HomeMy WebLinkAboutBuilding Permit #712 - 63 BARKER STREET 6/19/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: 6. /�- 0 /
I PORTANT: Applicant must complete all items on this page
LOCATION�Z,,,rr
PROPERTY OWNER arI(- Print
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residenti
Non- Residential
New Building
T i
4_
eb
I PORTANT: Applicant must complete all items on this page
LOCATION�Z,,,rr
PROPERTY OWNER arI(- Print
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residenti
Non- Residential
New Building
Addi '
Two or more family
Industrial
ltera
Atio
No. of units:
Commercial.
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
N -eh rcac� r1 (�n,6d q
OWNER: Name:
Address: &3 Gar
Identification Please Type or Print Clearly)
5 t . J �/, N7eb to M Q� I f5 5�
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License:
Date:
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
�? � co a ► 33� tQ
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �- la, FEE: $ /
Check No.: Jo ( Receipt No.:�i 13
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
vuner
Pignature of Agent/0 — ignature of contractor
Location 6LI
No. 1 / ,3�— Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ f
Building/Frame Permit Fee $ - J
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # /011cr-
22*1 Wil} - -
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
CONSERVATION Reviewed on Signature
COMMENTS
u
HEALTH Reviewed on Signature
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 Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department 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
MGC Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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 2.2008
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Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Pinmbers
Aicant Info rMati in
Name
Address: L, 3
15a r JC&)Z— S~t
City/State/Zip: 41, t4�.)btrrq rp�_ al gq�5_
Phone 9. 9-1 9 (-,? 33-7 C,o
Are you an employer? Cheek the appropriate box:
1. ❑ 11 am a employer
The Commaerrvea&k of Massachusetts
I
Department of Industrial Accidents
Dice Investigations
_V4
of a
ori the attached sheet. !
These sub -contractors have
600 Iffashington Street
Boston, MA 02111
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Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Pinmbers
Aicant Info rMati in
Name
Address: L, 3
15a r JC&)Z— S~t
City/State/Zip: 41, t4�.)btrrq rp�_ al gq�5_
Phone 9. 9-1 9 (-,? 33-7 C,o
Are you an employer? Cheek the appropriate box:
1. ❑ 11 am a employer
with
4. [] 1 am a general contractor and I
2. Elemployees {full and/orpart-time).*
am .a.soie proprietor or
have Dred the sub -contractors
tasted
partner.
Ship and have no employees
ori the attached sheet. !
These sub -contractors have
working for me in any opacity.
(Tao workers' comp. insurance .
workers' comp. insurance.
5. ❑ We are a corporation and its
3 ` �required_]
I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself [No•warkers' comp.
c, 1S 2, § 1(4),'and, we have no
insurance -re uired. t
9
.employees. [No workers'
comp irrsusan fired.
Type of Project (requirep:
6.New construction .
7. Remodeiing
8. ❑ Demolition
9. ❑ Building addition
I 0. ❑ .Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
1317 .Other
'Airy applicant that tbecks bole # I must also Sit out the section below chow.ing thein woeni' oo , '
? homeowners who submit this atiidavit indicming they am doingall worts pensetioti poltoy infomtahon
�Cotrtractors that cheek this box rust end than hire outside contractors must submit t new affidavit indicating such.
arlsebed an additional shaC showit he name of the sub-comrsetors cad their workers' ee,„.. ^=i.
i err ser ervloyer that is m r p-• i trfosmetion.
{► . , v.►�futg:workers compensadorr tnsuraace for
inforrnatfon. H7 employees: Below is t4eP054Y and job site .
lnstirance Company Name:
Policy # or Self -ins. Lic. #: - ,
. Expiration Date;
Sob Site Address: -
CitylState/Ztp.
Attach a copy of the workers' compensation policy declaration paoe (showing the policy number and expiration Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminaip ��
fine up to $1,500 00 and/or one-year imprisonment, as well es civil penalties in the form of a STOP W trim ORD
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded penalties of a
ER and a fine
investigations of the DIA for insurance coverage verification. Y ded to the Office of
I do hereby certify under the airs acrd en
p aloes Vrpej*7 that the hrformatfan Pro tided above it true and eotreA
Sr tta e:
Date: !� (Styria
Phone -3-3
OfWcial ase only. Do not write is this area, to be completed b or town
y
City or Town:
#
Issuing Arriitorify (circle one): Permit/Limnse
I. Board of Healtb L Bnildittg Department 3. City/Town Clerk 4. Electrical Inspet for S. Plumbing Inspector
6.Othe'r
. Contact Person•
Phone #;
f NORTH TOWN OF NORTH ANDOVER
: ow OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
s�Too; North Andover, Massachusetts 01845
Gerald A Brown Telephone (978) 688-9545
inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
DATE: /9 TUA' oq
JOB LOCATION: �3 � ICeJZ.— S� ,
�.
Number Street Address Map/Lot
HOMEOWNER
Name
home moue
PRESENT MAILING ADDRESS (1 3 Caarlc�L �L .
Work Phone
City Town state zip Code
The cununt exemption for "homes wneas" 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 strvctares. 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 BuildingCode and other
des,
Applicable coby-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she wands the Town of North Andover Building Department
muumnm
inspection Perim and requirements and that he/she will comply with said procedures and
rte• ,.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Reviaw ioiw5
Form Homwwn= Eamon
BOARD OF %PPEAIS 6,39-9541 C0NSFRV.1T'ION Fxx-9530
HEALTH 6xx-9540 PD-NNING 6R9-9535
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