HomeMy WebLinkAboutBuilding Permit #868-16 - 55 MILK STREET 2/23/2016PAM UL y a
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BUILDING PERMIT
TOWN OF NORTH ANDOVER ° �o
APPLICATION FOR PLAN EXAMINATION ;
Permit NO: �( Date Received
Date Issued:
RTANT: Applicant must complete all items on this
LOCATION_HlIk- SJreC-
. Print
PROPERTY OWNE
-- `` Print /� 0 �/ z -� � `" &,
MAP NO�PARCEL:� ZONING DISTRICT: istoric District yes
Machine Shop Villaae ves
s
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non -Residential
❑ New Building
PlOne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
I(Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
Floodplain ❑ Wetlands
-- Watershed District
❑ Water/Sewer
Glm;irn, (.1�n� 11ndow.
Identification Please Type or Print Clearly)
• - �.' i' w rPhone:
Address:
CONTRACTOR Name:
Address:
Phone:
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: $ IN, no O FEE: $ @ i �f
Check No.: Receipt No.:
o t ac
NOTE: Persons cng with unregistered contractors do not have a ess M the guaranty fund
Signature of Agent/Owner &o+%tlC Ov, A4,. Signature of contractor
L
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
q_ cocnawewrc. - �•
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
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
11 Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
Ut5(:KIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License:
Home Improvement License:
Phone:
Exp. Date:
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: $,
FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
TE: 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/Cross Section/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
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
4. 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
2012 IECC Energy code
�. Engineering Affidavits for Engineered products
OTE: 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: Building Permit Revised 2014
Plans Submittedf! 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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On
Signature,
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comm
Wafter & Sewer Connection/signature &Date Drivewav Permit
DPW Town Engineer: Signature:
._,_._.._ 4 Osgood 38 good Sfireet
FIREttDEPAR+TMENT Temp�Dumpster�on„site sno� J
_..._
Located�af124(Mamrst�eet• = ” " � - _ -=-__a
'Fi,re,Departtmentssigrafure/date
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
MGL Chapter 166 Section 21A—F and G min.$1oo-$loon fine
NOTES and DATA — (For department use)
M
❑ Notified for pickup Call Email
Date Time Contact Name
i -
Doc.Building Permit Revised 2014
Location
Check# I � &
Dateo
/ Y -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�90
Foundation Permit Fee
Other Permit Fee $
TOTAL
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
8,000.00
m
$ -
$
216.00
Plumbing Fee
$
27.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
27.00
Total fees collected
$
370.00
55 Milk Street
868-2016 on 2/3/2016
Kitchen Remodel
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2
Gerald A. Brown
Inspector of Buildings
Please print
DATE: Q 1511(p
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Telephone (978) 688-9545
Fax (978)688-9542
JOB LOCATION: SS H ► I k Si
Number Street Address Map/Lot
HOMEOWNER Yj CQ rG, C1 7 - 8'8 (D - Lf 3SSr
Name Home Phone Work Phone
PRESENT MAILING ADDRESS— M I I k S1
IJV t9r&yQr L -PA 01 R45 -
City
45 -
City Town 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, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
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 he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements. %%,,��,,,�����
HOMEOWNERS SIGNATURI4YYx,lil Q/LA lQ _ 6%9fj,0,_
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
Department of IndustrialAceidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): K(>t c ri ne Cnr-t-
Address: S I I k -ta of
City/State/Zip:�A/ Ad()yt( _M A D 184S- Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/or part-time).*
2.FJ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
IN I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.:
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. FX] Remodeling
9. ❑ Demolition
10 ❑ Building addition
I LE] Electrical repairs or additions
12.0 Plumbing repairs or additions
13. E] Roof repairs
14.0 Other
*Any applicant that checks box #I 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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing ivorkers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under thepains andpenalties of peljuiy that the information provided above is trite and correct.
Signature:A6c PA Ii Date: 2-3-1(o
Phone #• 7 9- S 9 (D - 4 35 S_
Official 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 #:
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