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HomeMy WebLinkAboutBuilding Permit #431-11 - 38 EMPIRE DRIVE 11/18/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1 ' Date Received Date Issued: a J IMPORTANT: Applicant must complete all items on this page LOCATIONJ�� ; Print PROPERTY OWNER kI I LL'Z,C — Print �-�/ MAP NO/O 5 PARCEL/&#?,-ZONING DISTRICT Historic District yes ?no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ;!Mew Building ' One family ❑Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other :Septic ❑'Well 0 Floodplain ❑4Wetl�ds. Watersh�d�D� ,-strict: Water/Sewer Q r DESCRIPTION OF WORK TO BE PERFO D: L - Identification Please Type or Print C r1yJ OWNER: Name: 6ix C �L Phone: Address: PTo���� hone:CONTRACTOR Name: t Address: Q D J0r C I / EXP. � Supervisor's Construction LicenseDate:: Home Improvement License: �(� ��� Exp. Date: l l ARCHITECT/ENGINEER c �{ �� Phone:D70 ELS/C? Address:, �• Reg. No. 2 g FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. � O Total Project Cost: $ ' FEE: $ O Check No.: F �'L— Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fungi Si nature of contractor Location No. - Dated �aRT� TOWN OF NORTH ANDOVER 0 F w P f • 4 : ; Certificate of Occupancy $ i Building/Frame Permit Fee $ +cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1`4 32- 2 3 72- 0 Z.►2372. 0 Building Inspector Plans Submitted'- Plans Waived ❑ Certified Plot Plan 4P� Stamped Plans g TYPE OF SEWERAGE DISPOSAL f Public Sewer Tanning/MassageBody 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 DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on 410 Sign ture COMMENTS HEALTH Reviewed on Signature CbMMENTS 3 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes it 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 r NOTES and DATA— (For department use i El i I I Notified for pickup - Date Doc:.Building Permit Revised 2008 1 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 o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract i ❑ Floor Plan Or Proposed Interior Work o 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 Q Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o 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) o Muss 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 Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ 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 ❑ 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 Chat 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 ORTH TO" of Andover O dover, Mass., COC MIC ME WICK V ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........Drz.:�6.r.d ................. ......... .. ... ... . . . .............................................................. .......... . Foundation haspermission to erect......................... ..,. .....L'1!��1!"8..... �'LI ........... f Rough p buildings on g Or Chimney to be occupied as............................... .....D. vv ............ . ................ .... ................................................................... provided that the person accepting this permit shall in every respect confoRA to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC SJFARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the7 Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - � Street No. SEE REVERSE SIDE Smoke Det. ORTFI 0 0 f Andover0 -CON LAKE_ o cs dover, IVMass., COC NIC NE WICK � AD RAT E D P'P�,��� 7 S BOARD OF HEALTH PERM IT T D Food/Kitchen Septic System BUILDING INSPECTOR Dr&_6rd U i LLC. THIS CERTIFIES THAT .................................�I . ...................... ......................................1.4 ......... . ............................... .... Foundation has permission to erect........................................ buildings on .., �'.....C- . r 4e ...0!4 ........ � Rough �^ to be occu ied as dl,� Chimney provided that the person accepting this permit shall in every respect Co to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS S ARTS ELECTRICAL INSPECTOR UNLESS CONSTRUC Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. � �., i The Commonwealth of Massachusetts Department of IndustrialAceldents Office of Investigations 600 Washington Street Boston,MA. 02111 UIR www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers Applicant Information ��,, Please(Print Legibly Name(Business/Organization/Individual): Tc k A �� L,-LAG E 4-LC Address: �7e4^1` 6Np G4J ��e City/State/Zip ©')(Cp�(� I�•0( �2 Phone#: 9 7o0^Ft7— T/0 Z Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with ❑ I am a general contractor and I 6. gNew construction employees(full and/or part-time).' have hired the sub-contractors . � . 7. ❑Remodeling . sheet. the attached 2.�I am a sole proprietor or partner listed on h ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. C]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.El am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.[]Roof repairs insurance ]uired.re q employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 7 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 their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certj&under the pains andpenaldes ofperjury that the information provided above ' true and correct. Si afore: all`'\ Date: b Phone#• 9 7 ff' -7 — ✓16 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): 11 I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: