HomeMy WebLinkAboutMiscellaneous - 21 BRADFORD STREET 4/30/2018 (2)i
Location,
�.N o. Date 1
TOWN OF NORTH ANDOVER
Certificate of 9c
Building/Frame`- F
14U FWation 136,11 a
IthVPermi
Sewer Connectio�r
Watiprfonnection
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EERJtIT.avo._,a % o4APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. ,' PAGE 1
MAP 4-40.
I LOT NO.
2 RECORD OF OWNERSHIP (DATE
BOOK iPAGE
ZONE
SUB DIV. LOT NO.
LOCATION !
PURPOSE OF BUILDING OL44
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRES q J
Y
BASEMENT OR SLAB
ARCHITECT'S NAME
dR
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME •� ./1
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12 ,
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED A�APPROVED BY BUILDING INSPECTOR
DATE FILED
OF OWNEf OR MITHORIZED AGENT
FEE (L� 7•
PERMIT GRANTED
-;4- C/
19
OWNER TEL. #
CONTR. TEL. #AU 3 " 0 6'
CONTR. LIC. #
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COSTO
EST. BLDG. COST PE SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY _ S-ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI, FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA -
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
M
CONSTRUCTION
2 FOUNDATION
—{
8 INTERIOR FINISH
d 1 2 13
PINE
CONCRETE
CONCRETE BL K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
DRY VJALL
_
UNFIN.
3 BASEMENT
AREA FULL
FIN. B'M'TAREA
_
1/1 1/2
ATTIC AREA
N_O B M T
FIRE PLACES
_
_
HEAD ROOM
MODERN KITCHEN
4 WALLS ( 9 FLOORS
CLAPBOARDS
B
_
ll�
1
2 3
�_
_
_
_
DROP SIDING
WOOD SHINGLES
CONCRETE
EARTH
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
HARDI!J'D
COMMCN
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
CONC. OR CINDER BLK.
ATTIC STRS. & FLOOR I_
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR I- I POOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
HIP
BATH (3 FIX.)
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd _
1st 13rd
ELECTRIC
NO HEATING
M
OFFICES OF:
Town of
120 Main Street ,
APPEALS
•; �•
::..
NORTH ANDOVER
North Andover.
BUILDING
�.:.;
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Massachusetts 01845
CONSERVATION
@'"OM1s`t
DIVISION OF
(617) 685-4775
HEALTHAG
PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
1
In accordance with the provisions of MGL e 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 c 111, S
150A.
T"ne debris will be disposed of in:
(Location of _Facility)
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.
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BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
g
Permit NO: Date Received
Date Issued: (T-
TYPE
T
16''ryO\
O? 0
0
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic 'Vti/el1
Floodplain- Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Please Type or Print Clearly)
OWNER: Name:
Address:
4
ARCHITECT/ENGINEER Phone:
x
Address: -Reg. No.
FEE SCHEDULE: BULDINC PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ C — — -- FEE: $ 7&' / IdL_'
Check No.: e2 Receipt No.: 9 y
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location!
No. Date
�aRTM TOWN OF NORTH ANDOVER
w
9 fi
Certificate of Occupancy $
CNust� Building/Frame Permit Fee $
Foundation Permit Fee $
a
Other Permit Fee
TOTAL
Check #7
f r- �r
20496)
Building Inspector
f
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:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Located at 384 Osgood Street
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 2 1 A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
OVA krxcf-
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❑ 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: A I dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Plot.Plan
PloPlan
❑ Workers Comp Affidavit -
❑ Photo Copy of H.I.C. And C.S.L. Licenses _ -
a 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)
NOTE:
❑ 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
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
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ' Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/ZipP
A/�Y +k , %li Phone
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
7; !
Department of Industrial Accidents
�,
Office of Investigations
listed on the attached sheet.
600 Washington Street
These sub -contractors have
Boston MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ' Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/ZipP
A/�Y +k , %li Phone
Are you an employer? Check the appropriate box:
I.�m a employer with �;
4. F -1I 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.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
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.❑ Plumbing repairs or additions
l 2.�of repairs
13.❑ Other
-Any applicant tnat cnecks box #i must also til I 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 and 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. #:
Job Site Address
,I—
Expiration Date:
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 andpepenalties ofperjury that the information provided above is true and correct
Sigmature: / � Date: "—ll '—elli %6.
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 #:
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