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HomeMy WebLinkAboutBuilding Permit #070-14 - 4 SURREY DRIVE 7/22/2013 ■ TOWN OF NORTH ANDOVER j�j APPLICATION FOR PLAN EXAMINATION Permit N V Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Sl,Lr,r __ 6 ve .nt PROPERTY OWNER . _ Cj ­ _- _ _ Print 100 Year Old Structure yes no MAP N0: _ PARCEL: ZONING""DISTRICT. _ - Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well Li Floodplain Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: (,C1 Identification Please Type or Print Clearly) OWNER: Name: h UYN �_k �.� cad e° Phone•G�r1g• �D Address. C_( +� CONTRACTOR Name:.... . _ _ Phone:. Address: Supervisor's 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: $ -� Check No.: Receipt No.: NOTE: Persons contractin re e d contractors do not have access to the guaranty fund Signafure=of Agent/Own i afure.of.contractor _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF`.SEWERAGE.DiSPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑. - .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 d Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted Y es Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date Driveway Permit DPW Todvz Engineer: Signature: Located 384 Osgood Street EIRE-DEPARTIViEW - Temp Dumpster on site yes no Located at 124 Mair., Street Fire Departmerf signatia"reldate'' ` ' ` - " 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 ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol;owing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofirg, 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 apo.-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+._ted with the building application Doc: Doc.Building permit Revised 2012 Location errCXJ No. Date • - TOWN OF NORTH ANDOVER • S���U+'6Ais . i . y y Certificate of Occupancy $ Building/Frame Permit Fee C —J Foundation Permit Fee $ jPF,t} ; s4' Other Permit Fee E© $ TOTAL $ Check#� 26643 Building Inspector NORTH Town of 2Andover O � . 0 tlU .004 �Ah , ver, Mass, Z Z 1 coc..Ic«ewfc.. '1 �a A04ATEo hS S V BOARD OF HEALTH Food/Kitchen PER ! T LD Septic System THIS CERTIFIES THAT .. LT ....... ......................................... BUILDING INSPECTOR has permission to erec Sa !r. Foundation ....................... buildin son ...... ...... 4�.....fi�.�................. Rough to be occupied as ..... i�!� .......... ....... ... .. .... ......... .................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI RT Rough Service ..... :...... ............ ... . Final BUILDING INSPEC GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE .2o F—I f N,-2dC) j I '� NYThe Commonwealth ofMassachusetts - .f Department o De artIndustrialAccidents P Office of Investigations 600 Washington Street Boston,M4 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/fndividual): Address: City/State/Zip: Phone#• Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/orpart-time).x have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.z �• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, workers'comp.insurance. g• C]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.CK I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12,QRoof repairs insurance required.]t employees.[No workers' comp.insurance required.] 1311Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am 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.Lic.#: 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 requiredunder 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 gins a alfies ofperjury that the information provided above is true and correct. ature: Dater Phone O a Offccial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost ... ���0.GO . m $ - $ 99.00 Plumbing Fee $ 12.38 Gas Fee 100 comm. $ 1Ono: Electrical Fee $ 12.38 Total fees collected $ 223.75 4 Surrey Drive 070-14 on 7/22/2013 Basement Remodel 3 � °10 6 TO"OF NORTH ANDOVER °- • OFFICE OF W"INGDEPARTMENT 9 1600 Osgood Street Building 20,•Suite 236 ,yes ° North Andover,Massachusetts 01845 Gerold A.Brown Inspector of Buildings Telephone(97$)688-9545 ' HOFax (978)688-9542 ' -5 MBOWNER•LTCENSE$XENIPTION ICATION easempA --�'l�l: JOB LOCATION: N Q 01 :.umber Street ddress Map/Tot UOAM0 MR Name. Home Phone WorkPhone PRB-SENT MAILING ADDRESS City_QIm T `- tate- 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 notpossess a license acts as supervisor). State Building (Code Section 108.3.5.1) • p ,provided that the owner DBFINMON OFHOMBOWNBR Person(s)who—Qwns 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 family structures. A person who constwts more considered a homeowner. that one home in atwo-yearpeniod shall not be The undersigned`110medwner"assumes responsibility for compliances with the State Building Applicable codes,by-laws,rules and-regulations. g Code and other The undersigned`'homeowner,,certifies that he/she understands the Town of Forth Andover Building Department minimum inspection procedures and reuimetad at he/she rrequirements, comply withsaid procedures and HOMEOWNERS SIGNATURE\�.. APPROVAL OF BUILDING OFRCIAL Revised 72009 Form Homeowners Exemption 'BOARD OF APPEALg 688-9541 .. ° CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9595