HomeMy WebLinkAboutBuilding Permit #565 - 53 Marblehead Street 2/28/2007 BUILDING PERMIT of"O oT;�ti
oC" ,1
TOWN OF NORTH ANDOVER -
APPLICATION FOR PLAN EXAMINATION
0"
Permit NO: Date Received �4 ""
Date Issued: 2
za_J -12 2 Ss S
IMPORTANT: Applicant must complete all items on this page
LOCATION si'•
Print
PROPERTY OWNER Rz! r AAA.-n,a
Print
MAP NO: PARCEL �� ZONING DISTRICT; HISTORIC DISTRICT yes o
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
Public Sewer `' ' titer 0;Flood lain C Wetlantls Watershed;District
DESCRIPTION OF WORK TO BE PREFORMED:
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'�/Oli'v1��D,�N Qy1 P_1'�(S'T1 v�c� U✓�•C'1 v��Snc� -���G` ^t- lG O✓
Identification Please Type or Print Clearly)
OWNER: Name: pe A7_-v- o Phone: q'1945Z 4o42
Address: S3 Ma✓blc kc~-A S�- a. moi M
CONTRACTOR Name: Phone.
•Address
Supervisors Construction License: Exp: Date'
,
t .
tome Improvement License. < Exp: Date
ARCHITECT/ENGINEER Tv-;v°t knin +ce✓•V%C' Phone:--I qt 21?? 00-1-7
110 tau,v►
Address:- Wnt,wk mA cis o t Reg. No. 419 ( 2
FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ 06 -
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agen Owner Signature of contractor
Building Department
artment
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
o Building Permit Application
Li Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
• Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan
And Hydraulic Calculations (If Applicable)
a Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
a Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
v Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan
And Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
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 2.2007
Plans Submitted ❑ Plans Waived_❑ _ _Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
d
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
A
DATE REJECTED DATE-APPROVED
HEALTH 0 r
COMMENTS ,
a I
` f
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanningl,Massage/Body Art -i ❑ Swimming Pools, k El
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ - 4
Permanent Dumpster on Site ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Sic nature& Date ,
Driveway Permit
Located at 384 Osgood Street
FIRE DEPARTMENT Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date '
COMMENTS t
Dimension
Number of Stories:______ Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
i
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
i
i
❑ Notified for pickup - Date
i
F--
Location
No. S6�- Date
+ORTN TOWN OF NORTH ANDOVER
' Certificate of Occupancy $
cMusts� Building/Frame Permit Fee $ COD
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2U � � G�' M
Building Inspector
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DETAIL 1
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DETAIL 5
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NORTH
own of t _ over
No. ��DS - _
ower, Mass.,
OCOCMICKEWICK ��
7,p ADRATED PPS` �5
l`s BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT... .......................................................................................................................................................... Foundation
has permission to erect........................................ buildings on... ...M,�.0046164. .. .#*+�,r✓D ... Rough
to be occupied as.... I..y11 .1. ... .. . -�.0................................................................. Chimney
. .... ..
provided that the person acce mg this permit sha in every respect conform 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
G i O PERMIT EXPIRES IN 6 MONTHS Final
ELECTRICAL INSPECTOR
UNLESS CONSTRU ST TS Rough
Service
B SPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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
i
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
' 1600 Osgood Street Building 20, Suite 2-64
9,,` ^r•> +''i15 North:kndover, Massachusetts 01845
S^C HU`•�
Gerald A, Brown Telephone 9?
Inspector of Buildings P (. 8)688-9545
Fax (978) 688-9542
H0�IEOWNER LICENSE EXEMPTION
Plcasc Print
DATE: l to
JOB LOCATION: — S—/ ✓ cj— b �
/ �eq
Number Street Address F/ VT
Map/Lot
HOMEOWNER C`c ti 0 0 7
Name Home Phone 3
Work Phone
PRESENT MAILING ADDRESS —A/C_ 6 14 �� �� 0) 34—
Y3 C-1 .
City Town 4 ( � T
� State 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 r
acts as supervisor). State B provided that
Building (Code Section 108.3.5.1) t the owner
DEFINITION OF HOMEOWNER
Person(s)who owns 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 hei she understands the Town of North Andover Building Department
minimum inspection procedures and requireme nd th t he/s will comply with said procedures and
requirements.
HOMEOW'iVERS SIGNATURE_
APPROVAL.OF BUILDING OFFICIAL
Rc•,iscd —
I'on n Hom-wncrs Excmptiun
Q\i;i$-'+*3q tIF,\L-TH ?;i-'I tll
NThe Commonwealth of Massachusetts
c Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston MA 02.111
www.mass v
.go /dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information t Please Print Legibly
/Individual):
Name (Bus iness/organizati T��•C✓� AAC-AV\V0\ 0
Address: 53 C,-4-.
City/State/Zip: N o. Ary4A&icv, MA Phone #: x') 8' 432- dc0+2_
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
p )
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. + 7• Wernodeling
ship and-have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.� 1 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'
13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I must also till 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 nmst 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 andjob site
i
information.
Insurance Company Natne:
Policy#or Self-ins. Lic.#: 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.
Ido hereby certif unt rd pains and penalties of perjury that the information provided above is true and correct.
Si anature: Date: 7_12-9'1071
Phone#: .,�, 432, Ac42-
Official use only. Do not write in this area,to be completed by city or town g1ficial.
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#: