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HomeMy WebLinkAboutBuilding Permit #165 - Exception 8/30/2007 pORTH BUILDING PERMIT o`,t�E° 'bq'�o 2 ��. ....,. 6 O TOWN OF NORTH ANDOVER C, APPLICATION FOR PLAN EXAMINATION * ,� Permit N0: Date Received SACH 5 Date Issued: 'IMPORTANT: Applicant must complete all items on this page x ' �£ 4 DIN kl) r P .0, ERT MAP1`1®Y PAR� . wZONING DISl'R1( T � tortc Li #t�c# y�s3o ' k ach TYPE OF IMPRO_VEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family El Industrial ❑ Alteration No. of units: ❑.Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other I. I , ❑ Septt ❑�lll1t ❑ Foodplaan ; 11Ietlands t © Al UatershedC3Isrtt: r 11Water/5err� tip .. . �, ,. , DE CRIPTION OF WORK TO BE PREFORME : r� Identification Please Ty a or Print Clearly OWNER: Name: o S' Z Phone: 40 c V I Address: eQ aO S , , x a C(JNTRATC)R Iarx�e Phone" rM. 'r r�ji'iM •§ "�r� ,;Y v, aa Address: €cR vF, " St pervlsor's Cta st ctian Ljdbnse:�, xp Da#ei � a Horne,lmproverre�if t��cense pw ARCHITECT/ENGINEER y �S � cr 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: $ )YYc Q2C FEE: $ f 72?"' Check No.: 03-5"- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty.fund Signature„of Agent%Own `* Signature a c�ntac or 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street FIRE DEPARTMENT ; Temp Dempster.on S."ite yes no 'Locatedat,124Mairi Street.' ; Jre Department signatureldete -� m COMMENTS t 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 11A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date ..................................................................................................._._.......---_..............................................._._..._.....-......................._._...._................... Doc.Building Permit Revised 2007 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location A6190 0- - 0 ball No. Date � _.3U G MORTh TOWN OF NORTH ANDOVER °c a • • i ; • Certificate of Occupancy $ CMus`� Building/Frame g/Frame Permit Fee $ t�f�h$4' Fo ndation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �6.3s ti 20550 Building Inspector NORTH TO" Of .. Andover No. (Aso r o dover, Mass.,—P/f Q LAKE A_ COCMICMEWICK V RATED P' �5 7 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System /� BUILDING INSPECTOR THIS CERTIFIES THAT (l ' ... ...... / .:.... ... .. ..e........................................ ..................................... Foundation has permission to erect._......... ' g �� �� � / Rough ^........ ...... buildm son... ... G16......�� �C .�........ r ' , Chi mneyto be occupied as... . c < ...............................................� . provided that t erson accepting this permit shall in every respeccon�o�rmtothe 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. Roush Final a2 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TS Rough .... .... ..... ............. .................................... Service BUILD PEC R Final 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. SEE REVERSE SIDE Smoke Det. ✓1� oo�v.�, a BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 048040 Birthdate: 10/29/1955 Expires: 10!29!2007 Tr.no: 8053.0 i Restricted: 00 TADEUSZ DOWGIEERT 175 BRADY AVE = 5� SALEM, NH 03079 Commissioner Mar 06 07 12748P 6038900192 P.1 Rl/1dJ ivvr sa..ry ..ao ��•����"""" �� , ACM. CERTIFICATE OF ry 1l�8URANCE 2 ooucsw —NIR OF ipc. �or� me �e'l ' OR ma `mom 5"00 01645 01/t� �� z" co MOM D t7Q G'I'YGI� co1' wu� a 8 DL70D68 PAVK moo: Ift 01810 ���DYt�1tAtiEOR f6�0igf�Y4'MEa16tlIt�M10 OF aacm sM►Y �EO � Cly cC aF 11f�l GDNfItlrCF at � � rvoALTM�i�. ld i s..� is s.v porow Tim 50 00 c i„_ j_04.�. w mwa ®=7 101Z8JQi 10/25/p� *eRow�++�► " s 0 CpP00"437 _oor�or,�oo s 1 Q O ses�,�aoa�►rtu��wwss WCgilYLEtw� c on �uaw�cwirtrn W,MWLWEaAVTW s mmmj as �usoae.�-m►�cacs s cAKVMwsnar s iwrwttm rte.accts s S s o�ucnstE s LMIL�, a Sao.s4u s, .,�► a o0_000 D 0=703930 10/26106 10126107 _�� i 500-000 OVER s�avnoasc 54 –8 –0 aaur�s�uwce<►m�O1F�o'�'�`�` GTE $"OU MW tM M Vs wu. To s IO om wwrwm 01►te to'tni tSri Z:YtJt fauWRETo oa 50 Eluit� ony vr4pzRxWSs, aF N 1D7�E MMS s�0'sE hp On OR�t�t1n Mr lona W"W"�+ SOM MOD MA 01845 �xsa Atma�c. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street i`• Boston,JMAA 02111 r � www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Businesb/ttrgminition/tndividualY ( -,e—, f Address: City/State/Zip: Z,,-Up /UL ,,..-Phone#: �S-5"0 3_ Are you an employer?Check the appropriate box: Type of project(required): 1.9!j�am a employer with„ f� `t••❑ I am a general contractor and[ 6. Q New construction employees(full and/or part-time).*. have hired the sub-contractors. 2.Q I am a sole proprietor or partner- listed on the attached sheet.t 7. emotkling ship and have no employees These subcontractors have 8. Q Demolition working for me in any capacity. workers'comp.insurance. 9. Q Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their ME]Electrical repairs or additions 3.Q 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.Q Roof repairs insurance required.] employees.[No workers' comp.insurance required.] 13.Q Other *Any applicant that checks box 01 must also fill out the section below showing their workers compmelion policy infommtion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside conhactors must submit a new affidavit indicating such. ;Contractors that check this but most atfactrod an additional sheet showing the name of the subcontractors and their workers'comp.policy infammtion. tam an employer that is providing workers'compensation insurance for my enrloyam Below is the po/icy and job site information. Insurance Company Name: u tr V`4Z / w� Policy t#or Self-ins.Lie.#: [� O W 4!::� > 9 3 t Expiration Date: p toZ Job Site Address: 19 City/Stateo, Qt,le 4�— 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 cert y under the pains and pcwalties o duty that the information provided above is true and.•��� - - r %i ature: Date- Phone it: Of7� �lr - �7�9 Z_ - Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitfUcense# Issuing Authority(circle one): 1. Board of Heaith 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i