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Home My WebLink AboutBuilding Permit #50 - 4 FIELDSTONE COURT 7/9/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:6--a Date Issued: IMPORTANT: ApI LOCATION ^f � h ?� ny S Date Received must complete all items on this (WeA t t r t) ( �0 '� v',�t�eu �6• ry� nOco OH T/ PROPERTY OWNER 4 feId9t Yrj ^e s Print MAP 210 PARCEL: _ ZONING DISTRICT:—Historic District yes no Machine Shop Village yes 'no 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 Watershed Dis€dct Water/Sewer DESCRIPTIO OF WORK TO BE i 11 a wfolwch nh &04p- Identif cation Please Type or Print Clearly) OWNER: Name: l j)O (n l Ne, ho v -es Pho Address: �b wed �idg�e �6Z ill �Y)JL7�e r G8�7d�3 R j CONTRACTOR Name: ay C 6 Z(a t'' Phone: 815 7;1 V5— Address:, 5—Address Supervisor's Construction License: C 5 f g Exp. Date: /o/9 Home Improvemei Date- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ � � ?00. 06 FEE: C�J) Check No.: / �,� Receipt -No.: NOTE: Persons contracting with unregistered contractors do not have access to the guayg ly fund Signature of Agent%Owner 4� �T�e. Signature of -contract' _. _ _ Location No. ISO Date J HQRT1y TOWN OF NORTH ANDOVER S Certificate of Occupancy $ Building/Frame Permit Fee $ QAC NUSE' y s Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #_ 20�1 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 Siqnature r'�'7MMENTS 0 Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes 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', artment 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 NV I t5 and DATA - (For ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 use 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 ca v w° Qj v, cn W a or. C-13tw U w W o � O a O ctl a - rA cn 0 cn ui am 74 P-4 I rz C ca 03 .E L O O CD Q a CA 0 V O. y C O O C C+2 O 0 0 O Q' �a c ev cc J .� O O Z CL CO2 C LLI U) U) 19 W W U) o � O H G r O V V •ate �: :ac ea cc �G U3 o ®zR .: err �+• m o n y G ;• r as C2 c+ $ u c� m c E CL GO C0 �mm y 3 H ._... cn G •p � _ y O m E y v �a�` y m m G: >o :=Z O cm Cl)" O a •v acs o o� cc m Z o ' ev :o CL CD c a m y m c co W 0ED �r�Z Z •ty/� ., c •- O � . E C= C .0 a . O c Z o W C.3 CD Q CD m COO O. 0:2 O� = . Ccc L4- C=o 74 P-4 I rz C ca 03 .E L O O CD Q a CA 0 V O. y C O O C C+2 O 0 0 O Q' �a c ev cc J .� O O Z CL CO2 C LLI U) U) 19 W W U) The Commonweizlth of Massachusetts Department o f industrial Accidents Office of fnvesboations ..600 R"ashine-on Street BOstOny AIA 62111 �+'►+ W. M'fzsS-govi&a Workers' Compensation Insuranceclavit: gderslContraetors/Electricians/P Iieant Information lumbers n, r�ease rrtnt Leaibly Name (Business/Organization/Individual):(�itQZ"('l/11e . Address: City/State/zip: d U'e V a q7� � 8� • / � 3 7 Are you an employer? Check the appropriate box: Phone #: 1 • al am a employer with _ 1 4. ❑ I am a Q Type of project (required): employees (fill] and/or part-time). have hirede� contractor and I the sub -contractors 6 New construction • ❑ I am a sole proprietor or partner_ listed on is- e attached sheet x 7. ❑Remodeling ship and have no employees These su contractors have ❑ working forme in any capacity. workers Demolition CC)insurance. 8. [No workers' comp. insurance 5. ❑ We are a co oration 9. ❑ Bwldmg addition required.] rP and its 3.7 I am a homeowner doing all work right off ve exercised their 10.0 Electrical repairs or additions myself [No workers I comp. Cmgtion per MGL 11.❑ Plumbing repairs or additions insurance required.] t c. ' § 1 �4•), and we have no employees. [No workers' 1 ❑ Roof repairs comp. insurance required.] 13.0 Other `: nV Miert that shams bot: is mi s? Homeo gist uu c_ the sectio eeiep' wnea who submit affidavit indicating they a_ _ dc�E aL' wort and �� A eri mss' +Conttactozs that chd is this bex m::st attached an additional shit showing then hire outside cont*actms • yv� _ c m the came of the sub c submit a new affidavit indicating such. I am an em P $ ont�aetots and their workers' comp. poiicy information. P�J'� that is rovidin workers' compensaiiorc insurance for my employees Below, is the oli , information. P � and job site Insurance Company Name: �j Policy # or Self -ins. Lic. #: e OQ ?i S -zj Expiration Date: Job Site Address: �Y Attach a copy of the workers, compensation policy declaration page (showing /e /Zip: /�✓✓-----C-e ✓ .�-r Failure to secure coverage as required under Section 25A ofM w Policy number -and expiration date). fne up to $1,500.00 and/or one-year imprisonment, as well as Glc. 152 can lead to the imposition of criminal of up to $250.00 a day against the violator. Be advised that a co penalties in the form of a STOP WORK ORDER penalties of a Investigations of the DIA for insurance coverage verification Office f a fine py of this statement maybe forwarded to the Office of Mc pains and penalties of perJurl' thQt &e information provided above is true and correct lye?' Official use only. Do not write in this area, to be completed by city or town off,ci,,L City or Town: IssaiQa Authority (circle one): I: Board of Health Z. Building Department 6. Other Contac Person: Permit/License # 3. Ciiy/Town Clerk 4. Electrical Inspector Phon: 'Y S. Plumbing inspector