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Home My WebLink AboutBuilding Permit #735-2011 - Lot 19 79 Empire Drive 5/3/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Zl 'lot/ Date Issued IMPORTANT:A 4�:1 Date Received must complete all items on this l t -L--Iy� le -I\ LC Print MAP NO: /Q PARCEL %�ONING DISTRICT Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ew Building KOne family El Addition El Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic Well` O Floodplain, ❑Wetl'and's.: El WatetshedlDistrict+ . Water/,Sewer:' od _ A _ -_- T)RSCRIPTION OF WORK TO BE PERFORMED: OWNER: N M CONTRACTOR Name: Address tion Please Type or Print Clearly) U ''-ff7 3/6 Z oio'�' JyIeS ;/N 11 Phone: 9f1EF9'23/07 2 -AA 6 () 11t 2 l Supervisor's Construction License: IUL-7-51 Exp. Date: 13 Z Home Improvement License: Exp. ARCHITECT/ENGIN AddresslWj Date: _ Phone:9 78- 3SZ- E3131, meg. No. 27 7� FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature_ of"eo ti mI Location 2 :F ,/5�If No. ? �� Date TOWN OF NORTH ANDOVER • , Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ /40— Other 40— Other Permit Fee TOTAL Check # 24,i5 E, $ Building Inspector 1 Plans Submitted K Plans Waived ❑ Certified Plot Plan Stamped Plans 9 TYPE OF SEWERAGE DISPOSAL Public Sewer K 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 PLANNING & DEVELOPMENT COMMENT CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ Reviewed on S / 3 h ) r �S Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Cafservation 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 124 Main Street Fire Department signature/date 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 servicedroprequires approval of Electrical Inspector Yes DANGER ZONE LITERATURE: Yes No, MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Doc:.Building Permit Revised 2008mi 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 j 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 2008mi �d t rA W s .I c � O L c H Ac C.3 CJ �( •C W CD O m • Ea Cl) .� Gmo C/) �• fit: S CL A CD 0 o o. 0 ts m c \O OCA m 3 r cm 'gym O zipC/) Uo o C \- V: y w m tl C?..'=.•00 = os Cn or m V y O i : 'GA o .r :=oo c fl. Q y O = O = m 0 3 N O rt0+ y m r0.. ~ O CA LUL IL .y O A = O H N dt Z = o 'r m .y O LU Ci O p CM c y CL m� O:5 = A a y C ti 2 6 O co u p w2 cis A w° U 7 w O a�' id w W O � u cn Cd u. Ccm a�' w W C. m� cn O cn c � O L c H Ac C.3 CJ �( •C W CD O m • Ea Cl) .� Gmo C/) �• fit: S CL A CD 0 o o. 0 ts m c \O OCA m 3 r cm 'gym O zipC/) Uo o C \- V: y w m tl C?..'=.•00 = os Cn or m V y O i : 'GA o .r :=oo c fl. Q y O = O = m 0 3 N O rt0+ y m r0.. ~ O CA LUL IL .y O A = O H N dt Z = o 'r m .y O LU Ci O p CM c y CL m� O:5 = A a y C ti 2 6 O co O r C ■ L O O v Z' Q O � CA C Ccm O■— CO2 O O -FE m m co CL ~ _ co � Off" 3 O 0 O O O d ME Ca � O ate■+ C Cc CJ J .O ■O. O }? c Z C V y O C C •= y IP 0 U) U) 19 W ce ,,Www v♦ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrintLegibly Name (Business/Organization/Individual):_!Tt�ny �LLA6c- Z_ &C Address: City/State/Zip�� . /�/� (� (� �( Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2..I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors add their workers' comp, policy information. I am 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. #: Expiration Date: Job Site 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 cerci nder the pains and penalties of perjury that the information provided above is true and correct.- .4 L P, — _,., _ o _ e—1 � f I, 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 #: The Commonwealth of Massachusetts Department of Industrial Accidents ` Office of Investigations 'A. ,a 600 Washington Street . ',1 Y Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrintLegibly Name (Business/Organization/Individual):_!Tt�ny �LLA6c- Z_ &C Address: City/State/Zip�� . /�/� (� (� �( Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2..I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors add their workers' comp, policy information. I am 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. #: Expiration Date: Job Site 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 cerci nder the pains and penalties of perjury that the information provided above is true and correct.- .4 L P, — _,., _ o _ e—1 � f I, 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 #: