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Home My WebLink AboutBuilding Permit #655-11 - 52 WATER STREET 3/31/2011Permit NO:� I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received I " EVIPORTANT: Applicant must complete all items on this pane LOCATION5,-,'' G 'v L l.7 Print MAP NO: PARCEL ZONING DISTRICT: Historic District es no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Ipdustrial Alteration - No. of units: - iq'Commercial ❑ Repair, replacement ❑ Assessory Bldg -❑ Others: ❑ Demolition ❑ Other - - RIV ,� or f$ �0 Septrc ®Well = � Floo `la ri� q WetI -d p ;� ty MAIL ti ®` he ers d District, ,�, ate: t l DESCRIPTION OF WORK TO BE PERFORMED: o i L U Identification Please Type or Print Cle rly) - - - OWNER: Name: �(o [� ' ?' -Y �i . ft l I- C i,,9 16, Phone: 0 CONTRACTOR Name: tr- t5'q- t' Ll// -:f 411 L 1045 /'L Phone: 9 t Address: Supervisor's Construction License: ExpDate: - Home Improvement License: Exp. Date: ARCHITECT/ENGINEER i Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT.' $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ S D - `' FEE: $ Check No.: Receipt No.: NOTE: Persons cont acting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Swimming Pools ' ❑ . ❑ Tanning/MassageB ody Art ❑ g Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ ! t THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _w DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH 6, COMMI~NTS Reviewed on Signature Reviewed on Signature - 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: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 1 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.$10041000 fine n Doc:.Building Permit Revised 2008 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 (VOTE: 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording . lust be submitted with the building application Doc: Doc.Building permit Revised 2008mi FA Location No. Date ?-3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 2 4 011 Building Inspector J C n O i bin cu i N y O .c. H J, 7 C j I `CL � Z �1 c C .�I o LU Z I�r 1 e:. M O W Lo Nm t Lf)9 Lij E w * NI ,,,p r+ , Y 11 r #n rt k i C c O IA <O --go r -t o U M —i Q. ::kO We 1 ;� w N LC C a W p C D cj�Q ED 2 J N o Y N 0 O =� w w Z U :q of �. m v. -d v LXX O _ r<0 w x cu O O_co I�\ 0 0) U 2 N CO d U1' 1 J The Commonwealth of Massachusetts Department of Industrial.Acciclents Office of Investigations 600 Washington Street Boston, MA 02111 �� sy www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electriciansfplaxmbers Applicant Information ]Please Print I,egilbly Name (Business/Organization/Individual): (tv I'A 7 - Address: `} `7 fn tj I A(S i , / x l—o City/State/Zip: 1 /e o5C Ed F' ,�) Phone #: q 7 3 6 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors -,employees 2. I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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. Bl modeling . 8. ❑ Demolition 9. [-]Building addition 10. F1 Electrical repairs or additions I1.0 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. X am an employerthat isproviding workers' compensation insuranceformy employees Below is thepolicy andjob site information. Insurance Company N. Policy # or Self -ins. Lic. Job Site Address: Expiration Date: 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 ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do liereb c tif�y under the �ains�and/pen�alti ofperyury th the information provided above is Prue and correct. SiQnai�rrP 6� rrr��=� '45 17ate --::Z ..3 1 Offrcial 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone GO cnv U C7 Z Ca L co a v w a e �' o • o° v o o :� coo � w o � CIS o G LL C/)u [s PG U Li. w LW w ) ti. G: tL W cn cn W CD L'w+ L GO CL _ p R ,, ++ CD O V LCO Cc O m p ca E a C/)p O �,'I.i O. Y id rO C/) • Fa ICM y= OCL y 0 U.l QE.S N . di r_J O O U L O C _ 1' O 14 m a 3 L H ,3 v1 l •� o 10 W as O p p , c r-+ -o ' Cn cc o a W CO cv = ,•-, O LiEm w O _-O W av m R O U) N m 4 a= C/) - �' •_ , c Cf) tea. 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