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Home My WebLink AboutBuilding Permit #155-11 - 27 HIGH PLAINS ROAD 8/23/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Dale Received Date Issued: 3 J/ 1 IWORTANT:Applicant must complete all items on this page I LOCATION o21`- Print D PROPERTY OWNER 0 Print MAP NO:��0 PARCEL: 0 O f3ZONING DISTRICT: Historic District yesno Machine Shop Village yes no lift TYPE OF IMPROVEMENT PROPOSED USE - Residential rNon- Residential D New Building XOne family 0 Addition _ -.11 Two or more family __ 0 Industrial ❑Alteration No. of units: ❑Commercial KRepair, replacement ❑Assessory Bldg ❑ Others: 11 Demolition El Other , ® Septic ' ❑gWell SIT - ®Floodplain r ®wetlands 9 .u. z'�, �Y � k x atersliedlDist`rict� yX, DES C.c TION OF WORK TO BE PERIF,'0iD: -rcv� OP (ru5-12— cz^J - it - (Identification Please Type or Print Clearly) OWNER: Name: _(1,/ -A M a x Phone: 4-7k-6 P'� —3Lo ,c Address: 7 �1 PIC, tz CONTRACTOR Name: _ t o i-_ �e u,,, _ - Phone: `�7� ' Z - .,-(-757 Address: o� '7 tM 5 G w�e�crL c�t iiy Supervisor's Construction License: Exp. Date: i i Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: it Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT,$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ac(77 FEE: $ 0 Check No.:— Receipt No.: ` O U NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - - - _ _ S nature of A ent/Owner . .: Ak� Signature of contractor g _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL ' Public Sewer ❑ Tanning/Massage/Body Art ❑ Swij m 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS - Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes r Planning Board'Decision: Comments Conservation Decision: Comments Wafer& 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 , h Fire Department signature/date COMMENTS { Dimension Number of Stories:_' Total square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: _ ELECTRICAL: Movement of Dieter 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 AT NOTES and DATA— For department use 1I _ ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi � 1 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 ❑ Wo—i kers Camp Affidavit ❑: Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg PerrN 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 ❑ Flo o r/Crossectio n/E levation Plan Of Proposed Work With Sprinkler Pian 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 Perm 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NNOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Perm 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: Doc.Building Permit Revised 2008mi i i Location / No. Date -Of ^ �1 NORTH TOWN OF NORTH ANDOVER O _ L mo Io Certificate of Occupancy $ s�cNUsE`A Building/Frame Permit Fee $ i Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � 24560 Building Inspector r The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street " Boston,MA 02111 www.mass90v1dia Workers' Compensation Insurance Affidavit: builders/Con>tractorsAFIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ��' � c < < / , 0 7�l�� Z)44c-t/)6_e_iP_ Address: v �3 i7't/-P ( A- 0 IFl`( City/State/Zip: (� Phone#: 9?s--6,K6 - 3 G o Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. F1 New construction employees(full and/or part-time).' have hired the sub-contractors 2. a listed on the attached sheet.1 7• ❑Remodeling ❑ I m a sole proprietor or artner- p p P ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.;[No workers'comp. c. 152,§1(4),and we have no . 12.0 Roofxepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeotiyners who submit this affidavit indicating they are doing all work and Then hire outside contractors must submit anew affidavit indicating such. tContractors 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.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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert!y under the pains andpenal 'es of perjury that the information provided above is true and correct. Si ature: A11c, Date: S-12 Phone#: [[OfTlecial use only. Do not write in this area,to be completed by city or town official ity or Town: Permit/License# suing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: F NoerH TOWN OF NORTH ANDOVER 20��t�e° r6 ayQ 6.� o OFFICE OF ti BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 'y ��.° °" 5 North Andover'Massachusetts 01845 �SSacHus�� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE:_ JOB LOCATION: Pic / r (�_J Number Street Address Map/Lot $OMEOWNER 1 h ►nI1 i' �.2� �7�" S-6 Name I Home Phone Work Phone PRESENT MAILING ADDRESS—.... /U, A-/\d w.-P r c� c l City Town Sure. 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 awns 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 fancily 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 r:. APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i N®RTH Town of _ rAndover , 0 No. � S' P- _ _ �y`q 2 - lover, Mass. Q ^ _ LAK O 1 C OC HICHEMCK �®ADRATED U BOARD OF HEALTH Food/Kitchen Septic System . .PERMIT . T 11 BUILDING INSPECTOR L THIS CERTIFIES THAT................... .. 0.h�....... - ................... . .................. Foundation P 1 � oun anon tz has permission to erect....... ............................... buildings on ....�. ... .......�. ..�... ...��.�.lt.................. ................. Rough to be occupied as................... ........... .1....' .....1..K..0=.......SA Q�........... .. ... .0=-•.........0............................ -Chimney provided that the person accepting this ermit shall in every respect conform to the terms of the application on file in Final 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 0000 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR O� UNLESS C®NSTRLJCTIRT TS Rough. .. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final c = No Lathing or Dry Wall To Be Done FIRET _DEPARTMEN Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SI®E Smoke Det. 1