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Home My WebLink AboutBuilding Permit # 4/23/2015 �ORTy BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ® _ �f cocNICM[wl< 4 Permit No#: Date Received ��SsAceaus�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION ( bt P, Print PROPERTY OWNER V 4 t . Eb 1C- I" t Print " 100 Year,Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes o 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 ill RE O � Ntl/rt WVN F.61'®N d IWN �� y,q" Y �n � e d �liN. fr� '°� �i•� DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly Phone: ' %hoc su �r' f i` OWNER: Name: Address:/() P, w4m ov`P-P 'Contractor Name Phone: Email: Address: Supervisor's,Construction License: Exp. Date. Home Improvement License: Exp. Date: ARCH ITECTIENG[NEER Phone: Address:_ Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ✓ FEE: $ Check No.: Receipt No.. NOTE: Persons contr ting r g ered contractors do not have access to the guaranty fund ,..,, , -7 ,,.. ✓ ao.;,.., �.fir.. . ,:.. 'I lm. ,.,,..,,; 7e,- r r,L/aV%i/D,rs?i aii„Frll „r'�'/' mr,m66 r r,e,.rfiNi iiai rkli ! rr,eri,r,,rr i I _ N v ulR�l 11 Af n /olllcrl,rl IUIr,�uIBG/ Y /,,r, o r, f r, Y Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiunming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennaneut Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR. OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Si natur COMMENTS l C} a_ - �CZ J- (C)i�' uj6 t IC HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Seaver Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP,�RTMENT Tim Durn sfer on site es no,; y fi _ ,,N � Locatedfat 1F2MainStreet r � � ,41 F ,r% �xa1 U ,. a' r ;S '-Yff�Y. s rte's v 1 'F,✓,�,;4'' � r FirebDepartmen#gig a cre/date, y ..� f� f � f CQMMENTS= r Y. 7_1111`7 9V tkORTH AL w. , o U V ell No. Z b h ver, Mass, O L COCNIC c"t Nl WICK ®�RATED P•QMINK ��.�y U BOARD OF HEALTH Food/Kitchen ,7 E RM IT T LU Septic System THIS CERTIFIES THAT .... :!?` !n .�jr ��'' BUILDING INSPECTOR ... ........................................................................................... has permission to erect .... buildings on Foundation f . . Rough tobe occupied as ..........� ... l?................... /....0c . .............................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT Final ITE I IN 6 MONTHSELECTRICAL INSPECTOR UNLESS CONSTRUCTIO S ARTS Rough �j .... ,...... Service ............. . ....................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. TOWN OF NORM ANDOVEP, .yS '�^.S`�✓^c"a -r■r�'-,v-`r•_••■s��-r�g®.Y 1.e.1''.•1gx:�B1 R.0 U:t,' j N'rrt "1600 Dsgoad Street Buff ding 20 'auxtc,235 Nbithhada-vex assaaumstta 018 .5 �'S3ftCi1115�� g Mb ' Garald A.Brawn - Telephaz�e(978 Fi88�� Inspector0 WIdings _ Fax (978)689-•9542 .�'leaseprint '• - . DATE: ' A)B LOCAT�bm, e,� - 741M d� . Number S7reetAddress �ap/�at ' IL Name. Work Whono PRESENT MAMG AD))RES(49 fujty Rat-- . .. Z ¢r zip coda The current exmmplion for 11omeownug''was exfeuded to elude oWnex❑cctipied diueltngs to t4�o units ox:ass and $a aTlolsuch 7,omeo,uersto angage au Ldi•vidual.forixe wno CIO as not possess a cense,pxa�lided that Ilio ownez acts assupezvisor). ftfe3uilding (CodeSeotlon DBMITZON O-VHOMEO WM ).'exson(s)Who gurus aparool of land.on which halsheresines or iutands to reside,on Waith there is,ox is infendad to 7�e,a ane ar tt o azaily strctcfazes. A.persoa who constmats more t7iat one hame in•a twoyearpmzod Shan not'be considered a7oomeowner. The undersigned"homeowner"assumes responsibxlitr fo_z compliances witft the StatoDuilding Code and ritzier Applicable codes,b Xaws,rules audxeguxatiow. Theuudexsigned"komeownex°'cerfWes that helsheTwders ds tTi To vxt of lortb Audo�ez33urtding De aztn�eut miuimum inspection prooedures and requixmments and th / 'h co requiremo.uts, y with;saidpxaceduxes and If ROAMO)ryN° RS SIGNAz'T - ' A= I)ROVAL 01?�BMDWG OFFICJAc. RDWSed 7.2009 - �DISA�DIIlPAWFIBLS�iX�117�7L74it - • - EOAR*D OFAPPEAM 68R-9541 CONSER,VAUON 688-9530 MAL.TH 698-9540 rLANNWG 68R 9535 The Commonwealth of Massachusetts ' .Department of IndustrialAccidents a l =r= I Congress Street, Suite 100 - ° Boston,MA 02114-2017 F www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Ei ketricians/Plumbers. TO BE TILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le •bl Nalne (Business/Organization/Individual): � Address: v$A- �q City/State/Zip: 1~ in Jd '/6,r Phone#: Are you an employer?Cheek tie appropriate box: Type of project()required): 1.F1 I am.a.employer with + employees(full and/or part-time).* 7, ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8• Remodeling ' any capacity.[No workers'comp.insurance required.] Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required]i 9. ❑ 10F]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I 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.E]Roof repairs • These sub-contractors have employees and have workers'comp,instuance,t 6.❑We are a corporation and its off',tcers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] , *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 and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing worlrers'compensation insurance for my emplbyees.'Below is the policy and job site information. j Insurance Company Name: Policy#or Self-ins,Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration elate). 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 WORD.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. X do hereby cern under Z in and naltles ofperjury that the information provided above is true and correct. /11 r° ✓ Si nature: 11�7, ' Date: k 14^0 Phone#: 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#: e\vv