HomeMy WebLinkAboutBuilding Permit #791-14 - 371 PLEASANT STREET 5/5/2014y f NORTFI q
BUILDING PERMIT o .11,106.6
TOWN OF NORTH ANDOVER ° ;ca
�4
ij ( APPLICATION FOR PLAN EXAMIN
Permit NO:7 Il '- I Date Received 2' -
II �•iORA 7F0
Date Issued: "J �ITSacUS
IMPOkTANT: Applicant must complete all items on this page
LOCATION 3-71
Print
PROPERTY OWNER'
G�� Print
MAP NO: � t- J PARCEL: 10 ZONING DISTRICT: Historic District yes`` no
t Machine Shop Villaqe ves rno
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain- ❑ Wetlands
11 Watershed District
ii ❑ Water/Sewer
Identification Please Type or Print Clearly)
OWNER- Name: �� *t -ea Z I(zex Pho
Address: zL 371 [Pketsoyt
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License:
Home Improvement License:
2
7- N l (o - 6-q o
Exp. Date: g
v� f
Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cst: $ SOO FEE- $ &e2
Check No.: (pt) Receipt No.: 2'12'1
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
- Plans Submitted ❑ Plans Waived ❑ . ---Certified Plot Plan ❑ Stamped Plans ❑
�TYPE-01 `:SEWERAC3EDiSP.OS
AL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales El
Food Packaging/Sales ❑
private (septic tank, etc- . ❑
Permanent IDiimpster onsite ❑
.:THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
-DATE REJECTED DATE:APPR-OVED
PLANNING & DEVELOPMENT ❑ ❑
�1 j
COMMENTS A11,9- PL "'u,vi J (!2'
-CONSERVATION Reviewed on 41
COMMENTS
Iq
HEALTH Reviewed on /ZI) lt-t Signature .
COMMENTS_
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision: Comments
Conservation Decision: :Comments
Water & Sewer Con nection%Signature & Date Driveway Permit
DPW Towo Engineer: Signature:
LOcatea 6M uS ooa Street
`FIRE DEPARTM ENT.-= Temp Durnoter on yes... no
Located7at 124 Mair Street
-Fire Departme►it signatu"re/date`'" R
N -
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
DANGERZONE LITERATURE: Yes No
MGL -Chapter 166.Sectlon 21A -F and G min.$100-$1000:fine
NOTES and DATA — (For danarfmanf umal
El Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
:--The following is'a-list of -the retluired.forms to be filled out for the appropriate -permit to .be obtained.
Roofirg, Siding, Interior Rehabilitation Permits
Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S:L Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
a 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
E3 Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
a Floor/Crossection/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
o 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
o 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 apw-�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Building Permit Revised 2012
Location
No. -1 C) 1-1
3�
Check # t ()(
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ (-,)y'�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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The Commonwealth ofMassachnseits , -
Department of lndustr1a1 Accid&ts
Offace ofluvestigations
600 Washington Street
Boston, MA 02111
www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Cont°actors/Electriciansmliiinbe3rs
Applicant )hformation Please. Print Legibly
A
Name
cJ 7'c1(io
Address: .37/ .SkPef
O/F415-
City/Siaie[Zip: AN Phone#: Cell :-947Z V167�'�
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (fulland/or parttime).* have hired the sub -contractors
IR am a sole proprietor orpartner-
ship and`haveno.employees
working forme in any capacity.
[No workers' comp. insurance
3)<xecluired.]
X am. a homeowner doing all work
////��\\�` myself [ffo workers' comp.
insurancerequired.] Ti
listed on the attached sheet .
These sub -contractors have
workers' comp. insurance.
5. [] We are a corpora�on and its
officers have exercised.their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ZI Building addition
1.0.[] Electrical repairs or additions
ILL] Plumbing repairs or additions
12.Q Roofrepairs
13.❑ Other
, Any applicant that checks box #I must also fill out the section below showingtheir workers' compensation policy information.
i -Homeowners who sabmit this affidavit indicatingthey are doing all work and then hire outside contractors must submit anew affidavit indicating such.
TContractors that checkthis box must aftached as additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
X Man employer that is providing workers' comperasation insurance for my employees Below is the policy and jolt site
information.
Insurance Company
Policy # or Self -ins. Lic.
ExpirationDate:
lob Site Address, City/State/Zip:
Attach a copy of the workers' comp ensation-p olley declaration page (showing the policy number and expiration date).
Failure to secure coverage.as reguiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a
fine up to $1,50 0.00 and/or one<year imprisonment, as well .as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised chat a copy of this statement may be, forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do lierehy cert& under the pains and penalties ofperpry that tiie information provided above is true and correct.
Sian 0: %%' /T �� Date:2 z -1t
Phone #• r L,/ ,;�LV 7 �f!&_5qp &
Official use arzly. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
TOWN OI-► i�TORTH ANDOVER
OFFICE OF
13LUDI NG DEPARTMENT
-1600 Osgood Street Building 20, .Suite 2-36
• North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 68$-945
InspectorofBuildings Fax (978) 688-9542
RC MSOWNER'LICENSE EXEMPTION
11WDIlNG PERYffT 4 PPI ZCATtON
• Pleas�rint .
DATE: KZ zl �f
JOB LOCATIDN: 37/ �tcQ
Number StreetAddress Map/i;ot '
' I;TOMEO�R a •�,� �a GBS 013 ..
Name. Home Phone
Work Phone
-PRESENT MAMING ADDRESS �3 ?l �l r
-
C`i �' Tn,=m ®lfi
Sf` fw zip Code
The current exemption for "homeowners" was extended to '.chide owner -occupied
to allow su.h homeoi�,Tes to engage an i�cividual•for hire -w:ao does n.of possess a license, provided that the owne�d
acts as supervisor). State Building (Code Seciioa 10rhir .i)
DEFINITION OFHOMEOWNER.
PD -be, a n(s) Who awns a parcel of land on which helshe resides or intends to reside, on which (here is, or is intended to ,
be, s one or two family sfzuctures. A person who constructs more that one home in. a two yearperiod shalt not be
considered a homeowner.
The undersigned "homedwner" assumes responsibilityforcornpliances with the State Building Code and other
Applicable codes, by laws, rules and -regulations.
c
The undersigned "homeowner" certfies that helshe understands the Town of North Andover Building Department
minimum inspection procedures and requirements and
requirements, that he/she will comply with,said procedures and
-UOhM0Vnq RS SIGNATURE
APPROVAL OF BU LDING OFFICIAL.
Revised 22009
Fonn Homeowners Exemption
EOARD OFAPPBALS 688-9541 CONSERVATION 688-9530`.:
HEALTH 688-9540 PLANNING 689-9535