HomeMy WebLinkAboutBuilding Permit #542-15 - 338 BLUE RIDGE ROAD 12/11/2014Permit No#: ' )J
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received 1,-Lii I
IMPORTANT: Applicant must complete all items on this
LOCATION 35 G fel-0�eE
PROPERTY OWNER
(� s
Print 100 Year Structure
MAP PARCEL: ZONING DISTRICT: Historic District
Machine Shop Vi
yes
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
YOne family
0 Addition
❑ Two or more family
❑ Industrial
❑ Iteration
No. of units:
0 Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
@ tr"t5 t k, I 001 -
Identification - Please Type or Print Clearly p
OWNER: Name: FA U L ,1UST- Phone:
AricirP.-,-
Contractor Name: Lo Vfes Phone: �° _coq
Address: 15 -j A nd-,q a--�
Supervisor's Construction License:. Exp. Date:
Home Improvement License: _
ARCHITECT/ENGINEE
. Date:
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: $ g� �Op FEE: $ -,30
Check No.: Receipt No.:0 J
NOTE: Persons contracting with unregistered contract rs do not have access to the guaranty fund
Signature of Agent/Owne ignature of contractor
Location
No. i Date 1
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fees
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #�
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. ❑
permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
No
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
'F o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
a Copy of Contract
Li Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
Li Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
a Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
a 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: Building Permit Revised 2014
The Commo4wealth of.Massachusetis ,
- Department o, f Industrigl Aceldents
office of Investigations
600 Washington. Sheet
Boston, MA 02111
vww.mass.gov/dia
'workers' Compensation Jf muranceAff'idavit: BuiXders/Contrcactors/Ble�cte� umb rs
Name (Business/Organization!>7•ndividnal):^
Address- 3 3 � �'� � � I P G 6-
C
-
CRV/Stafe FhA Pho2nie�
-7 �S-9-2
p: lo bE4N('
Are you an employer? Check the appropriate box:
4•. ❑ I a.m. a general contractor and I
1. ❑ I am a employer with _
(NI employees full and/or part-time).*
ylisted
have hired the sub -contractors
2111 am a solo proprietor Or partner-
on the attached sheet.
Thesesub-contractors have
ship and have no employees
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
officers have exercised their
equired.]
3. 1 am a homeowner doing all work
right of exemption per MGL
comp.
c. 152, §1(4), and we have no
myself. [No workers
insurance required.] i
employees. o workers'
comp. insurance required.]
Type of project (required):
6. [] New construction F
7. [] Remodeling
8. [[ Demolition
9. [] Building addition
10.[] mectricalrepairs or additions
11. E] plumbing.repairs or additions
12.[] Roofrepairs
131S�Other �oOtrL ���A
-Any applicant that checks box#1 must also fdl outthe section below showing their workers' compensation policy information.
t'Homeowners who submit this affidavit indicatingthey see doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
X am an employer that is providing workefs' compensation insurance for my employees. Below is the policy and jOh site
information.
Insurance Company
policy # or Self -ins. Lic. #l: Expiration Date:
Sob site Address: City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expixation date).
Failure to secure coverage as requiredunder Section 25A of MGL o. 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 $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office, of
Investigations of'the DIA for insurance coverage verification.
X do certo ur2der the pains and penalties of pedury that the information provided above is true and correct -
/ , ��---- -- 14
Qfcial use only. Do not write in tlais area, to be completed by city or town official.
City or Town: permit/License
Issuing Authority (circle (3ne):
1. board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _
Contact Person: Phone
To" OFNORTH.ANDOVEP.
O1-TICE Ole
BUIR`ING .BEP.AR.TAWNT
X600 DgbOd%reefBuilding20,-Suite 2-'36
' North Andover, Massachu setts 01845
Gerald A. Brown - Telephone (978) 698-9545
luspectorofBildings
Fax (97$) 688--9542
HOMEOW:NER LICENSE E: U PTION
please print .
DATE:.. I ;2-
rOB WcATIbn 3 3 ID66- pot
Number S rwtAddress Map)zot
' .�OMEMWNER T'v t __ �' ics Q q c�" 7
Name. 6 ��® �� ' 1,5 1 C S j 7
Noma Phone Work Phone
'RESENTM G.ADDRRSS
. e
d . L.�....fw • dip Codi
The current exemption for `$omeown_ers" was extended to � .0 -
to allow Suri, homeD; T - �chlde owner -occupied diuelangs to two units •ox ;ess and
peas to engage an hczvioual•for hire, -:ho does notpossess a license, Provided that the owxier
acts as supervasoz). SisteBulding (Code Section 108.3.5.1)
DBFMITION OFROMEO WNBR
POrSOn(S) who awns a parcel of laud on which he/she reskes or intends to reside, on c t there is '
bb, a one or two f'a�y siruciares. A person who constants more t7iat one home an� a W 1ihere eis, d shalt trot b a
considered a homeowner, twa Or infended to
The undersigned "ko�steo�yner"assumes responsibility fo_z cbznpliauces �witl� ilie State Building Code and other
.Applicable codes, by laws, xules a,dzegulations.
The undersigned "homeownef' cert,'Res that
, i he/she understands the Town of hi oxth AndoverBuzlding De em
xequisemem ents, • inspection procedures and requirements and that WM comply with,said procedures and
HOMEOWNERS SICNA.TURE ,
APPROVAL OF BUMD)NC, OF.FZCfAC,
Revised 7.2009
Forrn.Homeowners I3xemption
'130ARI3 OFAPPIMIS 688-9541 CONSERVATION 688-9530
HEAT TH 688-9540 PL4NNWG 689-9555
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