HomeMy WebLinkAboutBuilding Permit #901-16 - 29 BELMONT STREET 2/19/2016It�L� BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: U Date Received
Date Issued:
I PORTANT: Applicant must complete all items on this page
LOCATION' -'t -?l C-4�t l 5k tU t o Adyer
Print
PROPERTY OWNER Pa` c -%C . aso%�
Print 100 Year Structure yes
MAP Nl' PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
O �,�T L @ D • hb 46�Ci
:.
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no
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Noxi-' Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
Sep ictict ❑ Welll
-�-
L�71FI,00dplarn Wetl nclsi N
_
❑:1NatehedDisatnctb
LIP Water/Sew,e-..._� 1—,_
► _ :A�
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly 1,
OWNER: Name: eP\rzctc Sg Phone: 6A -X— FYI -22-143
Address: TO SeyDkav, O(C
Contractor Name: Phone:
Email
Address:
Supervisor's Construction License:
Home Improvement License:
Exp. Date:
Date:
,J
ARCH ITECT/ENGINEE
Address:
Phone:
Reg. No.
FEE SCHEDULE: BULDING PERMIT.
$12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST B t�SED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: LO Receipt No.:�"(
NOTE: Persons contracting with gnregistered contractors do not have access to the guaranty fund
Check#
3 0 02 9. -
Date �244 Ilk
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Pee $
Foundation Permit Fee
Other -Permit Fee $
TOTAL
Building Inspector
Lo cation
No.
Check#
3 0 02 9. -
Date �244 Ilk
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Pee $
Foundation Permit Fee
Other -Permit Fee $
TOTAL
Building Inspector
Plans Submitted 11
Plans Waived ❑ Certified Plot Plan F1 Stamped Plans El
TYPE OF SEWERAGE DISPOSAL
Public Sewer El
Tauning/Massage/Body Art El
Swimmiug Pools,,'- El
well El
Tobacco Sales F1
Food Packaging/Sales 11
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN (jFF'- U FORM
PLANNING DEVELOPMENT Reviewed On -Signat . ure,
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
;Conservation Decision: Comments
,f
Water & Sewer Connection/Signature Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
IRE DEP 'enUA uMpsier:on�site"bkoy,es'.4
,,
F.ireL
yepa
I KCI.Lureu a
"A
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
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.$100-$1000 fine
NOTES and DATA (For department use)
LI Notified for pickup Call Em
Date Time Contact Name
Doc.Building Permit Revised 2014
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
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
OTE:
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/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 -__
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 IECC Energy code
Engineering Affidavits for Engineered products
IOTE: 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
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
371 9''0,0 '0',0
m
$ -
$
454.80
Plumbing Fee
$
56.85
Gas Fee 100 comm.
$
1:00..0:0 ,
Electrical Fee
$
56.85
Total fees collected
$
668.50
29-31 Belmont Street
901-2016 on 2/19/16/
Kitchen, bath remodel
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1'he Commonwealth ofMassachusefts
Department of rndustrialAceldents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.masss go-p/dza
CompensationUsuramce Affidavit: 7Buziders/Contractors/Ei.ectxiciansffllumbexs.
TOBE7CI-ED'SATHTHEPEP'MT�Il�TCxATJTFf®1 1X. n..e,.-&
Name ($irsinesslotganization/individual):
-W, P td ra scc,LQ-
Address:
Jnr "y, #: 6 \-X psl a;1.43City/Stale/Zip: (�, ��, � .ei Phone
Areyou an ernployer? Checkt& appropriate box.
1.[] I am a employer with. , .: employees (full and/or part-time)-*
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity. poworkers' comp. insurance required.]
3..� 1 am a homeowner doing all work: myself ENo workers' comp. insurance required.] t
4. [I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers' compensation insurance or are sole
5.E] I am a general contractor and l have hiredthe sub -contractors listed on the attached sheet.
These sub -contractors hale employees and have workers' comp. insurance.,
6.0 We area corporation and its of�rrgrs have exercised their right of exemption per MGL c.
152 91(4) and we have no employees. Wo workers' comp. insurance required.]
Type of project (x'eclun•ed).
7. [( New. construction
8. [( Remodellrig
9. ❑ Demolition
10 [] Building addition
I I.n Electrical repairs or additions
13. [l Roof zepairs
14. [] Other
xAny applicant that checks liok41 must also fa outthe section below showing their workers' compensation policy information, ti
Homeowners who siililiriiii this afiidavzt mdjeatmg they are dalwork andthen hire outside contractors must submit a newr affidavit indioa 9 suoh.
YContractors that check this boxmusi�•attached an additional sheet showing the name of the sub -contractors and state whethez oz not those entities have .
employees. Ifthe sub -contractors Have employees, they must provide their workers' comp. policy number. - ;=,
Yarn an employer that is p7'ovidirzgworkers' compensation insurancefor' my employees.' Below is the policy and,/ob site
information.
Insurance Company
Policy # or S elf -ills, Lic.
ExpirationDate:
lob Site Address: City/State/Zip:
oxnpeusation policy' declaration page (showing the policy number and expiration date)-
Attach. a. copy of the vwor'J�ers' c
Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to $1,500.Q0
ent, as well as civi
and/or one-year imprisonml penalties in the form. of a STOP WORK ORDER. and a Fine of up to $250.00 a
out may be forwarded to the Office of Investigations of the DIA. for insurance
day against the violator. A copy of this statem
coverage veriFiic ation.
I do .aer eby cer iify u erg t;�epains nclpenalties of per t,p,, triat theinformaiionpr opided above is trueLancl co3 rect.
hone LL
#: 6 -) ' ��
Official use only. Do not -write in this area, to be completed by city or town Official:
City' or Town:
Permit/License
Issuing.A.uthority (circle one):
1. Board of health 2. )l3nadi�agDepartment 3. City/Town Clerk 4. Electrical Inspector 5. plumbing Inspector
6. Other
Contact Person' Phone
Gerald A. Brown
Inspector of Buildings
Please print
DATE:
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Telephone (978) 688-9545
Fax (978)688-9542
JOB LOCATION: S I (jeLADy�' T
Number Street Address Map/Lot
ti
HOMEOWNER ai5Crj.
Name
Phone
Ops -1 3
PRESENT MAILING ADDRESS 50 S'evi>q,lry or
Work Phone
me-XyAe t, mp1, OLSLy
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provided
that the owner acts as supervisor.
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 dwelling, 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. (780 CMR
Section I IO.R5.1.2)
The undersigned "homeowner" assumes responsibility for compliance with 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. A !
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535