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Home My WebLink AboutBuilding Permit #870-15 - 267 OSGOOD STREET 5/1/2015BUILDING PERMIT ""KI" 1 I X1, D• 6? TOWN OF NORTH ANDOVER o� yE,�ea�C APPLICATION FOR PLAN EXAMINATION -. �^ b Permit No#: J Date Received �pAo-- gRATFD SSACHl1`-+E� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Si Print �� PROPERTY OWNER �i jA /�o�lT�S Print 100 Year Structure yes no MAP �� PARCELM�� ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building '.One family ❑ Addition ❑ Two or more family ❑ Industrial XA'lteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ElSeptic ❑ Well Floodplain ❑Floodplain �.Wetlands El District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: %c�J5A ��lS�`�. �� 6/.c�� A5� &;&F - r I Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Address: Supervisor's Construction License: Home Improvement License: ARCHITECT/ENGINEER Phone: Exp. Date:_ Exp. Date:_ 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 C st: $ 14*_ — FEE: $ . Check No.: Receipt No.: ;�s (_ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Sianature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments a Conservation Decision: Comments Wafter & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street _ '(FIREDEP,AReT�,M�E�NT ernDumpster o. �iL�ocated atn�1�24�Main�Streeet, ��'_ � � ,, , --,- -•-�-- _ — �a�� 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 DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Klrl I=Q nnrl n®T® _ Wnr rinnarfmPnf use) M =C ..� ..gym .. �• -r- --------- - - ❑ 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 TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ,;6 Building Permit Application 4. 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 TOTE: 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 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 TOTE: 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 No. Date Check # �M TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL Building Inspector 4 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 141100.00 m $ - $ 169.20 Plumbing Fee $ 21.15 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 21.15 Total fees collected $ 311.50 267 Osgood Street 870-15 on 5/1/15 Basement Remodel M n s J W s LL o O m t -0 O O LL E N U 71_ Q U1 (n V d N1 zLLJ z m ° 'O 7 O LL L = O W C E L U td s LL O W a z z., J d t 7 O W _ t6 O LL O0 W a Z J u v W t O d' U _ i> N N to LL cc O 1- W VI N zui cD t j OO K _ r0 LL F- z W 2 a o w LL N i m z +' N v .� N a3 O1 o N Y O E N The Commonwealth of Massachusetts f Department of IndustrialAccidents 1 Congress Street, Suite 100 t Boston, MA 02114-2017 www.mass.gov/dia aV• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: /- Uf City/State/Zip:_�,�G�� Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time). 2.F1 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 41-11 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. S. ❑ 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) 6.8 We are a corporation and its officers 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. M' Remodeling 9. Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ 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 -contractors 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. 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 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 certif nder the pains and penalties of perjury that the information provided above is true and correct. Signature: ze�Date: 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 Person: Phone J ..+lS• . ,-M at*tgdhuseits-Dep�rtmentbfRublic;S fi . ` ! Board of Building Regulations and 5talndards ' Cdnstucti0n Supep<<isor - Cfcerise` CS -026854 PATRICK S CONS` 89 Ames St Methuen MA 01844 Expiration i Commissioner 06/23/201(