HomeMy WebLinkAboutBuilding Permit #821 - 340 FOREST STREET 6/6/2011TOWN OF NORTH ANDOVER
„A TION FOR PLAN EXAMINATION
Permit NO:V1.l'V Date Received
Date Issued:
IMPORTANT• Applicant must complete all items on this nage
W, rant
MAP NO: PARCEL:—ZCZONING DISTRICT: Historic District
Machine Shop Village
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
❑ Repair, replacement
❑ Demolition
OWNER: Name:
Address: 23
CONTRACTOR Name:
Address:
Supervisor's Construction License:
Home Improvement License:
PROPOSED USE
Residential
❑ One family
0 Two or more family
No. of units:
❑ Assessory Bldg
❑ Other
OF WORK TO BE PERFORMED:
Please
Clearly)
4611,e
Exp. Date:
Exp. Date:
ARCHITECT/ENGINEER Phone:
Non- Residential
❑ Industrial
❑ Commercial
D Others:
Phone:
yes n
yes no
Address _ — _ Reg. No.
BOLDING PERMIT. $92.00 PER $1000
FEE.00 S�HiDULE..00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $_ ad 4 ---FEE: $ O
Check No.: I�1� Receipt No.: j
NOTE: Persons contracting ith u�lgist�contractors do not have access to the guaranty
tY fund
21
�T��
Location
No. &/
Date
�o�TM
TOWN OF NORTH ANDOVER
O�t..w :•,'y0
F
9
Certificate Occupancy $
of
bis',^•' �t�'
J�CMus
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #
24/'--+9
Building Inspector
❑ Stamped Plans ❑
Plans Submitted
❑ Plans Waived Certified Plot Plan ❑
TYPE OF SEWERAGE DISPOSALSwimming
Pools
❑
11Tanning/MassageBody Art
Public Sewer in
El Tobacco Sales El Food Packag/Sales
g
Well ❑
Site
Private (septic tank, etc. ❑ Permanent Dumpster on
THE FOLLOWING SECTIONS FOR OFFICE FORME ONLY
INTERDEPARTMENTAL SIGN OFF
DATE REJECTED DATE APPROVED
P1�ANING & DEVELOPMENT
COMMEN
�r ► % � Si nature
\4CONSERVATION Reviewed on
COMMENTS 5�
=S::j�n tur
�HI=ALTE=I Reviewed on f
COMMENTS S
01
Zoning Decision/receipt submitted yes
Zoning Board of Appeals: Variance, Petition No:
' NOTA Planning Board Decision:
Comments
In all c; Comments
that the Conservation Decision: Driveway Permit
must beDate-------- -
Water & Seeger Connection/Si_ nature & _
Doc DPW Town Engineer: Signature' Located 384 Osgood Street
no
FIRE DEPARTMENT - Temp Dumpster on site yes
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 .$1oo-$1000 fine
Doc:.Building Permit Revised 2008mi
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
Li Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
a Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o 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
DOTE: 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
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111le 00 /As.s; f3s1
,.
- .per, � ;\J `` ;�,� � •
�i�✓ f \�`'~. �'i 'fit ,�
t t
The Commonwealth of Massachusetts
Department of IndustrialAccidents
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//Orrganization/Individual):_
Address: J `1®
City/State/Zip;%%&Phone #:
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.
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. [] 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.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box 41 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.
$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 DTA for insurance coverage verification.
I do hereby cert/ unlei• tVP ains AdOw alties ofperjury that the information provided above is true and correct.
Phone #:
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. EIectrical Inspector 5. Plumbing Inspector
6. Other
C ontact Persoh: Phone #:
of NORTH TOWN OF NORTH ANDOVER
f"1. ,6 N
°t OFFICE OF
9 BUILDING DEPARTMENT
"i" - 0
�, ^* 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 PERMIT APPLICATION
Please print
DATE: 5- ,S/-, l�
JOB LOCATION:
Number 1-7'�a Street Address Map/Lot
HOMEOWNER 14VZ %�% ��
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 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
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 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 he/shewip comply with said procedures and
requirements. A / / / ,
HOMEOWNERS SIGNA
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 685-9530 HEALTH 688-9540 PLANNING 688-9535