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Home My WebLink AboutBuilding Permit # 3/24/2015 �0- BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION % Permit No#: Date Received ZTED C3 CHLIS Date Issued: IMPORTANT: Applicant must complete all items on this page TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building El One family )A Addition El Two or more family El Industrial 11 Alteration No. of units: El Commercial 0 Repair, replacement &Assessory Bldg El Others: El Demolition 0 Other x i s rJ Utrrrrrr, JbblD� fi-�/"` )odplain�/,,,,,,�////.".,/,,,,,,�,,",,I Wotlah 5' sh i/l DESCRIPTION OF WORK TO BE PERFORMED: C,:j T-0 C Y, AZ4. e- 'To 5-n3jrr- ar -r Pe, I cr. Identification- Please Type or Print Clearly' OWNER: Name: I er 0 0%ro r- Phone: 3t3o Address: 0o 0 S-rc f. S°, ;x. /„�� J1/ / / r/%r a rx; /..r/ rJ , l f r� Ho 6 T— Jfs�� ! f��ul��J�r�� ;!1�'rh"�/ii//� /r r ,/r � r r r r r�'� , r r r.. r 1,I hlr /; �/ ��r ✓/J ,✓ ��;%'/�'�/J,,:r,;�� l 1�'��JJ� r, J' , ,� r` /r /i�'�'/ .......... ARCHITECT/ENGINEER S-rC 0< Jo-S-rer Phone: Address: 68 ra J o w t-ot ttt U. A Jot)C-r Reg. No. FEE SCHEDULE,BULDING PERMIT.MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. o -Go Total Project Cost: $ 0�20. 6� FEE: $O Check No.: Receipt No.: NOTE: Persons contracting witl unregistered contractors do not have access.,to the guaranty funs/ ig r nature of.Age' Siggature of contractor,,,-, . — . - 1. ,qt/Ow..nr, /W Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ T iJF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well El Tobacco Sales El 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on 1 Signature c. COMMENTS t��. c nS-�Z. , 12, Q^ (C) ' /-j--0[V\' ' "-U 5f - 00 HEALTH Reviewed on Sig natut ." w, 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp pumpster on,site yes.,,,. rio Locatedvat 124 Main Street ,.let Fire�De artment si nature/date p g r „ ril ll., i ire , r i l .iii i / n�/ 111%/ 1,�r///,O�iii��✓//9////i�/�i,;�i�/ l 1f�>�w, �, a �i�i � k it®RTH, - Town oE 1, ndover ® No. Zb % ver, Mass, 24 COC LAKE NICM2WICK 7,�5 RATED T'P V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System �Mb r THIS CERTIFIES THAT ............................... BUILDING INSPECTOR . Foundation has permission to erect .......................... buildings on .. ...�S+e ......5 . . Rough to be occupied as 51! .2,.. .. ...im-� ., , Chimney .. ... . ....... ..... . ....... ......... provided that the person accepting this permit shall in every respect conform to the terms f pplica Final on file in 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. Rough Final PERMIT EXPIRES IN, MO S ELECTRICAL INSPECTOR LESS COSTRU T Rough Service ........... .. ......................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building 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. Smoke Det. • ��K �r y T'QWN OF i§90RM AND OVEP, OFIFIC�E OF • ' o ,�, -1600 Dsgooa'StzeetBuifding 2-0s-Silito,?4-36 North Andowx,,n Massachusetts 0.845 '�s.3RCNus�� Goralct.A.Brown Telephone(97$)688-954-5 InspeetorofBuildings _ Bax, (978)689-9542 . t MEC7`WI3BR'L CEf+T E BXEMPLIO pleasebrint . DATE. PB LO CATfDN: C)Cr t �'°P ; Li Number Stxeef Address Map) of Mama. Boanel'lrone fork1lone PRESENT MAMigGADDRESS Zip code The cuzxent exempfion dor"ilomeowr!exs°'was extended to?nclLtde owner occupied dwellings to tttvo units or;eSS and 'cc)allolu such ho?Imdwners to engage an dzvid�.zal t'or lire-Who does note ossess a license,provided That the owner nets as supervisor). SfafaBuilding (Code uection 108,3,5.7) DBFM-ITION OBROMEO•WNE1i Pers0n(s)who 9was aparcel ot'land on which helshe resines or intends to reside, on which•there is,or is intended to M1 bb,a one or two faMfly straefures. Aperson wl�o constracts more that one home xn•atWa earperiod shall notbe considered a homaDwnar, The undersigned"hoxaeowner"assumesresponsibility ioz cbmpllances wifh the State Building Code and other .Applicable codes,Toy Zaws,xWes and-xegulafions. '.I'keundersigned'TIOMeowner"certiRes that he/sheunderst-suds the Town ofgoithAndoverBuilding Dc&rtszemt quir;,,,um inspection procedures aad requirements and that hc)/She will comply with,said procedures and requirements, -..... �,� ` HOMBOWN)3RS SIGNATT7 A?)?ROVAL OB BWI))NG OFFICIAL Revised 7.2009 �'onnTlomeownersT'ixemption xr ')BOARI]OPAPPEATS 688-9541 CONSFR'tl'A'RON 6889530 NE'ALTH688-9540 K�.'��WG6889535 . The Commonwealth ofMassachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0bly Name(Business/Organization/Individual): � ",i�e/_ , A J,0 . Address: .1 Q0 o • c r City/State/Zip: �t l ' t Phone#: .- '9 d i- 1 0 f ___ Are you an employer?Check the appropriate box: Type of project(required) LRI I am a employer with employees(full and/or part-time).* 7. M New construction 2.VJ I am a sole proprietor or partnership and have no employees working for me in $, FJ Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.n I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ V] 10 �Building addition 4.V]I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.FJ Other 152,§1(4),and we have no employees.[No workers'comp,insurance required.] IL *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation. 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: i Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi tinder the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: $ Phone#: d 1 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: