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Home My WebLink AboutBuilding Permit #429-2011 - 42 EMPIRE DRIVE 11/18/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: /1 1.Pld IMPORTANT:Applicant must complete all items on this page LOCATION ? 6-N&A - oelld e ( I Print PROPERTY OWNER �k-C4APZP d (LLAGC Z-LC- Print PARCEL/ _-ZONING DISTRICT: Historic District yes no MAP NO:� Machine Shop Village yes no ' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential *New Building XOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other M�Water/S F well ¢i ❑.EToodplain g EWetlands 0 Watershed District P DESCRIPTION OF WORK T D: i Z .a. Sptuep- Identification Please Type or Print Clearly) OWNER: Name: (f ral Phone:!??��?-3ia2 Address:1/ G1414T A/0 ��ty� �� 'c��s� AAA - 0fQ� CONTRACTOR Name: SSI, Phone: 2?-d0F7-3/0 2 Address:�`7 � � f nllJ Y`t cl P f;dg e2 01 L?�- Supervisor's Construction License: ,e�� Exp. Date: V31 Home Improvement License: Ex . Date: ARCHITECT/ENGINEER Jnlrilq I, Phone:,' 1-2tg Address:19&5-- c /v 3 Reg. No. 97? �S FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project dost: $ FEE: $ -/bl� Check No.: � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acc the guarantyfund of Agent/Ovvner �UpC"( Signature of coritractor; � i� Location No. y� —�� Date �o f NORTH TOWN OF NORTH ANDOVER � 0 P i Certificate of Occupancy $ . a, _ • . Building/Frame Permit Fee $ 14 Foundation Permit Fee $ 49& Other Permit Fee $ TOTAL $ Check # 23718 'guilding Inspector Plans Submitted°,Q-- Plans Waived ❑ Certified Plot Plan Stamped Plans F PE OF SEWERAGE DISPOSAL lic Sewer K Tanning/MassageBody Art ❑ SwimmingPoolsl ❑ 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 NSERVATION Reviewed on bo Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 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 124 Main Street Fire Department signature/date COMMENTS iii i 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 f I U Notified for pickup - Date Doc:.Building Permit Revised 2008 T 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) ❑ Muss 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 et t . PP his recorded at the Registry gof Deeds. One co and roof of recording must be submitted with the building application PY P g Doc: Doc.Building Permit Revised 2008mi ORTH TO" of _ _ ' 6 Andover No. /�� _ - _ D A== = o7, dower, Mass., COCKICMEWICK 7�ADRATED pP��"`� S V BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D / BUILDING INSPECTOR THIS CERTIFIES THAT (� / ��4v'clr:�/„�r. .... ..`.�.C......... .... Foundation ................... buildings on.........�'.....�!.� /'i�cJF has permission to erect.................... g .. ..................... ......................................... Rough to be occupied as �� /��....` �/...... Chimney provided that the person accepting this permit shall in every respconform to the terms of the 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR I 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. IF- SEE REVERSE SIDE smoke Det. The Commonwealth of Massachusetts Department ofIndustrial.A.ccidents Office of Investigations j 600 Washington Street Boston MA 02r11 www.mass.gov/ci'ia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib D ly Name(Business/Organization/Individual): � 12 �, ;LL-A a 6 /�-- , o— Address:.Z fqC,e.,,:4� 6J0 A) ,rlde— - City/State/Zip mit r� �° �j 2/ Phone#:92S�-o 7 "" 310 ?i 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 I 6. XNew construction employees(full and/or part-time).* have hired the sub-contractors 21A am a sole proprietor or partner- listed on the attached sheet.? 7• F1 Remodeling . ship a-ad have no employees These sub-contractors have 8. E]Demolition workingfor me in an capacity. workers'comp.insurance. g, E]Building addition Y p o workers'comp.insurance 5. ❑ We are a corporation and its p 10.❑Electrical repairs or additions required.] officers have exercised their 3.El I am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] employees.[No workers' 13.❑Other comp.insurance required.] *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 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. 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.Lie.#: 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 certify under the pains andpenaldes ofperjury that the information provided above i true and correct. Si ature: l Q Phone#• 979" 9 P ? 3/(52, Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermiMicense# 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 4: