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Home My WebLink AboutBuilding Permit #227-16 - 947 GREAT POND ROAD 8/24/2015 ii pp BUILDING PERMIT ` �oRT}� '. O`�tL@D 169,HO TOWN OF NORTH ANDOVER �a � a APPLICATION FOR PLAN EXAMINATION coc Permit No#: Date Received q�sgcHuis s�`��y Date Issued: 41A11ORTANT: Applicant must complete all items on this page LOCATION (7�I � + :9�- ;a/,_ x PROPERTY OWNER J Print Print 100 Year Structure yes n MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building KOne family [I Addition ❑Two or more family [I Industrial ❑Alteration No. of units: ❑ Commercial pWepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑rWell ❑ Floodpl nWet'I'antl r ❑�tNat shed District, /S "� - u ❑IWate'r sewer �T �� J •�, y d p ry w 3 .., DESCRIPTION OF WORK TO BE PERFORMED: ef-I e14 i I e tific tion e Te or Print Clearly k OWNER: Name: Phone: R2,41L-�— Address: ` 7l*` 0 Contractor Name: Phone: - 97-C ' ?15L/:3 � Email: Address: Supervisor's Construction License:('S• Qayjo Exp. Date: `Home Improvement License:/�gj, Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: tq� NOTE Peens con r in with unregistered contractors do not have access to the gua an fund 6~ �....L -H� - � . I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tauning/MassageBody 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature C C,?MMENTS I, Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments ri Conservation Decision: Comments Nater& Sewer Connection/signature&Date Driveway Permit _ DPW Town Engineer: Signature: Located 384 Osgood Street AFIRE DK EF TMEN11 Tem`�� P D` �p 4. , r - . . � mum ster ori;site ,- qLted at 124 Mam StreetF � �{t � y rt y p. Fire De artment si � Ypt gnatute/date "q ' .�:. r.. c a t; . `: #}'''F• y. y., YS S ♦ t t°ti :" s" - z ry 9 G td#i t s ` ` f• y i 1- �t 5 �'' I 4 ��`` 'R`'T '�9 da �k a ;' " _ �r r '4,ell :+.,f—:4 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Moverne6t 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.$1oo-$1000 fine NOTES and DATA— (For department apse) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 L 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 1 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 i 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/Cross Section/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 OTE: 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 46 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Doe:Building Permit Revised 2014 Location _ No. Date o TOWN OF NORTH ANDOVER rti e 4 Certificate of Occupancy $ ` Building/Frame Permit Fee Foundation Permit.Fee $ Other Permit Fee $ — TOTAL $ Check#. �) uilding Inspector 22:. r 1 NORT#1 +� E Auc . . ve". . O - 0 ai No. t l" h ver, Ma O ss, COCNICNlMACK �� BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System • THIS CERTIFIES THAT .........................C.( BUILDING INSPECTOR .. ............................................................... has permission to erect ...... .... buildings on . '.. ." ?40)a........ ..... .�vw. Foundation Rough to be occupied as .........11 . . ...... .... ... .. ... .. - - .............................................. Chimney provided that the person accepting this it shall in every resp t conform to the terms of the application Final on file in this office, and to the provisions 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 PERMIT EXPIRES IN WNT�6 ELECTRICAL INSPECTOR UNLESS CONSTRUC S Rough Service 3P .............. ..... ....................................... 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 bet. i i The Commonwealth of Massa chusetts Department o Industrial Accidents E=_ P It Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual):-04Z k_ ta: l Address: City/State/Zip:. Phone#: 3bq Are you an employer? Check the appropr to box: Type of project (required): 1, 1 am,a;e1 .mployei with ❑ I am a general contractor and 1 employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2 listed on the attached sheet. 7. ❑ Remodeling ❑ I am a sole proprietor or partner ship and have no employees These sub-contractors have o. ❑ Demolition I workingfor me in an capacity- employees and have workers' y ty � n. ❑ Euildinu aildic:on tido workers' connp. insurance comp. insurance.i ' required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12M Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] '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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site I` information. Insurance Company Name: & QvJ 06� "wt Policy#.or Self-ins:Lic. —?--Z-57 Expiratioii Date: � -/ir Job Site Address: Ci y/State/Zip:' Attach a copy of the workers' compensation policy declaration page(showing the policy nwnber 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 DIA for insurance coverage verification. Ido hereby certify under t pain and penalties of perjury that the information provided above is true and correct. _s- Si nature:® Date: Phone 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): I. Board of Health 2.Building Department 3. City/Torun Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: l i Office of Consumer Affairs& Business Regulation f OME IMPROVEMENT CONTRACTOR egistration: 46,722 Expiration: Type: Type' _ DBA 'EEFE CONSTRUC p f: 21•�R O'KEEFE AI~IS STREEjs ''SING, MA 018 4 'w •._�: _ _ _.:w--- ,4 Undersecretary i i Massachusetts_Department ot.'Public Safe Building Regulatio Safety Construction Super"isorns and Standards License: CS-068461 i . MICHAEL J pKE, FE 21 Francis Street - Lai i North Readingi = Ma OI864� I Commissioner Expiration 02/ 24/2016