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Home My WebLink AboutBuilding Permit #108 - 649 FOREST STREET 4/4/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO-6e- Date Received I Date Issued: EWORTANT:Applicant must complete all items on this page LOCATION h LlFad _�'4 ` (Vo/4 h AA Print �� 11 PROPERTY OWNER F� �' (L (�y 1 Y'uS� Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resicjential Non- Residential ew Building ne family ❑Addition ❑Two or more family ❑ Industrial [I Alteration No. of units: ❑Commercial ' 11 Repair, replacement ❑Assessory Bldg 11 Others: [i Demolition ❑ Other � f ��r�. .�`•� � ®tFilood��lain� ® Wetlands 3` `'��'�® Nate s ieci�IDistrict�y t' T ca ; ♦ � 4 ly" � �. i"1�. ff11 ,tom S 7 {"'"t qi �` .aC6 ,tw 'f DESCRIPTION OF WORK TO BE PERFORMED: V19-�-- Identification Please Type or Print Clearly) OWNER: Name: (24,1 y Trig Phone: - Address:_ _ �a YLr:P L �an r rI N4I CONTRACTOR Name: �A A [le 1 n G Phone: 0 3v 35Q5 i3�Address: �ry Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$72.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ tea FEE: $ Check No.: I Receipt No.: l d 0 NOTE: Persons cont acting with unregistered contractors do not have access to the guaranty fun ----- ---•---- --— - -- - ----- ---- ------ _ —_- - --- ---- ---- - e f. ritra - i_Si natiar O 9 1 0 8 Date,. //...... .. NpRTM 1TOWN OF NORTH ANDOVER pF ��ao ,^ ti0 o� PERMIT FOR MECHANICAL INSTALLATION �9SSACHUSEt This certifies that . . . . . . . . . . . ' ! 7`i . . . .C- . . . . hasermission for mechanical installation p in the buildings of . . . . . . . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . g. . .l'.?.T . . . ., North Andover, Mass. Fee. .r/.c - Lic. No.. ., yd . . . . . . . . GAS'9NSPE" WHITE:Applicant CANARY:Building Dept. PINK:Treasurer Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ FEWERAGE DISPOSAL ❑ Tanning/Massage/Body Art ❑ Swkm"ng Pools❑ Tobacco Sales ❑ Food Packaging/Sales ❑ c 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 {i i CONSERVATION Reviewed on Siqnature COMMENTS 1-IE.ALTH Reviewed on Signature COMMENTS 1 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 MGL 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals ia-t the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording - tust be submitted with the building application Doc: Doc-Building Permit Revised 2008mi The Commonwealth ofMassachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia 'workers' Compensation Insurance Affidavit: Biiilders/Contractors/JElectricians/JPlumbers Applicant Information ��^^ f Please Print Legibly Name(Business/Organization/Individual):�5c r_A1 P ! Address: J_? / zqr City/State/Zip: , /�,11 03&59 Phone#: A�re ars employer?Check the appropriate box: Type of project(required): 1.LI I am a employer with 4. ❑ I am a general contractor and I 6. [4I1ew 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.z 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 11.❑Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required] 13.❑Other *Any applicant that checks box41 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. tContractors 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.Liic.ff: Expiration Date:(7 7 / Job Site Address: f F o r'1'5� 54 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 ofup to$250.00 a day against the violator. Be'advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains Wpe es ofperjury that the information provided above is true and correct. Si ature: J Date: Phone#: 3 ' 3`q--3,50 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/I,icense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r COMMOIYWE—AL T"O Ma9�ACt1USETTS SHEET METAL WORKERS As A MASTER-UNRESTRICTEb "ISSUES THE ABOVE Li ENSE TO. 5��3,TT Eo CR'i'ALbl _ tv s A = vgi14 , . :o _ 2k'Z1 Q7/28/12 $89971;' J "d Fold,Then Detach Along All perforations 2 _