HomeMy WebLinkAboutBuilding Permit #689 - 54 HEATH ROAD 4/19/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: IUO_ . 1 Date Rece
Date Issued:
'IMPORTANT: Applicant must complete all items on this page
LOCATION'
-
PROPERTY OWNERbc, oc�
Print' 100Year;Old,Structure yes. n
MAP N PARCEL ZONING DISTRICT: _ Historic District yes n
Mach- PY
ine Shop Village es no
---_ 9 _-_
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, I
El Water/S,ewer
DESCRIPTION OF WORK TO BE PERFORMED:
��Ue i iV�rOLJ� poo ( � i 70 D �--
Identification Please Type or Print Clearly)
OWNER: Name: Po -O!u, Phone:
Address:>K wer'
CONTRACTOR Name: C�-u d I'tr�` (( u Phone:
Address: scitoo AN
Supervisor's Construction License- Exp. Date:
Home Improvement Licen
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project D
Co$ FEE:Check No.: 0) Receipt No.: �j�
NOTE: Persons contr cting with unregistered contractors do not have access tg71he g ara {tnd
gnature�of Agent/Owner Signature of contract
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Xtamped 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
PLANNING & DEVELOPMENT ❑
COMMENTS
DATE APPROVED
CONSERVATION Reviewed on Si nature
COMMENTS
HEALTH Reviewed on Siqnature
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 Towp Engineer: Signature:-
Locatetl 3a4 us ooa Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Departinerit 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
dv` d h o
® Notified for pickup - Date
E
r
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 r
❑ Photo Copy of H. I.C:-AndS' . 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 appy al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
most be submAted with the building application
Doc: Doc.Bui!ding Permit Revised 2012
LocationA2--T—
No Date
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TOWN OF NORTH ANDOVER;"
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Check
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MOA rivSOCISIQ SRI$IQ
5ti96-889-8L6 :131
The Commonwealth of Massachusetts -
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 6 "` 6
Address: 3'k -9cw 94-
City/State/Zip: lV 03071 Phone #: �o6,?— ;?9 -aQL3 6
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2
have hired the sub -contractors
listed on the attached sheet.
.I am a sole proprietor or partner-
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company
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 requiredunder 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.
1' do hereby certlo under the pains anken alties ofperjury that the information provided +velis true and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or town offrcial.
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