000 fine
NOTES and DATA--
— (For department
( use)
i
® Notified for pickup Call Email
_ I
Date Time Contact Name
Doc.Building Permit Revised 2014
Location a� moss Pv L
No. Date
• - TOWN OF NORTH ANDOVER
• N
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# lop
9
Building Inspector
sndover9
Town Of s
O
z h ver Mass
o
C OC HIC Nl WIC K
Ab
°RArEo 1p"Pa`y�(5
'9S U 'L
BOARD OF HEALTH
PERMIT T D
Food/Kitchen
Septic System
THIS CERTIFIES THAT 14. 4 h r
..... ................. BUILDING INSPECTOR
...►.................................................................
has permission to erect , buildings on Foundation
......................... .............................................................................
Rough
to be occupied as ROOR 14; V,............. `............................................pp............. Chimney
provided that the person accepting this permit shall in every respect conform to the terms of thea 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 CONSTRUCTION STARTS Rough
Service
................................................................................ Final
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.
°E p°Tst TOWN OF NORTH ANDOVER
°p OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
# North Andover,Massachusetts 01845
�SSACHUS�
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE:cA • t5 , 2-bkG
JOB LOCATION: 2141 Y'l&25-25• Ave- Uj , vim r),1A. O kVS
Number Street Address Map/Lot
HOMEOWNER q7
Name Home Phone „// Work Phone
PRESENT MAILING ADDRESS Z-{ (`-(CSS 4L4-
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
The Commonwealth of Massachusetts
Department of IndustrialAccidents
b X 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.
Aimlicant Information Please Print Legib
Name(Business/Organization/Individual): —�✓1Qr �,
Address: �(� ,,
City/State/Zip: e phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
apacity.[No workers'comp.insurance required.]
9. El Demolition
3. am a homeowner doing all work myself.[No workers'comp.insurance required.]t
,
10❑Building addition
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 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[ Of repairs
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. 14.E]Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
i
*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-contractors have employees,they must provide their workers'comp.policy number.
I attt att employer•titat is providitig wot'kers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.M 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 j
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 certify tinder th pains and penalties of perjury that the information provided above is true and correct
i nature: 4L, Date:
Phone#: 90041
Official use only. Do not write in this area,to be completed by city or tmvn 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#: