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HomeMy WebLinkAboutBuilding Permit #380 - 4 MAIN STREET 12/4/2008 "OR BUILDING PERMIT 0 "ORT";�tio 6 0 TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received '114pogwren,pp``,�y gSSACHUs�� Date Issued: ' IMPORTANT: Applicant must complete all items on this page LOCATION rin -PROPERTY OWNER; P nt MAP N0 PARC,EL: ZONING DISTRICT:, Historic District es no Machine Shop V l ge no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more familyI dustriall ---_ Alteratio No. of units: Commercial epair, replacem Assessory Bldg __Ofhers ` : emoli ' Other S iG - /ell Floodplain �.Wetlands Watershed District Water/Si DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: a CONTRACTOR Name: core Phone: Address: I Supervisor's Construction License: 3�3Exp. Dater a 1 Home Improvement Licenses 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: $ /S-1) FEE: $ Check No.: q�o ' Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acss to guaranty fund signature of Agen#/Ouuraer Signature of contractor 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 Application Revised 2.2008 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 b COMMENTS f 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 924 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Totals square feet of floor area, based on Exterior dimensions. q 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 ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 y.. r. Location No. Date AIL a MORTq TOWN OF NORTH ANDOVER ` Certificate of Occupancy $ ,�'�s•^•;.�• Building/Frame Permit Fee $ R Foundation Permit Fee $ ` Other Permit Fee $ TOTAL $ s Check # Wo 21737 Building Inspector NpRTM Town a• ` �. O Andover , of _ No. o dover, Mass, - • o 0 - CAKE coC..C..W.C.'ORATED `9S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System ' BUILDING INSPECTOR .. �...�I v.. ........ Foundation THIS CERTIFIES THAT......... ... .. .1............ ...... ... �.. tion • Rough has permission to erect........ ..............�............ buildings on ........ ............ �Ia......!i..�.........4. p• � ......xpg3e . .. ....... �.. Chimney to be Occupied as............. ... .� g/.. ............. .... . ................. provided that the person acce mg this permit shall in ry respect conform to the terms of 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 G MONTHS ELECTRICAL INSPECTOR UNLESS LESS CONS 1 R VT TS Rough ........................ ............................... Service BUILD SPECTOR Final Occupancy Permit Required t0 OCaipy 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. The Commonwealth of jllassachusetts Department o f Industrial Accidents Office of'..t•: �` , .ff Investi;ations ii c,c 600 Wash in,aton Street Boston, MA 02111 www,mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name (Business/Organization/Individual):-2,e t- Address: A3 Su 0 City/State/Zip: N iI►'►lJ We Irt 11/f Phone#: Are you an employer?Check the appropriate box: 1.❑ i am a employer with 4. ❑ i am a ae F7. ype of project(required): Hera b 1 contractor and I em i o ees fu p y ( ll and/or art-time . have New c p ) hired the sub-contractors ❑ construction 2.❑ I am a sole proprietor or P P partner- listed o P the attached sheet $ ❑ Rem.odeling. ship and have no employees These sub-contractors. u,b_contractors.have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ZWe are a corporation and its 9• ❑ Building addition 3.❑ required.] officers have exercised.their 10.0 Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL I 1-El Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no insurance required.] t employees. [No workers' 12Roof repairs comp. insurance required.] 13•❑ Other *Any applieOwle rs jhat checks box a I.must also fill out the section below showing their workers'compensation policy information. +F-iome�wners who submit.l9iis aiudazrit indication L'iey-ate voi:,� -::-_,r - -.• tContractors that check this box must attached an additional sheet showing he�rname of the sut,-Wnrractoirsrand heir wo'rken'co pupolicy information. I am ann employer that is providing workers'compensation insurance for n9'employ information ees. Below is the policy and job site //�� Insurance Company Name: N5,,c. 1 n L- ©`� � Avl_�_4 ' i.S✓YG 11(2 Policy#or Self-.ins. Lic.#: V wr, 6 0 Expiration Date: Job Site Address: City/State/Zip: N• �j D -e/ I'M 0 19 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce i and the pains and penalties of perjury that the information provided abov is tr a and correct Sic-mature: G� p o / Date: J q d Phone#: I )0 - 6 0 T 6 2� o p [Contact only. Do not write in this area, to be completed by city or town officiaL n: PermitlLicertse# hority(circle one): I. Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other son• Phone#: L1 4-1 11 y1 C� ,ef_.�1 ■ .M.[ti �t V OU J-�UOII ON i l t I