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HomeMy WebLinkAboutBuilding Permit #20-13 - 9 COBBLESTONE CIRCLE 7/10/2012 BUILDING PERMIT TOWN OF NORTH ANDOVER 3 >- - o , APPLICATION FOR PLAN EXAMINATION _ / I \ JM'Zt0 00 J Permit N0: ��JJ Date Received 0R�,E,,Qp�-cy* CHUS�� Date Issued: L / �SSA IMPORTANT:Applicant must complete all items on this page �._....t .•T Z.* �zrf R. , s .i t f 4C ! L CATIONI i' - 0JIM r -- 4 _- �~. Pring �;. j. PROPER;(Y OWNER i ""�` 1 .ti•�4 - .Pant` B "• '•`.' .• •�.�- —.v ,' .} ,� •r � L IMANOaFARCEL��_ZONING D STRIC°;l'� _ �Histonc�Distnctt S�yes„��,�no � �' c s 1'""'_ -a"ai` .4.. k„� 3;Y•"-rLp..:"� ..Sc ,yt r} rra ,��^5i. il�`�- -�. ?'�, r a.-.g, � ..: � �. -`.•� '� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building )ebne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial XRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _ ❑ Other ,'�,r ,., ert/�7�P:.,•.„Wer 3 J.x'.�l.i�+.r«".o.+x>.,-r '�'F"•"�-�4.loss"o-�hd-" 7.­ 1W7 –5t•O"f`tt* 1 e 51•? r�skAt#-1 1 n}� 1Q: e ladseSt,c0 ; F3� � 1 '011- 77,ct .+M�`•�: - -r�.:},?. - ( t DES CR IPTION OF WORK TO BE PREFORMED: 7i Identification Please Type or Print Clearly) OWNER: Name': �Fr-r ---y E60)uPhone: Address: e �ktfir `e�,'� k7y j.pe ti .,• �'S{� kms.�"'» Ya. ''+ ^ti.. •,,-�<'*Pt s((}ti" !'t +.44.e"r "r'zj�..�Fr•L+f� ':"1` �p.,� - i,. i{, llt�=. 'S R. 1 t'\�E !r' �' / ♦ 11 ],}4 .sl '4.•: .v k CONTRALTOme-a� - . + F y �, ..� r rte. 41,9 Supervisors Construction D �, .. #'i ,� ,K# rsr. t � �'?� Y•''.ir�+ .�• k; ..�tg.,i• esu,ly', a�� - �• 'tea- _ r ?. ,•t.-� .. �,�. •fi;'e. H,.omeImprovernent?License ?'iG� :{ w, i+ "? FEx � AR CHITECT/ENGINEER Phone: Address: -Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. r © � Total Project Cost: $ pt FEE: $ `� Check No.: CJq Receipt No.: a s-4 (i' NOTE: Persons contra g with unregistered contractors do not have access to the gu ranty fund Si na"tureof#A eriJOw ." >4: � _:: : �rSi`nature v Location 0 "V,6 No. Date v— • "" TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �1� �#'s yt Foundation Permit Fee $ f m' rbc 2s. Other Permit Fee $ TOTAL $ i F, Check#�y� 1•, `? -�..,�,� 25494 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ' El Tobacco Sales ElFood Packaging/Sales ❑ 1 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 1 CONSERVATION Reviewed on Signature i COMMENTS 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 AFIRE DEPARTMENT � .r , v+�ax• we.� �.a +21r Z`.-:..F ,'.*f "�. •Ck't� J. ". Y> .•. i ! = TMENT Temp-p Dumpster on site yes -,..,� .�; ` o no� � FLOcatet '24�MSt_,�fe@t �� H �IX t ..r �;r{ t Fire De -Artment,gighature/dates+. �tA+tip, ,P"`_,.�^7.v .. _-1,_... .. - .e-:.s�i.�k�'-�-.-'+�.:Gt.•3._tom.. h" fR \ � I!-..s�-.*^hs..:,[ r. .-.-.ate.- :w.... ..�..�-�.�... - a I l 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.$10041000 fine NOTES and DATA— For department use Notified for pickup - Date Doc.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Biding, Interior Rehabilitation Permits ❑ Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ' o Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan i ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o. Copy'Of Contract ❑ Floor%Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass�check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products M OTE: All dumpster permits require sign off from Fire Department prior to issuance-of Bldg Permit In all cases if a variance nor special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is'over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:$PFORM07 Revised 2.2008 f NORTH own of � � E : ., sAndover 0 .. p. - No. ZO t - _ h ver, Mass, - - A04ATED S U BOARD OF HEALTH Food/Kitchen PER LD Septic System - THIS CERTIFIES THAT ................. BUILDING INSPECTOR ..I............ ..............� ....... ................. Foundation has permission to erect ....... buildings on &16-. �'��.... �/�q Rough to be occupied as ...�...`!1'. ...•.........�,........... !. ...................----::: :.,._- .......... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 710 sow PERMIT EXPIRES IN 6 M0NTjrIS ELECTRICAL INSPECTOR UNLESS CONSTRURINP TS Rough Service ......... ...... .......................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. r SSE REVERSE SIDE .' oer • 4 µ N �20�•�4lp tib ONO TOWN OF NORTH ANDOVER . OFFICE OF BUMDING DEPARTMENT 1600 Osgood Street Building 20,-Suite 2-36 "�ssq�H�sc�5 North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 HOMEOWNER-LICENSE EXEMPTION Fax (978)688-9542 13UMING PERMIT APPLICATION Please print i DATE: JOB LOCATION: Number Street Address Map/Lot � IJOMEOWNERJ?oNa ePhonef ` Work Phone PRESENT MAILING ADDRESS 471s CCIr� Cid Toy=m Zip Code The current exemption on for«h o meowners., w include ase e to allow such homeolsmers to en a e an iricividu 1 fo shire whocoes not posses'ed alicense,provided that the owner and acts as supervisor). State Building`(Code Section 108.3.5.1) caner DEFINITION OF HOMEOWNER Persons)who Qwns a parcel of land on which he/she resides or intends to reside,on which there is,oris intended to be,a one or two family structures. A person who constructs more that one home in a two-year period considered a homeowner. y p riod shall not • - be The undersigned"homeowner='assumes responsibilityfor Applicable codes,by-laws,rules and regulations. compliances with the State Building Code and other 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 procedwes 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 ofMassachusetts • - Departmint offndustrlglAccidents - Office ofInvestigations UVI 600 Washington Street Boston,.MA 02111 www.massgov/dia Workeris'Compensation Insurance Affidavit:Builders/Contrcactolrs/Electricians/Plumbelrs Applicant Information Please Print Legibly dVaMG(Business/Organi`zation/Jndividual): Address: City/State/Zip:�) gf1e6oe/,*, Phone P 917L00/14(Q/� �' "�` 70 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am;a employer with 4. ❑ I am a general contractor and I 6. El New construction employees(fall and/oxpart-time).* have hired the sub-contractors ,5'emodeling/ �1 j 2.❑ 0 7• !rl KI am,a sole proprietor or partner- listed on the attached sheet.x ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. -1❑Building addition [No Workers'comp.insurance 5. ❑ We are a corporation and its 3.�required.] officers have exercised their 10.E]Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL ME]Plumbing repairs or additions myself[No workers'comp. c. 152,§1(4),and wehave no 12.E)Roofrepairs insurance required.]Ti employees.[No workers' i comp.insurance required.] 13.❑Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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. lam 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.Lic.#: ExpirationDate: 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 requiredunder 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. Ida hereby ce lry under•tlzepa' s anrdpenalfies ofperjury that the informationprovidecdabove is rue andcorrect. - Si ature: Date: 7 2J//,P, 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 Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other - - - Contact Person: Phone#: