HomeMy WebLinkAboutBuilding Permit #651 - 396 ANDOVER STREET 4/27/2010Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued:
V — z -�6
/ IMPORTANT: Applicant must complete all items on this page
LOCATION_
PROPERTY
MAP 210 ^
.. Print
Print
ZONING DISTRICT: Historic District
Machine Shop'
yes no
ves I no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Tw more family
Industrial
AI
No. of units:
Commercial
Re air replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
dentification lease ype or Pri learly) ��
OWNER: Name:XPhone:
Address: X1 7 "16"--
CONTRACTOR
6CONTRACTOR Name: Phone: /" -'
Add
ress:ra
Supervisor's Construction License: '%-- Exp. Date: tom'
Home Improvement License: � � Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING P IT: $1 PER�1� 0.00 OF THE TOTAL ESTIMAT7T,T BASED PER S.F.
Total Project Cost: FEE: $ C
Check No.: Receipt No.:—2
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Location
Date
No 44
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
SS US Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 2 0 6
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 Signature
COMMENTS
HEALTH Reviewed on Signature
p
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comm
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
No
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: Building Permit Revised 2008
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The Commonwealth of Massachusetts
Department o f industrial Accidents
Office of £nvestigations
600 Washing ton Street
Boston, M4 02111
www-massgorl&a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electri
3PIicacians/Plumbers
nt In ion at
Name (Business/Organization/Individual):_�4/2
r
Address: -2 (/AZe cc
City/State/Zip:.A/or�rw A 6,Dn �� 2
Phone #:
Areyou 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 I
ship and have no employees These sub -cone have
working for me in any capacity.
[No workers' Comp, insu_ranCe
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insuranc
Type of project (required): .
6. ❑ Nev, construction
7.-WRemodeiing
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12•❑ Roof repairs
e requued] I3.7f Other
:A-1, applicant that CL -ticks box.�l must a?s0 Gil cut the se- b -e^r• shove^., rt�
I )•tUIDeOWneI'S W110 6llbmlt this
affidavit
indicatingthey .i.: tt b �r wpn-:eIS' COSIIratia Y..L•C =for --
a
+Coatractors that wolk d
chic this box must attached an ddifioIIal sheet showm the� hireotnside cont:actc must submit a new affidavit indicating such.
name 0f the sub -contractors and their wk--,
I am an employer that is providing workers' compensation insurance for my employees
information.
Insurance Company Name:
Policy # or Self -ins. Lir. #.
Below is the policy and job site
Expiration Date:
Job Site Address:
City/State�Zip: ,41t b 6l8 yS�
Attach a copy of the workers' compensation policy declaration pace (showing
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to ththe e impositionolicy number
bof c criminnd al mason datea
fine up t$ $1,500 d and/or one imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
penalties of a
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office a
Investigations of the DIA for insurance coverage verification
I do
andpenatties of perjurj, thrrt the information provided above is true and correct
Official use only. Do not write in this area, to be completed bJ' city or town offciaL
City or Town:
Permit/I,icense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityaown Clerk 4. Electrical Inspector 5. Plumbin
6. Other dg
Inspector
Contact Person:
Phone
Weir Woodworking
39 Srightwood ave
North Andover Ma 01845
978/852/9727
Home Improvement Contractor # 157687
Job Name: Lafond Insurance agency
396 Andover St
North Andover Ma 01845
978/687/7098
Description of Work
The following is a simple break down of work to be preformed on the rear entrance to repair rot
and age damage to the structure.
The exiting 4ftx4ft platform to be removed and replaced using pressure treated lumber and trex
decking to match the front entrance.
The three stairs will be removed and replaced using pressure treated lumber and trex decking to
match the front entrance
Old footing checked, removed, if needed and new footings installed to code.
Railings will be cedar to match front enterance.
Repairs to trim on roof as needed.
Estimate $3500
Accepted by
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