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Home My WebLink AboutBuilding Permit #816 - 27 MARBLEHEAD STREET 6/2/2011Permit NO:rc/ Date TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received " " IMPORTANT: Applicant must complete all items on this -Daae LOCATION&9�Ta - NLS tI .e Ine�o_ J_ Print PROPERTY OWNER � _� o fl -Q Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition wo or more family [No. ❑ Industrial ❑ Alteration of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other -. _ 0't,S p cJ ,0Well I _ - i®tFloodplaii� I] We"Hands T-❑WatersledTst _ ct ater/Sewer - DESCRIPTION OF WORK TO BE P _ (Identification Please Type or Print Clearly) i OWNER: Name: Jam} -fit 1 CJ; )(DP_aln,Phone �l 35y`- � ys� Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: s®o --�� FEE: $� .Check No.: - 7 �� Receipt No.: NOTE: Perso— n�ont6•acting with unregistered contractors do not have access to the guaranty fund 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 ❑ 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) ❑ 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: Doc.Building Permit Revised 2008mi 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature s COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board -Decision: Comme Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes, Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no � 4 Dimensi®n 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 NU I t5 and UA I A — II -or department use LI Notified for pickup - Date Doc:.Building Permit Revised 2008mi joloodsul 6uipjing 217,tz # loaUo $ Iviol $ aad ;!woad J8410 $ aad IIWAGd uoilepunod ..Sn" $aad IiwJad aweJd/6uip�in8 v>o....�� $ Aouedn000 jo aleoi;ipoo R a3AOaNd HltION JO NMOL 1 _Z _ ales �z.b 'ON N m m m CO) m m v Nf •.0 C d CD a Z y CD O CL =rc 0. = CO) n� -v CD o p CD O CL CD CCD O CCD w w C O co) CD Q O CO) CO O CD z r V J n O cn C/) 2 ON OO Cn C 9 910 _ O • co- O Cc N dS m .0 y .:.1 »®c m C7 CD Cox CCD 7 aO M= Ma s m Cm y CD O m y p N O = m ® _ > >� co, C co CD OOZ y. C -A W .'ZOO' Cos =_ O aCD CD CD C C-3-0 CD m O H N CL C :a H �C9 O Z H H N Q O m H : CD a CD o 0 CACDo CD m a ;w CO) ��' O W d d n� CA O • :� C O CDO = � CD Cn Cn Z o to�r7 ro '� b -A Cn pi ro jC r" 00 ai V]o c' h 1 rt o y 0 9 v PL O v ,1 Iv �. µORTH TOWN OF NORTH ANDOVER pL OFFICE OF a O BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North. Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 - HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: lit JOB LOCATION: —s � mi' �1'p"% M- _ Number Street Address q Map/Lot HOMEOWNER_ c Tbith pu ae m Ca S Name Home Phone Work Phone PRESENT MAILING ADDRESS Uity t own St�t-e 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. 11, 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 SIGNA APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department ofIndustrial.Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information A Please Print Legibly Name (Business/Organization/Individual): lid Address: w. h City/State/Zip: t -Ly- GV hone #: qa:� — 39r Are you an employer? Check the appropriate box: 1. ❑ 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. 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 equired.] officers have exercised their 3. a homeowner doing all work 1am right of exemption per MGL I [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.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof rep - s / 13.❑ Other *Any applicant that checks box 41 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 their workers' comp. policy information. I am an employes that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy 4 or Self -ins. Lic. 4: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer i y under the pains andpenalties 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M,