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Home My WebLink AboutBuilding Permit #220-12 - 30 MILL ROAD 9/15/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: QDate Received Date Issued:–q IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER 9KS �rint I I,Q S l )c�`( AQ r'] Unit# //�� Print MAP NO: &ARCEL:�_ZONING DISTRICT: Historic District yes no Machine Shop Village yes o 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ i ion ❑Two or more family ❑ Industrial —erAlteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ - � -�,�- ® ep (MLNvu €®)Floocipl } Wetlands [® Watershed4Distnct - DESCR,(IPTION OF WORK TO BE PERFORMED: �I �'r IVLo X1714 O (.-Xjl7U' �X�' U d�Q I V IT M0 Yet (Identification Please Type or Print Clearly) OWNER: Name: Phone: 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.MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ Vt FEE: $ Check No.: Receipt No.: NOTE: Persons contra ting with u registered contractors do not have access to the guaranty fund ta'a.?` ¢i ai:.i'vt.•:: t !k, tid :✓F•✓L. a tf T Cinnat�ira�nf��nari♦/Ghnma _ CinriaWra nf,Anfr�r-tn, � 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 Permi� Addition or Decks ❑ Building Permit Application u Certified Surveyed Plot Plan i ❑ 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 MOTE: 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 e U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS ,HEALTH Reviewed on Signature lR OMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& 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 Fire Department signature/date COMMENTS 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 Electrical Inspector Yes of No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$1o0-$1000 fine NO i NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Location No. Date TOWN OF NORTH ANDOVER 40 Certificate of Occupancy $ Building/Frame Permit Fee $ MU Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 245t, Building Inspector 5 NORTH TON)m 0 _ � Andover �V" . VO No. � _� A K E 'o dover, Mass.,. COCHICHEWICK a� DRATED P'17 S �5 U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... .................S'l.. ........... ... .................... Foundation .1.�(0 has permission to erect..........:............................. buildings on ..ab..... ..........fZOLT...... ................ ... Rough himn y to be occupied as...��1�....14t;.r "' ��..:�........ ..��`...... . ... .. � e provided that the person accepting tpeshall inevery respect conform to the terms of the applic n 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC ARTS Rough ....................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Ocatpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 1 r• . { The Commonwealth of Massachusetts Department of Industrial.Accidents Office oflnvestigations 600 Washington Street Boston,MA. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information i \ Please Print Legibly Name(Business/organization/individual): 1\--,�s Sq tG' yofdA ) Address: _30 t3' A V . A yy6yer � Phone#:o�� Ci /State/Zip: F2.0 ou an employer?Check the appropriate box: Type of project(required): I am a employer with 4. ❑ I am a general contractor and I6 New construction employees(full and/or part-time).* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet.t �• ❑Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions ed.] officers have exercised their 3.91 am a homeowner doing all work right of exemption per MGL 1 L❑Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.] employees.[No workers' comp.insurance required.] 13.F1 Other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 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. lam 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.Lie.#: 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 cergry un er the pains andpenaldes ofperjury that the information provided above is true and correct. Signature: Date: �— (--' (� Phone#: Q7� �'�� 6`7 U Official use only. Do not write in this area,to be completed by city or town offtciaZ City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: µORT b H TOWN OF NORTH ANDOVER 0� ' ` �°� OFFICE OF BUILDING DEPARTMENT a "* 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 SACHUS Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERiNUT APPLICATION Please Print DATE: / IS-- JOB SJOB LOCATION: I Number Street Address Map/Lot IiOMEOWNER ;✓s' .�D S'7 'L -322 7 32 I-s Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town state. Zip Code- The odeThe 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 Persons)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 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. 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 APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 ' HEALTH 688-9540 PUNNING 688-9535 r 7 Date.....:............................ HORTol OL TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ass^CHU j7 � Thiscertifies that ...........F........r......................................... .............................. has permission to perform .. .. F /� c` G .. ........................ ................ 3.. .. . . j� wiring in the building of................................................................................... at............................................................................... .North Andover,Mass Fee)6............. Lic.No. :3 Y..G ..... "4.1 ELECTRICAL INSPECTOR mG Check # 3 7558 Official Use Only Commonwealth of Massachusettsfn Q Department of Fire Services Permit No. � Occupancy p d Fee Checked BOARD an ARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -- 0.- 7- 0-7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1 L Owner or Tenant RL 0-Rt slty Telephone No. Owner's Address -Zrl 1 LL Rb Is this permit in conjunction with a building permit? Yes Ell" No ❑ (Check Appropriate Box) Purpose of Building Fi,,,s Utility Authorization No. Existing Service Amps / Vods Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: iNSEPA F&q. N c_ 54-1,� 1 Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil: Fans Susp.(Paddle)FNo.of Total " Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.oI Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets 'L No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 1 No.of Gas Burners o.of Detection and Initiating Devices x No.of Ranges No.of Air Cond. TotalTons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of NoNo.of Devices or Equivalent .of Heaters Kms' Data Wiring: —Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: -'7-OLInspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andenalties of perjury that the information on this application is true and complete. FIRM NAME: r/ 55�1 t div �-LEC,)l►C)�},u 11 LIC.NO.: 3�1 Licensee: H 1-7610-ti a- Signature 7 LIC.NO.: l3 915 A (If applicable, enter "exempt"in the liense num er line.) Bus.Tel. No.: 60 Z J7 Address: l% tomes ,A�FL $4 AAAlt. Tel. No.: 1,9 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S" License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations U1 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organizatton/lndividual): M,Tc0 Rwt ii j0. Address: City/State/Zip: IY14 b 36 S Phone.#:_ /�g 16� 3 Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a ge7hedsthee tractor and I Type of project(requited):, _ employees(full and/or part-time).* have hire -contractors 6 ❑New construction 2. I am a sole proprietor or partner- listed on ted sheet. 7. ❑Remodeling ship and have no employees These subtors haveworking for me in say capacity. employeese workers' S' ❑Demolition [No workers'comp.insurance comp.insu9• ❑Building addition required.] 5. ❑ We are a cn and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers haxercised their 11. Plumbin myself.[No workers'comp. right of exemption per MGL ❑ g repairs or additions insurance required.]t C. 152,§1(4),and we have no 12•❑Roof repairs employees.[No workers' 13.❑Other 496,.,c Grz o P2en 1 comp.insurance required.] *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. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers comp,Policy number. 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 of this statement may be forwarded to the Offi Investigations of the DIA for insuran a coverage verification. ce of I do hereby certtfjZ!unVefth ains n enalties of perjury that the information provided above is true and correct Si tore: /�) qq Date: Phone#: — [6.0ther fflclal use only. Do not write in this area,to be completed by city or town official ty or Town: Permit/License# uing Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ntact Person: Phone#: