HomeMy WebLinkAboutBuilding Permit #804 - 39 HAWKINS LANE 5/31/2011BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued:/
IMPORTANT: Applicant must
LOCATION 5 lloc .l k t kl 1
PROPERTY OWNER
MAP NO:ho -& —PARCEL:
Date Received
all items on this
i
Print
ZONING DISTRICT: Historic District
!Machine ShoD
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 ke:fna. 7?Hr
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DE5GRIPTION OF WORK TO BE PREFORMED:
0 z pec c,1
eWc) x 3 0 7uA a�, � a.7� cam-► � ��/
E-emoe-
v"P e,-7� (115-111 ",
Identification Pease It, a or Print Clearly)
OWNER: Name: %(2r)eek7 Phone:F? -r�93-l9S09
Address: e"ik t k, S �Ge! ZL
CONTRACTOR Name/ -/0 Pb - Phone: -,TI- ?d9--'/cr
Address: ,r3� o / vo
Supervisor's Construction License: r Q Exp. Date: -2,Z`3
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER 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: $ � - FEE: $ 30
Check No.: 3(D Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the 9 -hu, Urltv fund
Sinature of A ent/Owne
9 �._ g _ of contractor
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
t.
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
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
L_
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.$10041000 fine
Doc.Building Permit Revised 2008
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
❑ 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/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
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
❑ 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
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
G!�
Location
No. Date
NORTq TOWN OF NORTH ANDOVER
310 "� :•,�O
_ O
.. f
• • ; Certificate of Occupancy $
sCMUsgt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
24 i
Building Inspector
r,ltcrrW, ofli
14'A i,2 j 1-
Add ress:_Z3,2____ Cilli-/
City/Stale/Zip:L%iYj_P_S �%2 _ Phone',,`: 2F/-- 7�2
Are you an employer? Check the appropriate bon:
1. I r:? a er<,j �lo� er am a general confi actor and 1
.i. l-. a --..,� i7:. 'I ti;C �'. C•.'•:;h-a `Ji�rj
2. ❑ I atn'a sole proprietor or partner_ listed on the attached slieet.
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No Nvork`s' comp. insurance. comp. insurance.
required]
3. ❑ I am a horneowner doing all wort:
myself. [\7o workers' comp.
insurance re uv ed -j
❑ V e are a corporation and its
officers have exercised their
right of exemption per MGL
c_ 152. §1(4), and we have no
cilplo}-ees- [moo �s or �.;:rs'
comp. insurance re ;uircd.]
Tyke of project (required):
G. ❑ New cor:_ir,tctio;;
7. ❑ Re nooelu7g
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or addiiions
-I.L[l Plumbing repairs or additions
12_❑ Roof repairs
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I
Homeowners who submit this affidavit indicating they are doins all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this bos must attached an additional sheet showins the nzme of the sub -contractors and st2te v. hether or not those entities have
employees. if the sub -contractors have employees, they must provide their workers' coma. policy number.
I anz oli ei.iploi ' -
1'er tlro_ i pro rirr:,,g trorlrers conzpezzsc:fion i;zsrrrance for my ea ployees. Below is the policy and job si;e
infornzalion.
Insurance Company Name: ew 1 L� r�a�7 r h �/� S i,-6
Policy ' or Self -ins. Lic. l=: t/,U C � Lo 3 � Expiration Date: /U
Job Site Address: l 4J k i n City/State/Zip
Attach a copy of the Nyorkers' conipensation policy declaration page (sL-owing the policy cumber 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 DIA for insurance coverage verification.
I do hereby c,rtifh under thepoins an penalties ofpe/jrely that the ilzforz.zalion pronided abo fe is fizre and correct.
Phone #.: ?Ki /d - (:�"u-T�
Official use only. Ito not write in this area, to be completed by city or town official
C c: Tcti°,;r_:
PernIi: `f,?. _...._ ._
Issuing.4uthority (circle one):
1. Board of Health 2. 13uilding Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector S. Plumbing j:._,;ector
Picone t`:
:1 re
1re ""fl—davif:
1;`lili_lf• .'"..t'
�;-- , .t
Add ress:_Z3,2____ Cilli-/
City/Stale/Zip:L%iYj_P_S �%2 _ Phone',,`: 2F/-- 7�2
Are you an employer? Check the appropriate bon:
1. I r:? a er<,j �lo� er am a general confi actor and 1
.i. l-. a --..,� i7:. 'I ti;C �'. C•.'•:;h-a `Ji�rj
2. ❑ I atn'a sole proprietor or partner_ listed on the attached slieet.
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No Nvork`s' comp. insurance. comp. insurance.
required]
3. ❑ I am a horneowner doing all wort:
myself. [\7o workers' comp.
insurance re uv ed -j
❑ V e are a corporation and its
officers have exercised their
right of exemption per MGL
c_ 152. §1(4), and we have no
cilplo}-ees- [moo �s or �.;:rs'
comp. insurance re ;uircd.]
Tyke of project (required):
G. ❑ New cor:_ir,tctio;;
7. ❑ Re nooelu7g
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or addiiions
-I.L[l Plumbing repairs or additions
12_❑ Roof repairs
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I
Homeowners who submit this affidavit indicating they are doins all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this bos must attached an additional sheet showins the nzme of the sub -contractors and st2te v. hether or not those entities have
employees. if the sub -contractors have employees, they must provide their workers' coma. policy number.
I anz oli ei.iploi ' -
1'er tlro_ i pro rirr:,,g trorlrers conzpezzsc:fion i;zsrrrance for my ea ployees. Below is the policy and job si;e
infornzalion.
Insurance Company Name: ew 1 L� r�a�7 r h �/� S i,-6
Policy ' or Self -ins. Lic. l=: t/,U C � Lo 3 � Expiration Date: /U
Job Site Address: l 4J k i n City/State/Zip
Attach a copy of the Nyorkers' conipensation policy declaration page (sL-owing the policy cumber 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 DIA for insurance coverage verification.
I do hereby c,rtifh under thepoins an penalties ofpe/jrely that the ilzforz.zalion pronided abo fe is fizre and correct.
Phone #.: ?Ki /d - (:�"u-T�
Official use only. Ito not write in this area, to be completed by city or town official
C c: Tcti°,;r_:
PernIi: `f,?. _...._ ._
Issuing.4uthority (circle one):
1. Board of Health 2. 13uilding Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector S. Plumbing j:._,;ector
Picone t`:
`-100.000 Lj I
CANC_E_LLA1lON_
SHOULD ANY OF THE ABOVE DESCRIGFD POLICIES BE CANCELLED PEFORE
THE EXPIRATION OAT[ THEREOF, . NOTICE LVjlj, 13C C)CI-IVF-RE[) IN
ACCORDANCE WITH I HE POLICY PROVISIONS.
AUTRORIZED -PRUSENTAFIVE
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THE EXPIRATION OAT[ THEREOF, . NOTICE LVjlj, 13C C)CI-IVF-RE[) IN
ACCORDANCE WITH I HE POLICY PROVISIONS.
AUTRORIZED -PRUSENTAFIVE
CORD 25
NS025
(D 19j8_20C .F�[J CORPORJITIGN. All n9fits re
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MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02180
Expiration: 4/27/2013
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