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HomeMy WebLinkAboutBuilding Permit #311 - 58 CHURCH STREET 10/22/2007 BUILDING PERMIT of "°DT" TOWN OF NORTH ANDOVER �? '`"` `_•.6'a o APPLICATION FOR PLAN EXAMINATION Permit NO: J Date Received ��SSACH�ISE� Date Issued: 0'- 2-2 IMPORTANT:Applicant must complete all items on this page LOCA?iON 1?R©PfRTY D1INER . NI ► 'X10 ' PP►fiCEL: ZONING-DISTRICT 1-listocic Dis#r"ic# yes no ti '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 Septic; 1=loodplain V�letlands :UVatens'hed D`istrrct ' - 111 atec/Sever DESCRIP-TIN OF WORK TO BE PREFORMED: 2 �c�� ON �IL A F Identification Please Ty a or Print Clearly) OWNER: Named ,� 7 ��( 1,� Phone Address: C NTRACTOR Name:. _.phone: Address. ' _ Supervisor's Constructioraicense Exp :Da#e- Horse lmprovement License Exp_ Date. ARCHITECT/ENGINEER Phone: Address: Reg. No. ' AM FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.r Total Project Cost: $ loco do FEE: $�gy Check No.:_G Receipt No.: a37-109-, NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Adent/Owner. "A Signature of contractor `' Location J C yt d rL L A S No. e'�, Date / ? 0 MaRTM TOWN OF NORTH ANDOVER t. o Certificate of Occupancy $ r � CHU < Building/Frame Permit Fee $ _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2G 'i Building Inspector 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH 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 Located at 384 Osgood Street Temp p to yes . no FIRE DEPARTMENT °-Tem Du.m sten on :site Located at 124-Main Street .Fire Department�signatureldate .' 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 ❑ Notified for pickup - Date i Doc.Building Permit Revised 2007 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 2.2007 the Commonwealth ofMassachusetts lklID Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ud1_0l Address: 5-J S(, G�v rL L " City/State/Zip: Phone #: :)t �{o 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 I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL l 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.R Roof repairs surance required.] t employees. [No workers' 13.❑ Other 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy 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 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. I do hereby certify under the pains and ena e of perjury that the information provided above is true and correct. Si natur : Date: Phone#: Offici l 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#: I NORTly _ Town of over o over, Mass.,Aa • �ftlr OIL COCHICHEWICK ylt. 7�ADRATED pPat�� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... .. ., ....... U. .. ................................................................. .. Foundation S �. ........... buildingsn Ch� �....:..... Roughhas permission to ere ............. . to be occupied as..... �. ......... Chimney . . . . ... ....... ........ ....... .................................................... . provided that the person ac pting this perm shall in eve respect conform to terms of the application on file in' Final this office, and to the provisions of the Code 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC STARTS Rough :;. Service G INSPECTOR 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. SEE REVERSE SIDE Smoke Det. O+ KORrp TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT + 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 1SSACWUStt Gerald A.Brown Telephone(978)688-9545 Fax (978)688-9542 Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Please gdA DATE: JOB LOCATION: /9 Number Street Address Map/Lot HOMEOWNER , Name Home Phon6 Work Phone PRESENT MAILING ADDRESS go 0 PO-,P- 0 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-oocnpied 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 strictures. 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 SIGNATURE n APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Foam Homeowms Exemption HOARD OF WPE:II.S 638-9541 CO,NSERX-ArION 638-9530 HEALTH 683-9540 PLAN'NIVG 6u8-9535 opThe Commonwealth of Massachusetts Department of Industrial Accidents Ofte of/nvestigadons Boston, Mass. 02111 Workers'Compensation Insurance Aff davit Name Please Print N � kL city �D . 1�D U�� Phone S 102 I am a homeowner performng all work myself. I am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers'compensation for my employees working on this job. Comoanv name: Address City: Phone!� Insurance Co. Polim 0 Comma name: Aridness City Phone;Ilk X Insurance Co. 1l .T .l C (,r Al Policv a Fdkrre to securo coverage•requirod under SecBm 25A or MGL 152 can lead to the krposMm d crhni, peneitlea d,a fine up to=1,500.00 andfor one years'inprhorrnent_aa MratLas.cbA4m oakias h]b9 h=d,BTVP.V.VDWDRMR and_a.fkw d.(.si wAWA dW aga im ma. I understand that a copy of this statement may be forwarded to the Office of Invesugdlons of the ISA for coverage verification. 1 db hereby cw*under the peirra and penalties of perjury that the Inkbrmadon provkiad above la Erre and coned. ` ^ 4 X Signature Date "Q Print name d Phone OfficW use only do not write in this area to be compieted by city or town older City or Town p []Chock,f ❑ 6uildng Dept Immediate response!a raquisd ❑ L.kerWrq Board Contact person: 11Selectmen's Offitre Phone rt ❑ Health Department ❑ Other TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: Est. Cost �To = Address of Work Owner Name: Date of Permit Application. I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied t/' Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: G is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws:Chapter 148 Section I 0A. The debris will be disposed of in: G� (Location of Facility) Signature of Permit Applicant Fire Department Sign off. Dumpster Permit Date