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Home My WebLink AboutBuilding Permit #268-13 - 45 LACY STREET 10/4/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 3 Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION .� . A L Print PROPERTY OWNER Print 100 Year Old Structure yesrnoMAP NO: PARCEL:` ZONING DISTRICT: Historic District yeMachine Shop Village ye 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 ❑ Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ��f�cc/tJ G l✓_1401Q S p � Identificatio Please Type or Print Clearly) OWNER: Name: !" C_\\f Phone: q7W-66Z -/6Yo Address: �{� (ACY 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: kL9 b FEE: $ Check No.: Receipt No.: r�� 1" " NOTE: Persons contracting 'hnr ' to ed contractors do not have access to the guarantyfund Signature of Agent/oOwn r Signature of contractor Plans Submitted ❑ lans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 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 Osciood 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 E {E E Doc.Building Permit Revised 2010 - 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) o 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 2012 Location No. Date • ' TOWN OF NORTH ANDOVER s . � Certificate of Occupancy $ Building/Frame Permit Fee $ ` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ _ Check#—M 25787 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT. 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly n,_04VL_ Name (Business/Organization/Individual): &b_c Address: q, (.Ae-Y City/State/Zip: l kA ty A 018f 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/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ?• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.0 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.]t employees. [No workers' comp.insurance required.] 13.❑ Other i'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. C am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site reformation. Insurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: lob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby cr fy c tl r t e pains and penalties of perjury that the information provided above is true and correct. .i nature: Date: 'hone#: �� Z e-16 Y-L�3) Official irse 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: NORTfi Town of : t E . Andover No. _ o �h ver, Mass, • l COCHICHl WICK y�• AOR^rEo �Pp��S S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT mi,�l... BUILDING INSPECTOR has permission to erect .......................... buildings on ........ ..� 077.9p......... 4�i... ......... .....••••• Foundation . . Rough to be occupied as ...... ................ ............. .l. .. .� ............. 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. �/ n' u Final PERMIT EXN EXPIRES IN THS ELECTRICAL INSPECTOR 110 ' UNLESS CONSTRUC TA Rough Service ......................... ..................................................... Final BUILDING INSPECTOR 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 WN OF NORTH TO ANDOVER ° -�� °M OFFICE OF BUILDING DEP • � ARTMENT 1600 Osgood Street Building 20,-Suite 2-36 �'�ssgFu�s c�5 North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(97g)688-9545 HOMEOWNER-LIaNSE EXENIpTION Fax (978) 688-9542 GUIDING P'RMIT APPLICATION Please print DATE: 2 JOB LOCATION:_q-�: � "J / Number Street Address `-" ( Map/L t HOMEOWNER - lT Its- •G ro � - Name Home f Phone - `?'f Z y—8Z7a Work Phone PRESENT MAILING ADDRESS 5 ----------------- City To•*fir S{'a+ ' Zip Code The current exemption for`homeowners"was extended to include owner-occupied dwellings to t4vo units or less and to allow such llomeotT7ners to engage an;individual-for hire who does notpossess a license,provided that the owner acts as supervisor). Slate Building (Code Section 108.3.5,7) DEFINITION OF HOMEOWNER Persons)who Qwns a parcel of land on which he/she resides or intends to reside, be,considered a homeowner.one or two family structures. A person Who on which there is,oris intended to consconstructs more that one home in a two-year period shall not be The undersigned"homeowner"assumes responsibility for compliances with the Applicable codes,by-laws,rules and regulationsState Building Code , and other The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and re rem is and that she will comply with said procedures and requirements, HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption 130ARD OF APPFALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 ¢ NORTH Town . of s ndover 0 . . ,. •� No. _ Z - � > h ver, Mass, . t 4===Ococ�1c„ewfcw �1 L) BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ................... ..... .kltl.... ........... .......... ........... ......................................... BUILDING INSPECTOR has permission to erect ........................... buildings on ........ ..17.........(..&`... ......... Foundation........l.......... R ough to be occupied as ...... ........ ................ ............. .l. . .��/it ................ 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 , NTHS ELECTRICAL INSPECTOR Iv ' UNLESS CONSTRUC TA Rough ...., � Service . .............. Final BUILDING INSPECTOR 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. SEE REVERSE SIDE Smoke Det. I