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HomeMy WebLinkAboutBuilding Permit #524 - 32 LINCOLN STREET 1/9/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received IMPORTANT: Applicant must complete all items on this Daae LOCATION _3� Llwoln Sf Aoay"r 114-4 oI�tLS ' / Print PROPF,RTV nWNFR V I /1 r e n 7_„) P, r 47rAx 1Av% 7)A _f D4G, ' ' ^T n7 it 9a Print I MAP NO:PARCEL:ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition Wfwo or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other -77 (] Septic ` ®Ftloop'dpla` ©We lands® Watershed�District ®urate /,Sewers S - DESCRIPTION OF WORK TO BE PERFORMED: ERR OWNER: N � 6 Please Tvn( or Print Clearl.Y) nbnt-e� Pr Address:32 - 3q L,C,1•, 5 f A And oy-Cl All Of f �� CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Exp. Date: 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: $ 9 �- ®PL FE Y�v_ Check No.: ��% Receipt No.: NOTE: Persons contracting wjth unre el contracts d of ave acce q guaranty fund 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 PLANNING & DEVELOPMENT ❑ DATE APPROVED COMMENTS CONSERVATION Reviewed on Signature COMMFNTS j HEALTH Reviewed on Signature COMMENTS 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 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 2011 June/mi 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 ob Location4,Z2 " 3( M cyr► -'s-= No. l Date Check # 24967 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ _ Building Inspector W co O • l'CD c Cc � O O O CO) O V C.2 •- �Q-0 O Co m o $ CL ow C) $ vu � ca m c M n :mm CM C C m a t C m N e0 N sCD mo V L o.c� y m m CD's C r: I.s Na G C Z MCD G CS N Z O O.� ca =O a o Q o ca -mc = m Q.w• 30 CO) CD LUr •H O.t M C LCC E5 - m .N ci u �. OC CO) m� = W C La :N CL cc E OI C ✓ 5 -) O u ri U O O v v a� O E Q■ L ts O z °' CL O CO) p C CD cm COD O •— CCD p� ._ CD CD 0 CD m m CL~ ♦_•+ Q p Q L O O CDQ o cc c cv v d O �Qr C CL V h O C C . ■ C CO2 p LU U) uj to 19 W W 19 W C4 O a -0 G U w r.i a w w ono a: �� aGi cn o co G kr . . t PQ 0 cn Q 0 U) . O • l'CD c Cc � O O O CO) O V C.2 •- �Q-0 O Co m o $ CL ow C) $ vu � ca m c M n :mm CM C C m a t C m N e0 N sCD mo V L o.c� y m m CD's C r: I.s Na G C Z MCD G CS N Z O O.� ca =O a o Q o ca -mc = m Q.w• 30 CO) CD LUr •H O.t M C LCC E5 - m .N ci u �. OC CO) m� = W C La :N CL cc E OI C ✓ 5 -) O u ri U O O v v a� O E Q■ L ts O z °' CL O CO) p C CD cm COD O •— CCD p� ._ CD CD 0 CD m m CL~ ♦_•+ Q p Q L O O CDQ o cc c cv v d O �Qr C CL V h O C C . ■ C CO2 p LU U) uj to 19 W W 19 W C4 I W W i. O z WC/) v � a - U o o w2 CO w° U w a°' w w°' cn w w rA cn o cn c y- 0 • j �.m c 7 : C H O C C.) V ♦: �d'O CLC. V R ` 3 ® c N � +-. c cL floCL N Sco "..' C.) voc elm 75 C L t: O y ce ED3 c Ca CO c� � = c N O r=N s CD p - LA O m 'O C O Q y , N m COi H O. Z Q oc a m: cc Hcmc _ CD _W O =.. -=o4DLL O * c r E:. .60 gat cc C O 4- •N C.3 CD COO C3. O .- O CL.,.. m z c c CO h=-1 L 0 cm c N m Z CD , Z CD zip z 0 U 501 'am l 0 O O E L O s Z v. co O y p c I ccm O•— � p� ._ M g m m CD 0 CD 0. I-- 'c.+ CD O � � CD p o e_cav o a a. S Q -o o0 -C cc V J 'C3 C Z ts C.3 CO) O c c cc CO)CL p LU CA 0) C4 W LU W U) /j W w A O0 HOH P O 0H O R . w v O u o w cn or. w a: U G w" a a4 G w W w o w' cn 0 w o w w" w ° cn Q o U) • c c :CD oma O cc v O . V .j 'ate cc :4D m c or y m Ea •: m r = CL CD 0 C V r.+ cm CL o m J�m3 h QZ:: C � � � m a t C h cu EH N O m V• IL o Q aEt •oo'C � Z c � p v. O d O N m c = m C* $ Go CD LL y O C H. N GZ W .E o 'o v .ca V O O .O C _ a Occ H H Z a4 m T --4�. U O 42 vll 2 y Mo .E CL CD c O CD V M CL CO) 0 0 Q CO2 C O cc _cc �. H LLI U) LLI Y/ W LLIw W co The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 " www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 1-3q L i it r City/State/Zip:. AA do V-r°y, 144 Di sY 5" Phone #:_ g,5_7 — O 9— $ d 73 Are you an employer? Check the appropriate box: I. ❑ 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. t 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 r -,/required.] officers have exercised their 3. LM I am a homeowner doing all work right of exemption per MGL myself [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. El Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other -rsuy aIJp„oau" u,ai UMCKS oox s i must also nu 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. 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 7— q -1'70A 3 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): VI V1 Address:_ -3 D, Ltncvi, City/State/Zip: �, /Tti d vJ 2(,,yi/� 0 O 5 Phone #: q 7.9 — 3 7 5---q 75 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, t 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. M I am a homeowner doing all work right of exemption per MGL myself. [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. Eg"Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -Any appncamt mat cnecxs oox P1 must also 1111 out the section below showing their workers' compensation policy information. Ti 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. Lic. #: Job Site Expiration Date: 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. Ido hereby cert' p under t e p in and penalties ofperjury that the information provided above is true and correct. -37S-- Official 37S" - 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 #: Gerald A. Brown Inspector of Buildings TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT '1600 Osgood Street Building 20, -Suite 2-36 North Andover, Massachusetts 01845 Telephone (978) 688-9545 Fax (978) 688-9542 HHOMEOWNER-LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: I 5 1 JOB LOCATION: oZ i Cy 11+ _ Number Street Address I30MEF-OWNER I�' C -ep7i t)1,j } Name Home Phone Work Phone PRESENT MAILING ADDRESS—5- lfoZd .,r City T km O/966) Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeov.,ners 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 family structures. A person who constructs more that one home in a two-year peri a homeowner. d shall not be 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 TOWN OF NORTH ANDOVER OFFICE OF 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 PERYHT APPLICATION Please print DATE: --461) JOB LOCATION: 3 y L 0641 Number Street Address HOMEOWNER Name Home Phone PRESENT MAILING ADDRESS Map/Lot -�7a9'g072 Work Phone Ctwtw . . Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units -or less and to allow such homeov.Trers 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 gwns 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 forcompliances 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 SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535