HomeMy WebLinkAboutBuilding Permit #542 - 250 ANDOVER STREET 4/15/2009BUILDING PERMIT
ttLED 6
TOWN OF NORTH ANDOVER 02
APPLICATION FOR PLAN EXAMINATION
Permit NO: i5v Date Received i p
9SSACHUSE�
Date Issued: /f—af
IMPORTANT: Applicant must complete all items on this Daae
LOCATION
PROPERTY OWNER M g N 0 P drint
OU
Print
MAP NO:PARCEI.,0 ZONING DISTRICT: Historic District yes no
- PMachine Shop Village yes no
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
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
OWNER: Name:
Address:
CONTRACTOR
Address:
DESCRIPTION OF WORK TO BE PREFORMED:
R
or Print Clearly)
Phone:
/- T /4/1d Ove l M A -
Supervisor's Construction. License:
Home Improvement License:
ARCH ITECT/ENGINEE
Address:
Phone:
Exp, Date:
Exp. Date:
Phone:_
Reg. No._
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
.o
Total Project Cost: $ �U �% 1 FEE: $ y
Check No.: 1-44� Receipt No.: tX l
NOTE: Persons contracting with unrigistered contractors do not have access to the guaranty fund
'_Agent1Owner E ignature of contractor
Location ,)o
No. 5� Date
MOR7M
TOWN OF NORTH
ANDOVER
/O.
9
Certificate Occupancy
of
$
�'� s"••° • tt�
AC Nus
Building/Frame Permit Fee
$
Foundation Permit Fee
$
V
Other Permit Fee
$
TOTAL
$
Check #
21952
Building Inspector
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
a
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comm
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)
❑ 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
❑ 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
D 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)
o 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
❑ 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
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
r I www_n uss gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual): %loo cl �e_-
Address: 2LO 4 —d Dc. , S
City/State/Zip4— 2a —0)-6L(6—Phone #:
q 7T / 5 l
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (fun and/or part-time).*
2. ❑ I am.a:sole proprietor or
have hired the sub -contractors
listed t
partner-
on the attached sheet
ship and have no employees
These sub -contractors have
working for me .in any capacity.
comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
red.)
officers have exercised their
3.6/1workers'
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.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
- — m • �uuai wav nu out me ==On below showing their workem compensation policy information.
t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contactors must submit a new affidavit indicating such.
4conttactors that check this box mustatUtched as additional shectshow itg. E}te nems of the su`v-conttactots and their wortcerz' a_..;, , p^VlicJ infomratioa.
lam an employer that is provWtng:workers' compensation insurance for my information emPloyem, Below is he o 'and ob site
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 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 font 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby cf Jy under th,,pat and p%en ofPerjzuy that the information provided above is true and correct
Signature: G"( Ld�� � l
Date-. P—
Phone #:
Official use only. Do not write in this area, to be confpleted by city or town ofcial
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector
6. Other 5. Plumbing Inspector
Contact Person: Phone #:
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 689-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Plean mint
DATE: 200!1
JOB LOCATION: 2S-0 qvjoAel-
Number Street Address
HOMEOWNER A f UC q62
Name Home Phone Work Phone
f
PRESENT MAILING ADDRESS 2 �0 A J v J f >-r
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 winch 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
I
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeawam Exemption
ROARD OF \PPEA1- S 689-9541 CONSERVATION688-9530 HEALTH 688-9540 PLAN-NING 688-9535
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