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Home My WebLink AboutBuilding Permit #273 - Bldg 36 10/6/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: /J Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION PROPERTY OWNER Print Igys Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Two or more family Industrial Alteratio No. of units: ommercia s' `tiav� Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ��C—rclai2 ALl��2.��/ rdz �1J��I�or.,�� S��✓�h, � Identification Please Type or Print Clearly) OWNER: Name:_G�U�/Ls� - (�o� Zip,, o Phone: Address: OnJC yi&oY -AV-ezz 5 O/ CONTRACTOR Name: 1-4Ke u�� vs,�i c� �v Phone: g Address: � So Sy�Oa. r-� 02. x,>>a4e-Ao0 �''- s4-Vr c� , L,4J 5-3/s% Supervisor's Construction License- 96 3�? Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENG INEER_ Phone: Address:_4G I y—- -1-7 652.Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1500, FEE: $ 000 Check No.: �Z C) Receipt No.: 22 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner --.,� Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body 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 - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes F`lanning 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 924 Main Street Fire Department signature/date , - fid 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 f I NOTES and DATA— For department use a ❑ Notified foricku - Date p p _.._................_._..._...-....-.................................-......._.-......_-......................._..__..._ _......__............-----.............................._..____..._........................._..__..............___......................_.._._..._........-..............._......----.................... . Doc:.Building Permit Revised 2008 i Building Department i 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 2008 Location No. V 7 3 Date NORTN TOWN OF NORTH ANDOVER /O. 9 * i • , Certificate of Occupancy $ CH Building /Frame Buildin /Frame Permit Fee $ �.000 � s� ust� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 00 s 22 4 ; ?, wilding Inspector NORTH "IXT.", Andover TO" of No. 6 6j dover, Mass.,__� 6Z C% LAKE 1, COCHICHEWICK 040, C OATED BOARD OF HEALTH Food/Kitchen Septic System . PERMIT T D BUILDING INSPECTOR Foundation THISCERTIFIES THAT.......... ...................................................................................... .... .......... ..... has permission to erect........................................ buildings on ................ Rough .........aA y, Chimney 4.1 .. j.. .... .oe...... ... 7� A to be Occupied as............ provided that the person accepting this permit shall in ever'V re ct conform to the terms of t application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of PLUMBING INSPECTOR Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough .......... #.4 Service ...... ......(1, BUILD G INSPECTOR Final ng Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER '• � ` '� CONSTRUCTION CONTROL swcwM PROJECT NUMBER: ®9 07 PROJECT TITLE: laJ PROJECT LOCATION: c/ tom + 3•�C 1��/_ 3 � NAME OF BUILDING: �.A4.& �G NATURE OF PROJECT: IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, S�tL-G Ea-T I REGISTRATION NO. t 6`l 4S BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT 0 ARCHITECTURAL'jrat STRUCTURAL 0 MECHANICAL 0 FIRE PROTECTION 0 ELECTRICAL A OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become, generally familiar withethe progress and quality of the work and to determine, in general, if the work is being Wormed in a manner consistent with the construction documents. ...................1. PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY , A PROGRESS REPO.. �� ,�J•SARG��TF�,T,,,,, TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING I TOR. o UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO N 6 SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCC E y �SIGNATURE •..............SSP,r SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF SO N WRY PL49LIC 1 MY COMMISSION EXPIRESission Explres April 02,2014 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 s www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizafion/Individual): l,) 0n Cxmm Address: J'e m r, 05 f r- a.nm City/State/Zip: V j�e, , Phone#: a(el 6JC`� ,M e Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. E]New 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.t 7. gRemodeling 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' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their--,orkers'compensation policy information. f 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 employee& Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a q P 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. I do hereby certify under the pains and penalties of perjury that the information provided(above ��iss�true and correct. Si gnature: Date: ct Phone 9��,_VILO 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: