HomeMy WebLinkAboutBuilding Permit #146-12 - 393 FOREST STREET 2/19/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: �® Date Received
Date Issued:
IMPORTANT:A licant must complete all items on this page
LOCATION Q-;9 �,? Oe�'P,s
T T �
Print
PROPERTY OWNER eA 7e�d E ��d � Unit#
� Print
MAP NO: PARCEL ZONING DISTRICT: Historic District y6no
Machine Shop Village y100 year-old structure y
TYPE OF IMPROVEMENTPROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition
❑Two or more family El Industrial
❑Alteration
No. of units: El Commercial �
0 Repair, replacement ❑Assessory Bldg ❑ Others: I
13-Demolition ❑ Other
to Se tic ❑ Welld - -
p 0 Floodplam� 0 Wetland's -
E Watershed Distct
❑ Water/S;ewer -_
DESCRIPTION OF WORK TO BE PERFORMED:
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non
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1�
(Identification Please Type or Print Clearly) d
OWNER: Name: 6
Phone:
Address: r
CONTRACTOR Name: Phone:
Address:
Supervisors Construction License: Exp. Date:
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: $ C20 _
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
��p"�., -((✓•ate'
�,�ignature ofrAgent70wnQr�����`� A.. �/
�Signafureof}cont`ractor
Location 3ci3 71
No. t o Date
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
24490
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on °I 7► Signature
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COMMENTSLD k .
d� �`�
HEALTH Reviewed on Signature
F COMMENTS
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Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
I
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Drivewav Permit
DPW Town Engineer: Signature:
i 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
NOTES and DATA— For department use
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❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
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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
a 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 rior to
p p issuance of Bldg Permit
Addition or Decks
❑ Building Permit Application
o 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)
a 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
a 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
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NORTH TOWN OF NORTH ANDOVER
�`•aH°0 OFFICE OF a
.00
- BUILDING DEPARTMENT
=o e* 1600 Osgood Street Building 20, Suite 2-36 a
'�ppOq+n° "ayes North Andover Massachusetts 01845
�SSACHUSE�
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• � -
Gerald A.Brown Telep one(978)688-9545��'Y�'�
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: /I
JOB LOCATION: Sy"_?
Number Street Address Map/Lot
HOMEOWNER �� � � /SCJ �/i34� �/7-- 1���_' C�✓�3
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town. StYrP. 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 Awns 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 fanuly 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 that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535., `
f. .
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The Commonwealth of Massachusetts
Department of Industrial,Accidents
Office of Investigations
600 Washington Street
Boston,MA. 02111
UIP
www mass gov1dia
Norkers' Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plulmbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): yS1 n d j`xJ,.
Address: J 1.� ��J''_-PS 7-
City/State/Zip:
City/State/Zip: Phone#: (0 I ?_ ,�/a �� FCGI
Are you an employer?Check the appropriate box: Type of project(required):
'L❑ I am a employer with 4. ❑ I am a general contractor and I 6. []New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. E]Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL I L E]Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs
insurance required.]i employees.No workers'
comp.insurance required.] 13.0Other
*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 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.
lam 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.Lie.M 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.
Ido hereby c under the p andpenalties of perjury that the information provided above is tru and correct.
Si ature: Date: /
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 CIerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
NORTH
�c T® ® dover :.
An
No.
o , dover, IVMass., •
COC H IC HEWICK ��•
ORATED p'P�,��S
U BOARD OF HEALTH
PERMIT. . T D Food/Kitchen
Septic System
THIS CERTIFIES THACT tt BUILDING INSPECTOR
T............... � ............... Q. .I. �1............. ........... .
' ::::::: Foundation
............... b 'Idings on ...... 1 g
has permission tit
oerect...... A ............................'....... Rough
toibe occupied as.............. �� .. .............................................................................11111W Chimney
............ ............ .............. ............... ....
provided that the person accepting this permit shal in every is
conform 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
306 PERMIT EXPIRES IN C MONTHS ELECTRICAL INSPECTOR
7 �TT TT
UNLESS LESS CONSTR V CTI �TS 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.