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Home My WebLink AboutMiscellaneous - 151 SALEM STREET 4/30/2018 151 SALEM STREET 210/037.D-0028-0000.0 _ r Location ` No. Date 4011T►1 TOWN OF NORTH ANDOVER � 9 # Certificate of Occupancy $ ♦ i .: # s'•"'•Eta Building/Frame Permit Fee $ sAC 14 Foundation Permit Fee $ L Other Permit Fee $ w TOTAL $ Check # c-,23 7v 17491 Building Inspv r a� 4 • TOWN OF NORIB ANDovER BUILDING DEPARTMENT APPLICATION TO CONSEia R1 1IENOV.A OR Rf MOLISH A ONE OR TWO FAMILYwo BURDING IERMtT NUMBER: j?"DA-ThP.ISSUED: rf d siGNATUitE: Ll / 74 Baiidi ssioltar o thin Date - d� Z SECTION 1-SITE INFORMATION 1.1 Property Address 1.2 Assessors Mo mnd Psrod NW*w. 16P Pircti°ber .1.3 zoning la boudion: i.a Frapsxey pienmdm. 13E 7kninsvimet mpLaw use Loat Area rvnatr a 1.6 BUILDING SETBACKS 1t Front Yard Side Yard Rear Yard keotred P:tl�lde Provided Provided 13. Food zoecbamod n, 1.S' saa+evrgemvm S)U= / Powphrivm tor. OatsiA Mmdzoo a Mmnki o onsiftnispwi Sym IY M4 SECTION 2-PROPEL OWNIRSHWAUTRORM AGENT , m I i?unmer Of Record oma(Print) Addrew for service rgnatura Telephone ownerofR . Q, LAC. N s print Address for Serviw. e s Si afore Tel SECTION 3-CONSI'RUC'i'ION SERVMCES 3.1 Licensed C druction Supervisor Not 4plisabie 9-11 Licensed Cermtructim Suparviso. - Q LiaeaseNamber Address �>r' . Expiration Data' Sipature Telapbona r 3.2 Registecad Home Improvement Contractor Not A,ppticable COmpaaywome Registrstim►Number r` Address Z EivimtimDato G) S' Te e I i • SECTION 4-WORKERS COMPENSATION @ML C 152 Warkem Compensation Insurance affidavit must be omtpleted and submitted w tb this sWkafitm. Faduro to provide this affidavit will result in the denial of the issuance of the buildio - ` Si ed affidavit Attached Yes......A No......A SECTIONS DOcidtflonn of Ptd' Wot ct*& lite New Construction0 ' Existing Building UK Repair(s) K Alteratio0s(s) 0 Addition •I] - Accessory Bldg. 0 Demolition • 0 Other 0 Spocify Brief Description of Proposed Work.• SECTION b-ESTIMATED CONMUC'I2ON COS'T'S . Item l slimatc d Cost(Dollar)to be t n �. J`O TCIAI.'USE O19LY ., l t` ;'s 2egleed t cant +. 1. Build'mgp (a) Building Pewit Fee 0 Q Multiplier 2 Electrical (b) 'Estimated Total Cost of -Construction 3 Pl!!!gj'M Building Permit foe(.)x.(b) 4 MechanicalIIVAC' S Fire Protection b Total 1+2+3+4+5 Check Number SECTION 7e OWNER AUTRORIZATION TO BE COMPLETED WHEN OWNERS GENT OR EQMCro APPLIE R RUILDDIG PERM T I, asl uthorized Agent of sub cct Property Hereby as Drize , to act on ' r My babel,in ell its relative to s building permit application,' W $� re o owner Date �-a�-o�r �• SECTION 7b OWNERAU THIMMIRD ARMECLARATIOfe i r-eAcc, OwmerlAuftrizedAgentofabject propeq Hereby declare that the statements and information on the foregoing application are true and awmte,to the best of my knowledge r and bolief r rrint a I si frac of Owner/A Date RIES - SZE ASEMENT SLAB F FLOOR TIMBERS 1 2 3 SPAN DICvt MONS OF•BILLS DRAENSIONS OF POSTS D56NSIONS OF OMERS HEIGHT OF FOUNDATION THICItt3EBS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDINO ON SOL®OR FU ED LAND IS BULDING CONNECTED TO NATURAL GAB.LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: 6Location: SCS lt?IAA- c J&�. Cit' �,04 6dM&E Ra Phone a3 1 am a homeowner performing all work myself. 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 jab. 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 penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify der the pains and penaltie"pe4u thinformation provided above is true and correct. Signature Date V Print name Phone# �-()I.� Official use only do not write in this area to be completed by city or town official' 0 Building Dept []Check if immediate response is required Building Dept p Licensing Board p Selectman's Office Contact person: Phone A 0 Health Department 0 Other FORM WORKMAN'S COMPENSATION A North Andover Building Department artment 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: S beA%Q (Location of Facility) Si nature 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 II TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: C_ k- Q Est. Cost Address of Work Owner Name: Date of Permit Application: �Gc I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied _Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: �-/dG/os Date Owner Name i RT" TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING 40 sSA cmus, This vertifies that . . . . . . . . . . . . . . has permission to perf6rm_—.,&.- ,..—,—, . . . . . . . . . . . plumbingn the buildings of . . . . .4-4-e--o . . . . . . . . . . . . . . . . . . at. , ; . . . . North Andover, Mass. . . . . . . . .. .. . . . . . . . . . . . . . . . . . . ... . . 43 5Y Fee Lic. No'm? . . . . . . . . . . . ... . . . . . . . . . . . . . . . PLUMBIN Ni E TOR v Check # 6291 (Print or T eI� ®/ C�9 t N�d u •P� , Mass. Date /,,-? I .Z Permit # Building Location J / qo. �PvtiJ J Owner's Name l�'t►� o� Type of Occupancy 11Pw (� Rnnn,rat nn f-1 V�1�;URES Ync r1 v z m 3 Z Y Q I f- G� N O = 7 W W Y J (n OZ SA Q �S z S y Z 0 Q W 1- W N (X U Y < N — a Wim' J 1 W S ~ ~ W 3 O G ' —AN G l < Y O C W CL < S 3 C 0 > O N aJ Q S Q d N Q a J ¢ ¢ rz Q O < sue-8S MT. 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR x 8TH FLOOR ' Installing Company Namez,Jr awe �rg g Check one: Certificate Address 3 Qur e �t c ❑ Corporation o. e� c;l, ❑ Partnership Business Telephone To -3 S 9^ 9756 9 ❑ Firm/Co. Name of Licensed Plumber '.� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. � Yes No ❑ If you have ecked Vis, please indicate the type coverage by checking the appropriate box A liability insurance policy ) Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requ;rome Check one: Owner ❑ Agent ❑ Signature of Owner or Owners Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate.to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. Sc_nature of bcensea Flumber Title BELOW FOR OFFICE USE ONLY 4AL INSPECTIONS SKETCHE$ PI_,-)GHESS IN_;1 ECTIONS FEE �� Ir r rI NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING b LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUVIBING INSPECTOR r r..ry