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Home My WebLink AboutMiscellaneous - 1150 Gnt Pond i I a I i I i i i�, Location M1 �1 * No. Date 7 �ORTM TOWN OF NORTH ANDOVER 1O 9 I Certificate of Occupancy $ s" M�s Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ LI0 cy3 Check # 17494 +I/ Building Inspector t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: �^ 17— X SIGNATURE: Building Commissioner/ImeEtor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ` Map Number Parcel Number 1.3 Zoning Information: 1.4 Properly Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Reqttired Provided Raqllired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Pubfic ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIUP)AUTHORIZED AGENT listuft M 2.1 Owner of Record Name(Print) Address for Service v J Signature Telephone 2.2 Owner of Record: ame Print Address for Service: z M Signature Tele on SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date ic Signature' Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ v `-�— CompAny Name rn Registration Number 11L/411 eaojy Address 9 Expiration Date Z Si nature Telephone Y SECTION 4-. WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 "Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other„ ❑ Specify Brief Description of Proposed Work: . 7e rc \ SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFIct USE ONLY om leted by permit applicant k` 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT T I> 2- as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Sianature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2ND 3FLD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS 1 i , � ]�• � HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING _ . . X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ? `•1 1' 104"1 _ North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: Oaf 1) /Sos�L (Location of cility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector �r Y'. r 'rr'F'• 'ti ti .d d - ,{l+d� i Board of Building Regulations and Standards r HOME IMPROVEMENT CONTRACTOR Y Registt 142928. < Exp=iratt��1/2006 ; + WIND )� ti S.G.M.CONSTRUCLI(�N� SERGE MiCHAL;i 't 2 TATE ST. HUDON,NH 03051 Administrator All% �h r .d�sr p J f g� rr a ! 5ieY� Z u The Commonwealth of Massachusetts u r d Department of Industrial Accidents Office of Investigations �F Boston, Mass. 02111 see Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity F-1 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone#. Insurance.Co. Policv# Company name: Address City: Phone# Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one years'imprisonment-as_well.as.civil..penalties1n.sheform jof-a_STOP WORK_ORDER..and_afine cf.(.$1.00..00.)-ai:byagainst.me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under n / 9 t ry the information provided above is true and correct. Signatures Date Print name Phone# Official use only do not write in this area to be completed by city or town official' City or Town_ Permit/Licensing � Building Dept []Check if immediate reSSa 1. r u,r ❑ Licensing Board J E] Selectman's Office Contact person: Phone#: ❑ Health Department t Other _ �tORtFf Town of North Andover Building Department y 27 Charles Street North Andover, MA. 01845 SNCHO`�� D. Robert Nicetta . Building Commissioner `(978) 688-9545 (978) 688-9542 Fax s HOMEOWNER LICENSEE EXEMPTION MPTION Please print. DATE JOB LOCATION Number Street.Address Map/lot "HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homedwners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than onehome in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other .Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE N. APPROVAL OF BUILDING OFFICIAL , NORTH Town of _ Andover 0 go O L A Q E a dover, Mass., jo Jo f/ COC MICHEWICK �V ,p �RATEO 0'P � 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT......�.A0.0. 41 St- 4.0 I BUILDING INSPECTOR .................................................................................. .... ... """'Po Foundation has permission to erect..V� ................ buildings on .../e$0....,.a I ................................................ Rough to be occupied as..... .......� � qC�/Iti1* I 0 Chimney provided that the person accepting his permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and B Laws r atin to the Ins ection, Final Buildings in the Town of North Andover. y g p eration and Construction of Q s y 40W PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTIONS ART ELECTRICAL INSPECTOR A Rough ...... ........................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display-in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done Final Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. IL SEE REVERSE SIDE Smoke Det.