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Home My WebLink AboutBuilding Permit #618 - 475 MASSACHUSETTS AVENUE 4/14/2010Permit NO: Date Issued: / Ly 116 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION {{( � PROPERTY OWNER I i_J)O, 1 e i'�'C Print MAP NO: PARCEL: ZONING DISTRICT: Historic District Maclfine Shop' I. _D °t ,p 1. H yes no ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building VOne 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 Water/Sewer PTION OF WORK TO BE PREFORMED: OWNER: Name: Address: CONTRACTOR Narne:&MKS Please Type or Print Clearly) 1W('rn.nc I A� tJ (% ' Supervisor's Construction License: -30 Exp. Date:-, Home Improvement License: A 0 Exp. Hate: /aq Lam - ARCH ITECT/ENG I NEER O 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: $ 1�aoo oc) FEE: $ -6 0 Check No.: 102(l Receipt No.: .221.3/ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 4 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 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 COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE .DEPARTMENT -Temp Dumpster on .site yes - no Locatedat124 MainStree#- w- 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.s100-s1000 fine Doc -Building Permit Revised 2008 Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fe CHUS e $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22931 dui(ding Inspector CO) m m C m CAm m _) y C � � ° d CO) Cl) mo 0 CD n Z y CL O �• r c mm : o d = y Cm) o pCD CDCL O cr d CD CD o CD gm y CD C1 O CO) �C CD � v CO2 O 1 Z CD .O•r O CD C CD 0 0 tx 19 C_ 0 O 0 O O 7 m 0 C 0 m C', m CL O N C 0 Cos m C 5,oOa . O =r y cr F m m y d ')d 0 O C �• 7y =r C= d ?� w O "L7 O y O i, G T G 0• :J CD O Cn d y �, � O COY O Z .�• COY mom: =r CD m y 0 O a, CD y IW y G d m y f m� •oCD .% ca: CD CD 0 Ot C -o n•o:� n� S o �\0 7 CD Cn O CC/ 14 Q M � I w ')d 0 4/ GO071 � '�v w 7y H ?� w '� "L7 z w 0 i, G T G 0• :J r c� Cn d y �, h,071 O x O O z O C v W 0 c The Commonwealth of Massachusetts Department of Industricad Accidents Office of Invesdgations r + 600 Washington Street Boston, MMA 02111 www masxgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organiaat oMndividual): ,!-)i--OGi K5 o n &? t.C*�o4'1 e�,; Address: l t i� ' 1 t' i C%C 4 ` 1 �'�, ' _ L! i�j t is i CG a mice.( ,{ City/State/Zip:L i t , rY NJ J V-1 010-H Phone #: In � q.Li.� Are you an employer? Check the appropriate box: Type of project (required): 1. (31 am a Y emp 10 er with , 4. ® I am a general contractor and I 6' New construction employees (full andlor gart-time).* have hired the sub -contractors. '• ❑ Remodeling 2. [1 1 am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have 8. (] Demolition workingfor me in an 'c ci Y � h'• insurance workers' comp, insurance. 5. C1 We are a corporation and its 9. [] Building addition [No workers' comp. required.] officers have exercised their 10.El Electrical.repairs or additions 3.0 I am a homeowner doing all work right of exemptibn per MGL 11:0 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' #3.C] Other I 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy acrd job site information. la Insurance Company Name: I' E > i'Y CE) �}t lC C A �,� {~`%/YIS t / Policy # or Self -ins. L.ic. # �/ ' � g ra� J� Expiration Date: S) �elQ Job Site Addres r ' �C Val (A�� 1 t � /� ? . City/State/Zip �] Aoje MAC)1,946 Attach a copy of the workers' compensation policy declaration page (showing tate 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. T do hereby /}c�e/frte; fy and the /�alJins and penalties of perjury that the information provided above is true and correct nature:� / V1A�n1 Date: ti Sig Phone #: I Official use only. Do not write in this area, to be completed by city or town offlciat 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 #: Massachusetts - Department of Public Safet. Board of Buildin!! Ro-ulations and Standards Construction Supervisor Specialty License License: CS SL 99730 Restricted to: WS MARK DIPRIMA_ 37 HAWK DRIVE SALEM, NH 03075 Expiration: 2/20/2012 < ••uvni�-i..ncr Tr---. 99730