HomeMy WebLinkAboutBuilding Permit #609-11 - 89 MARIAN DRIVE 3/11/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: hai / Date Received
Date Issued: b�.
IMPORTANT: Auplijeant must complete all items on this page
LOCATION 3 9 fk4v `- -
Print
PROPERTY OWNER ` `� w K.e-
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MAP NO: /,%.0- PARCEL;OP4 ZONING DIST CT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
AOne family
❑ Addition
❑ Two or more family
❑ Industrial
Iteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification Please Type or Print Clearly)
OWNER: N
Address: (iq WT r-(A.t, Dry_ AU;r
CONTRACTOR Name:
Address:
Supervisor's Construction License:
Home Improvement License:
Exp. Date:
Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No
Phone:
FEE SCHEDULE. BULDING PERMIT -7=00 PER $1000.00 OF THE TOTAL ESTIMATED COST/BASE $925.00 PER S.F.
Total Project Cost: $ U FEE:91
$
Check No.: Receipt No.:�
NOTE: Persons c ntracting with unregistered contractors do not have access to the guaranty fund
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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: Doc.Building Permit Revised 2008mi
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
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
I
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
1
Planning Board Decision: Comm
Conservation Decision: Commen
Water & Sewer Connection/Si-nature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes Locatedno384 Osgood Street
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
Location M — Z22eiA ,,e4
No. Date
40PTh TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CH I
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I--
23954
Building Inspector
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Gerald A. Brown
Inspector of Buildings
Please print
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
DATE: S r %
JOB LOCATION: (MCL�t
Number Street Address
HOMEOWNER /Vc "Aq� 1(J- N Vkell ,
Telephone (978) 688-9545
Fax (978)688-9542
Map/Lot
W— 6?9-_5'-/F56
L? F�5 - -i- -362
Name Home Phdne Work Phone
PRESENT MAILING ADDRESS 153- IM Ci rr&4
X6r Al AIAcWV'er— 019 /, --- ®C 811-f 5_
City Town 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 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
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
C)
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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3: W930L
4: W3012
5: UF3
6: DB18 4DWR
7: CDK18
8: SB27 BUTT
9: UF3
10: CW2430L
11: UF6
12: BSS36R WD
13: W2430 BUTT
14: UT2424X84 4ROTB
15: CWS2430R WD
16: W2130L
17: BPC32734
18: W3012
19: W1530R
20: UT1824 X 84R AS
21: BWBT18-2
22: OVSF396
All dimensions size designations
given are subject to verification on
conditions.
job site and adjustment to fit jobI'm
This is an original design and must
not be released or copied unless
applicable fee has been paid or job
order placed.
Designed: 1/29/2011
Printed: 1/29/2011
1129081366 KIT Legend Drawing #: 1
The Commonwealth of Massachusetts
Department of Industrial.Accicients
Office of Investigations
600 Washington Street
Boston, MA 021X.1
UV
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/JPllumbers
L1
Naive (B.usiness/Organization/Individual):
IC, (�Qm
Please Print
Address:
City/State/Zip: M - Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
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
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
o workers' comp. insurance
S. ❑ We are a corporation and its
' required.]
officers have exercised their
3. I am a homeowner doing all work
right of exemption per MGL
yself. [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.bgRemodeling .
8. ❑ Demolition
9. [] Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConiractors that check this box must affached 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 Self -ins. Lie. #: Expiration Date:
Job Site
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 DLA for insurance coverage verification.
X do Hereby certify under• the,gains andpenaldes of perjury that the information provided above is true gnd correct.
Date: / l
Official 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 CIerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
