HomeMy WebLinkAboutBuilding Permit #653 - 27 FOSS ROAD 4/9/2007BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued: I
Date Received
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DESCRIPTION OF WORK TO BE PREFORMED:
�o
Identification
OWNER: Name:
Type or Print Clearly)
W'
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: $cf� (1c)o - ca) FEE: $ 3
Check No.: Receipt No.: tsl—UJ de�-
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Locationc
No. 615— Date
32
TOWN OF NORTH ANDOVER
Certificate Occupancy
$
i SIL
o
of
Building/Frame Permit Fee
$ 3D
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
Check #
20'1 08
g Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Swimming Pools ❑
Public Sewer 11Tanning/Tanning/Massage/Body Art 11
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 ❑ El
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION El E
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ElE
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planr+ing Board Decision: Comments
Conservation Decision: Comm
Water & Sewer Connectio
Located at 384 Osgood Street
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
Doc.Building Permit Revised 2007
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
o Building Permit Application
o 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
L, Certified Surveyed Plot Plan
a Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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
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)
❑ 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
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 2.2007
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NORTN
TOWN OF NORTH ANDOVER
9SSACHU`'Et
BUILDING DEPARTMENT
1600 OSGOOD ST
BUILDING 20 SUITE 2-36
NORTH ANDOVER MA 01845
978-688-9545
978-688-9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print
DATE0-7
JOB LOCATION 1 S 1 Coli P
Number Street Address Map/Lot
HOMEOWNER D ( Rem O'k
Name
PRESENT MAILING ADDRESS 5/3
City/Town
Home Phone W
State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings of
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, one or two family dwelling, attached or detached structures attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a two-year
period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance 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. k
HOMEWOWNER'S SIGNATURE
APROVAL OF BUILDING
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
a www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual):— . 1 /, AlS fM Oes__ .n�
Address:
City/State/Zip:_/A) Phone #: �'1 4�35D del
Are you an employer? Check the appropriate box:
L ❑ 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. I
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
required.]
officers have exercised their
3. I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, b 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.❑ Electrical repairs or additions
11.❑ Plymbing repairs or additions
12.❑ Roof repairs
13.❑ Other
-tiny appncanr mai cnecKs oox s i must also till 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.
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. Lica #:
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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby frtify under the patins and penalties ofperjury that the information provided above is true and correct.
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 #: