HomeMy WebLinkAboutBuilding Permit #638 - 62 ELM STREET 5/29/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NOb �O
Date Issued: d i
I PORTANT:
LOCATION''7�
11:161:443-61
Date Received
must complete all items on this
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MAP NO: PARCEL: ZONING DISTRICT: W Historic District yes no
Machine Shap Village Kves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family,--
amilyrAddition
Addition
Two or more family
Industrial
Alteration �
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
t x, r,
DESCRIPTION OF WORK TO BE PREFORMED:
dentification Please Type or Print Clearly)
OWNER: Name: i 4,eo IV _ 1-9e /? rclj' Phone: 7E/- S- 7,--) - a 3'.,Z
Address:
2 c%.-, Sf N14
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement Licen
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: $ `7 1)
Check No.: ( �q Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the gu ranty fund
Signature of A- ent/Owner114W-4-----
a_ g g�� Signature of contractor
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Comments
Conservation Decision: Comments
Zoning Decision/receipt submitted yes
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
Hire Department signature/date
CSO iPu1 TIVO ti'
Location ev &:-z� �-7/—
No. 6 3 k-- Date
40*TN TOWN OF NORTH ANDOVER
+G& Certificate of Occupancy $
$
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # 4fl4j,4,
Building Inspector
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Gerald A Bmwn
Inspector of Buildings
lease Pdx1t
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
-09
Telephone (978) 688-9545
Fax (978) 688-9542
JOB LOCATION: Co v- Z--/,,?— 5 4 A)4
Number Street Address Map/A
HOMEOWNER Aa 2a'v p "eki 78' ';7 Sa --n e 4e
Name Home Phone Work phone
PRESENT MAILING ADDRESS 6,2 r-/,1 S�
11110 fe
City Town
6tVY2 /414 4VCe-el
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 helshe understands the Town of North Andover Building DepwUient
min��impu�mp inspection procedures and requirements and that he/she will comply with said procedures and
mi
requirements. A
APPROVAL OF BUILDING OFFICIAL
tzevind 10.2005
Form Howwwtmzs Exwpgon
ROARD OF 1PPF.0-S 688-9541 CO.\SERV.MO\ (;88-9530 IIEA1,11i 688-9540 PL.\-'\"VI\G 688-9535
k -
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 N-ashinqon Street
Boston, MA 02111
c I www.massgov/dia .
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Mllt'$Ht Tnfarmnfinn
Nome (Business/Organiration/Endividua!);_ _ /Iqa ii 0,V
Address:
Z-//-" SF
City/state/Zip: AI'2 x✓u i�/% al��l j Phone #:. 753 / ' )� 7 o-?
Type of proles (required):
b. ❑ New construction
7. Q Remodeling
8. Q Demolition
9. Q Building addition
10.Q Electrical repairs eradditions
II.Q Plumbing repairs or additions
12.[] Roof repairs
I3.Q Other
Homeowners who submit this affidavit indicating they ars doing all work end then hire outside cmon�s
ttactom mu ubmiitt aenewtiolL affidavit indicating such.
;Contractors that check this box mmtattached an addt'tio=l sheat showing the name or the sub -contractors and their worksrsI camp. polis; infatrnation.
I am an employer that is provrding:workers' compensation insurance for mV employees: Below is and the policy 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.
urger the pains and„pena�ies ofPedury that the information provided above is true and correct
I do here:Vert
Phone #:
Ofj'icia! ase only. Do not write in this area, to be completed by ri(F or town official
City or Town;: Permit/License #
Essuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Are you ae employer? Check the appropriate box:
i. ❑ It am a employer with 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2.[] I am.a.sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet. $
ship and have no employees
These sub -contractors have
working for me .in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3.R I am a homeowner doing
officershave exercised their
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_]
7 Any applicant that checks bo)e# I must also fit[ out the section below showin their workers' oo
Type of proles (required):
b. ❑ New construction
7. Q Remodeling
8. Q Demolition
9. Q Building addition
10.Q Electrical repairs eradditions
II.Q Plumbing repairs or additions
12.[] Roof repairs
I3.Q Other
Homeowners who submit this affidavit indicating they ars doing all work end then hire outside cmon�s
ttactom mu ubmiitt aenewtiolL affidavit indicating such.
;Contractors that check this box mmtattached an addt'tio=l sheat showing the name or the sub -contractors and their worksrsI camp. polis; infatrnation.
I am an employer that is provrding:workers' compensation insurance for mV employees: Below is and the policy 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.
urger the pains and„pena�ies ofPedury that the information provided above is true and correct
I do here:Vert
Phone #:
Ofj'icia! ase only. Do not write in this area, to be completed by ri(F or town official
City or Town;: Permit/License #
Essuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #: