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HomeMy WebLinkAboutBuilding Permit #35 - 439 WINTER STREET 7/14/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: 14.,_--J IMPORTANT: Applicant f/ must complete all items on this age LOCATION 73 I must J q EET Print PROPERTY OWNER VAM CC SRAi r4AA19 Unit# �� Print MAP NO: /0 PARCEL:ZONING DISTRICT: Historic District yes n Machine Shop Village ye no 100 year-old structure yeon 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 ❑ Watershe&District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 4F-4f2 (Identification Please Type or Print Clearly) t . OWNER: Name: <qM r Phone: Address: 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: $ /5 DOO FEE: $ D. o v Check No.: 3 Receipt NOTE: Persons contracting with unregistered ntractors do not have access to the guaranty fund Signature offAgent/Owner S,ignature.of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL 1 Public Sewer. ❑ Swimming Pools El Art ❑ 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 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 Dimension Number of Stories: Totals square feet of floor area,ea, 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 I Doc:.Building Permit Revised 2011 June/mi 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) o 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 Location %S� No. s3ss�— "— Date • ,.Oak TOWN OF NORTH ANDOVER 9 . ' Certificate of Occupancy $ s�CMU s I Building/Frame Permit Fee $ Foundation Permit Fee $ ' Other Permit Fee $ " TOTAL $ Check # YJ 246 r �- I!! / 2 Building Inspector The Commonwealth of Massachusetts Department of IndustrialAceidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lealibly Name(Business/Organizafionandividual): 74m-es S'-1 e- —4--Pyt Address: if 39 01rIn'i` d-r. City/State/Zip: /1J. A^tD. /M.q 0 j Q V 5r Phone#: 178. 51rq-. 5Y�L4 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.ElI am a sole proprietor or partner- listed on the attached sheet.# 7. FJ Remodeling ship and have no employees These sub-contractors have 8. [❑Demolition working for me in any capacity. workers'comp.insurance. g E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.� 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.E]Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] *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. lContractors 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: AYQNDV rA Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: � `J 0I N-tZ,�1G f? /� 'I IV 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 pai s nd Ides ofperjury that the information provided above is true and correct. Signature: Date: /G d& Phone#f: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: F µoRTH TOWN OF NORTH ANDOVER 32Qb i+L�o R`a"°L OFFICE OF a' -W YK BUILDING DEPARTMENT CL " Y � M a kti* -A 600 Osgood Street Building 20, Suite 2-36 F North Andover,Massachusetts 01845 C SACHus c Gerald A.Brown Telep one(978)688-9545��''�� Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE:_ ,.TUG V /V. ?_0// JOB LOCATION: /-Y-77f (,Jln/tr0_ /0414 �O Number Street Address Map/Lot HOMEOWNER Tq/nES q,IV-A 4nlK f-T-6 ST-7 S t{76 Name Home Phone Work Phone PRESENT MAILING ADDRESS 79 GJ�N S� A/ 01N.P e)j1ek- /ir 0.9 City Town 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 awns 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 cpm ithsaid procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535.• ' r1ORTH T0VM Of 2 _ '' O ndove O No. LAKE o �` dover, Mass., COC MIC HE WICK ORATED a7 ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... !. ...........94.4.L..... -.. ............................................ Foundation buildings �... ........... �Xi Rough has permission to erect..... . .... g .......... . ........�..... ....... �... ... g y t0 be Occupied as........... .. ...... .... .... tw�..�..:....�.� �...... ..........�......:... .. . .... �..�1.� neprovided that the perso accepting is ermit shall in every respect conform to the terms of th plicdh file in Final this office, and to the provisions of he 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 lko-J PERMIT EXPIRES IN 6 THS ELECTRICAL INSPECTOR. UNLESS CONSTRUC N S ARTS Rough ..... ................... .... .. ......... Service BUILDING INSPECTOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do, Not Remove Final No Lathing or Dry (Mall To Be Done FIRE DEPARTMENT. Until Inspected and Approved by the Building Inspector. Burner - Street No. SEE REVERSE SIDE Smoke Det.