HomeMy WebLinkAboutBuilding Permit #805 - 407 MARBLERIDGE ROAD 5/31/2011Permit NO: D S
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received 27// /
Date Issued:
IMPORTANT: Applicant must complete all items on this paize
Pridt
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes no'
TYPE OF IMPROVEMENT
PROPOSED USE
Residential -
Non- Residential
❑ New Building
❑ One family
❑ Addition
'P-1`wo or more family
❑ Industrial
❑ Alteration
No. of units: Z
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
®CSep� c' Well j r
�kF-%6dp�a n W and
?Waters c1 District
Ater/Sewera
- -
DESCRIPTION OF WORK TO BE PERFORMED:
entifiication Please Type or Print Clearly)
OWNER: N
Address: �2e-- Azx/) ,
CONTRACTOR Name:
Address:
Supervisor's Construction License:
Home Improvement License:
Exp. Date:
Exp. Date:
ARCHITECT/ENGINEER Phone:
Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Tota! Project Cost: $ E o ) e- FEE: $ 0
Check No.: a1147l1A- Receipt No.:
NOTE: Persons contracting with #Amgistered contractors do not have access to the guaranty fund
Signature of'Agent®wner_ignatureoof,contractoriF
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: Doc.Building Permit Revised 2008mi
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art ❑
Swimming Pools
Well
Tobacco Sales ElFood
Packaging/Sales 0
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMEN
DATE REJECTED
N
DATE APPROVED
ONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signa+�•re
��
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
tl�
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/signature & Date Driveway Permit
DEW 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 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 2008mi
Location'4;t-
No. Date
MORTry TOWN OF NORTH ANDOVER
e. • O
_ _ L
.. 9
Certificate of Occupancy $
,'ss�cMusE�� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit. Fee $
TOTAL $
Check #
24202
Building Inspector
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
quo www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ Iectricians/Plulmbers
Applicant Information Please Print Le0bly
Name (Business/Organization/Individual):
Address:
City/State/Zip: , hone #:
Are you an employer? Check the appropriate box:
1. ❑ lam a employer with
4. F1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
[No workers' comp. insurance
quired.]
officers have exercised their
3. Z I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c 152, § 1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.,�Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
T 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. 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 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 certyo,
theC�i/�ns and alties o perjury that the information proviaea aoouv/ve is true aritt vu"eut.
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 #:
F µaRTH TOWN OF NORTH ANDOVER
ott, OFFICE OF
BUILDING DEPARTMENT
e� 1600 Osgood Street Building 20, Suite 2-36
sq� q,ro �p�{c5 North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION:
Number Street Address
HOMEOWNER t�G�G 5-
Name Home Phone
PRESENT MAILING ADDRESS
1--41) c2(
Map/Lot
� -z
Work Phone
City Town Stwte . 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 owns 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 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 V
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MASS.
SCALE:1 "=40' DATE: 11/28/95
Scott L. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
I7 \
EXIST. HSE. FHD.
�
35.5'
LOT '13'
PLAN #4840 N.E.R.D.
30,576+/- S.F.
R=20.00'
L=19.68'
GE -
I CERTIFY THAT
THE OFFSETS OFFSETS SHOWN ARE FOR THE USE�N
OF.THE BUILDING INSPECTOR ONLY
SHOWN COMPLY
WITH THE ZONING AND SUCH USE IS FOR THE
BY LAWS OF DETERMINATION OF ZONING .13972 o
CONFORMITY OR NON -CONFORMITY �frMERE� �
NORTH ANDOVER
WHEN BUILT WHEN CONSTRUCTED. AC Lab�°U�