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HomeMy WebLinkAboutBuilding Permit #640 - 80 WINDKIST FARM ROAD 3/25/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO•V- Date Received Date Issued: X�— 1 BRORT-A.NT: Applicant must complete all items on this page LOCATION 1�0 UJ W O� I ST f �4 tM Q4 {')0)n 1 OV I M ( Print PROPERTY OWNER �!-y ` QG ft 0 S / Print MAP NO:/ 0 � PARCEL: 67OZONING DISTRICT: Historic District yes o. 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 Septics (]Well :; `D Floodplaui--s��W,etlandsi `©i WatershedDistnct_ '� t �tWater/Sewer t# DESCRIPTION OF WORK TO BE PERFORMED: Q,v JCPe l 5� w c Identification Please Type or Print Clearly) OWNER: Name: Phone: M.. CONTRACTOR Name: Address: Supervisor's Construction License: Home Improvement License: ARCHITECT/ENGIN Exp. Date: Exp. Date: Phone: Address: Reg. No Phone: FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BA D ON $925.00 PER S.F. Total Project Cost: $_`� FEE: $ . Check No.: Receipt No.: NOTE: ers s ntrac n�v,h unregistered contractors do not have access to the guaranty fund a Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENTEl COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Consetvation Decision: Comments b 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 COMNMNTS 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 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) ❑ Muss 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 Tiro 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 iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Location ]-PWU- No. Date TOWN OF NORTH ANDOVER 0-� J Certificate of Occupancy $ Building/Frame Permit Fee $ vs CHUS Foundation Permit Fee $ Other Permit Fee TOTAL Check# 23991 Building Inspector w O v u O w v cn x A c G O w O w x U G iw x a p w G w o � a wG p w ir. p w G w w- w v C G CO z cn v G co w O O FM4 r-1 ,61 c o � c c' s o ` C3 N +;, O vO C.3 CL c c := O p i CDCA Ea L CD C :... CD rt0+ O. Go E� c� 0 O s c CA m c m c c ._ �c y I I 3 YI Ck W CIO ° o � Q '1r 0 � \NG c o � c c' s o ` C3 N +;, O vO C.3 CL c c := O p i CDCA Ea L CD C :... CD rt0+ O. Go E� c� 0 O s c CA m c m c c ._ �c y I W CIO ECD D m o y m ; za Cco im- Cc O O. y=.+ i4 W = �O • N C . O•.0W v LU • E o.�. Ot ca vy CD 'CCU a p c o �j COD CD = O y= _ � CO .c Y a 0 Om E L CL y cycm CDy C» C S CIO O co c �C N m Z 0 Z O O F. P-4 z O U I v O O v ,all 2 O 0 0 C• L 0 is Z co 0. O y � C cm I � C CO2 G _� W y 0 0 •E m m CLiDlm% CL) ~ �•+ 3.0 CD 0 Cc 0 d • �Q CO2 C O Cc •v J 'C 0 C Z CD CL. V COD C c C C cc a C/2 LLI LLI U) 19 W LLI It W U) µaR7H TOWN OF NORTH ANDOVER Ofs1,eo ^6'S4, _a oL OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERNUT APPLICATION Please print DATE: JOB LOCATION: �0 l ►:l Q K 5� � �" W 2T 14 l Li'l 00U(� 1 Number Street Address IJOMEOWNER L� I RG �-G-S Name Home Phone PRESENT MAILING ADDRESS Noa-gl -� AN b e V if4 silty ! 0-%vn OJir0OkI5r- fA-Am Vh4- Sty+w . MA 0(hS- Map/Lot �l - FU Work Phone o ( � y. - 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. 11 The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and req ' e d that she wi Iomply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Xndustrial'.Accid'ents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass:gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/JElectriciansfPlu>m.bers (R Name (B.usiness/Organization/Individual): ` A U � Q� V S Address: �U (U I �J O l-/1 CO- ��/t City/State/Zip: N 0 r rl+ AN() u V Phone #: ot) U Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. i ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 8. [( Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *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. X am an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or SeIf-ins. Lic. Job Site Address: Expiration Date: 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby ce under h airs an e a ies ofperjury that the information pro videdaboverisss trrruue In {d/ correct. .lY Csl-i a'filra• �fltP.' � / v `-' [' Phone #: .-C ? t1 V t q l �S 6 / Official use only. Do not write in this area, to he completed by city or town official City or Town: PermftUcense # 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 #: