HomeMy WebLinkAboutBuilding Permit #458-16 - 322 ANDOVER STREET 10/9/2015.0-).Qk,h1Zn /d/is/s-
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BUILDING PERMIT ®F
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION _
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K 1
Permit No#: Date Received �ZED
Date Issued: "
ORTANT: Applicant mustcomplete allitemson this
LOCATION
in
PROPERTY OWNER Ae�e
Print 100 Year Structure
MAP PARCEL: _J_�ZONING DISTRICT: Historic District
Machine Shop Village
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
�aOne family
El Addition
El Two or more family
❑Industrial
El Alteration
No. of units:
[I Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others.
❑ Demolition
�O Sept 0 Welf
❑ Other
DIFIo®tlplanmvet;lands; ,�
§0. 1/VatershediD� strict
nF wnRK TO RE PERFORMED:
nGcr1P1PT1nN
OWNER: Name:
Address:
Contractor Name:
Email:Q47r,
Address: _-3-
- P4e4se Type or Print Clearly
ll��rr�►i- S /I-
'hone:���'
Supervisor's Construction License: Exp. Date:
r—
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: $ FEE: $
Check No.: Receipt No.:C2!q,m2
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location��L�Yw
No. y �^ �a�
0
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ —�
Building/Frame Permit"Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
2 C'E S 1 0 Building Inspector
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. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On Signature.
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Com
Conservation Decision: Comm
Water & Sewer Connection/Snature ®ate Driveway Permit
DPW Town ]Engineer: Signature:
RTME�T + Te Located 384 Osgood Street
FIRE DEPA 4 y
r -pipumpstet an site. es
r a 4. r s y rrj }y ~�"{ ♦ i t.l lY + :.a 4'S.i t3i�•.�noA.. �i — _s�__a:
Lo atedat124IMamtStree g .� -- __►
7' �" o - + (`, S y„, ► i t.. Z r f''Z li`754rw
Fi�elDepa �ment signaturbldate ,
t �r�, E C rl rg. o°. F 9r- , r3:a� w,. tt5�. V tf�4# Lbw .L ► '1.�
1K:7i1 t t :2 y r � . �t .• i.. :i r + . . � � �� . � �y. �� • �'i . K 7'= .w.. .';Y {. -r 4i
COMMENTSi
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
Doc.Building Permit Revised 2014
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
OTE: 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4 Mass check Energy Compliance Report (if Applicable)
Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
dT Certified Proposed Plot Plan
6 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
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
OTE: 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/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
IOTE: 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
4; 2012 IECC Energy code
4� Engineering Affidavits for Engineered products
TOTE: 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
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The Commonwealth of Massachusetts
. Department oflndustrialAccidents
ire tl 1 Congress Street, Suite 100
Y= `� Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Iudividual):�
Address:
city/state/Zip: _1,6 �i2��/ � Phone #:.
6 gs- —9cf3 y
Are you an employer? Check the appropriate box: Type of project (required):
1.❑ I am a employer with employees (full and/or part-time).* %, 0 New construction
2. Q I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity. [No workers' comp. insurance required.]
9. El Demolition
3;EqI am a homeowner doing all work myself. [No workers' comp. insurance required.] t
10 ❑Building addition
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions
proprietors with no employees. 12. d Plumbing repairs or additions
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13J�q_Roof repairs
These sub -contractors have employees and have workers' comp. insurance.$
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
*Any applicant that checks box #1 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.
TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
-tam an employer that is providing workers' compensation insurance for my employees.' Below is thepolicy and job site
information.
Insurance Company Name: S"�
Policy # or Self -ins, Lie. #: Expiration Date:
Job Site Address: _g ,Z- City/State/Zip: -40'r
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify under thepains and penalties 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 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: 3�Z �,��nd�y 514-
Number
1-Number Street Address Map/Lot
HOMEOWNER
(' Name Home Phone Work Phone
PRESENT MAILING ADDRESS ,-� ��
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,rop vided
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 110.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.
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
Location ,yWL20VC--T �5T
No. `%!% i' Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
C*;�-Sewer, Connection Fee
' Water'Connection FPP
'991 TOTAL
$ / OG?
Building Inspector
�i
Div. Public Works
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TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION
ASSESSORS MAP
SUBDIVISION LOT(S)
PERMANENT ADDRESS (ASSIGNED BY D.P.W.
STREET 3 2 L Af.0 G�lEie S'T
APPLICANT �{�,,�/� %�-,j>f}r►.� PHONE
DATE OF APPLICATION
TOWN USE BELOW THIS LINE
PLANNING BOARD
TOWN PLANNER
4,"CONSERVATION.COMM4SSION
CONSERVATION ADMIN.
BOARD OF HEALTH
—Id 9=0 L I (0—
HEALTH SANITARIAN
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE APPROVED
DATE REJECTED
DATE APPROVED 1;3 /R(
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE Z—g S— 9 /
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from the
compliance of any applicable Town requirement or Bylaw.
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