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Home My WebLink AboutBuilding Permit #565 - Exception 3/23/2010 BUILDING PERMIT Ot NORTH q TOWN OF NORTH ANDOVER o� '. '`- ` '' .a �°^, APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �SSACHUS�� Date Issued: �'` IMPORTANT: Applicant must complete all items on this page LOCATION f 641ejeg''/nr, 4n,4W Print PROPERTY OWNER S?t� _I., �Aw _ T -4.a /./�, Print MAP 210 PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alterations/ No. of units: Commercial✓ Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer✓ DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: _ ��,,4,� Phone:9`1'% -(v83-t383( Address: , A16, CONTRACTOR Name:Tal--e5 Phone: J )'S 'tt{ol,4 410176 Address: _,t�2.e- Supervisor's Construction License: LS FS It S! Exp. Date:- tt>/(.4 �: . --Lott Home Improvement License: (Lt S(a J� Exp. Date: I ARCHITECT/ENGINEER Phone: Address: 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: $ FEE: $_ / Check No.: /0 d� Receipt No.: I NOTE: Persons contracting with unregistered contWiois 4o,no't have acc s o t aranty fund Signature of Agent/Owner� Signature of contract �^ - Location,:J��—� �- � 114,7x 7.4 ° No. Date .3'2-1-1d �oRTM TOWN OF NORTH ANDOVER ` Certificate of Occupancy $ CPoo, Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ s TOTAL $ Check #,,216 22U '/ 0 Building Inspector I i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERA=Tanning/Massage/]Body _ Swimming Pools Public Sewerody ArtWell Food Packaging/SalesPrivate(septic tank, ter on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM j I 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 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - yes n Located at 124 Main Street Fire Department signature/date nature/date to P 9 COMMENTS 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 regLires approval of , Electrical Inspector Yes No _ I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I NOTES and DATA— (For department use i I ❑ Notified for pickup - Date I ........._.._.....__............_......--............................................_...__... ---- ............................................................................................. Doc.Building Permit Revised 2010 J 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 ,iiit Workers Comp Affidavit _C6 &� ❑ PhotoCopy OfUJ-.4C': And/ 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:Building Permit Revised 2008 7 �_ TAORTH Tovm of RAndover �0 5 LAKE = dover, Mass.,' 23 - COCMICKEWICK ADRATED PPa� `S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System O THIS CERTIFIES THAT.....4BUILDING INSPECTOR Q�! !!1..s,�� .-............. .v. ...................... ........!!1 ;.............. Foundation C has permission to erect........................................ buildings on .......... .... ........ .� ..........�................. Rough to be occupied as......:;X.AG.4.1rof..:.... �...�.... CC�....AYh .....IN.G/1 ��.................. Chimney this provided that the person accepting permit hall in everywrespect conform to the terms of the 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 Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUK O T TS Rough ...... ....................................................... ....................... Service .. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display_ in a Conspicuous Place on the Premises — Do Not Remove RougR nal h No Lathing or Dry wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SID!L�j Smoke Det. 9z � 9Z SzNA 0 SZ oz bZ ez ez zz (� �1w�'` All zz 2 ,N ` I � t oz oz sti 6L 8l Ll LL 9t . 9 l 5l bl bl f� ti •- z ll i ` ll ot NJ 0 1 1 9 g b b e e z z ` , (99-ZL) ESS-N9 i co v r �� r a ,I !`r IZ v o r � i �U. dri °� Po The Commonwealth of Massachusetts Department of Industrial Accidents Office of fnves'tigations 600 97ashington Street Boston, MA 02111 N ww-mQs&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Armee you an employer?Check the appropriate box: 1•Lyl am a employer with Z 4, TykE]New project(required): ❑ I am a general contractor and I employees(frill and/or part-time).* have hired the sub-contractors 6. construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet �• emodeling ship and have no employees These sub=contractors have working forme in any capacity. workers' com8• ❑Demolition p.insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition 3.❑ required.] officers have exercised their 10.❑Electrical repairs or additions 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 insurance required.] t employees. [No workers' 12.[]Roof repairs comp.insurance required.] 13.[] Other Amy a-Thcant that checks box.41 must also fill out the se,_0- e" 1k,shown Policy omeowners who submit this affidavit indicating they are doing all work and then hire outside contractorsactors must.submit a new affidavit indicating such. .. _. :_s Plu lContractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers, a , otic information. I am an employer that is providing workers'compensation insurance or m e information, f y mployees Below is the policy andjob site Insurance Company Name: i Policy#or Self-ins.Lie.#: 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 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 andpenalties of perjury that the information provided above is true and correct Si ature: Date.:. Phone#: E only. Do not write in this area, to be completed by city or town offciaL n: Permit/License hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspectorson: Phone#•