HomeMy WebLinkAboutBuilding Permit # 6/9/2015 BUILDING PERMIT Of VkORTII
TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATI;�..'
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Permit No#: Date Received
Date Issued:-":.Yh-1
IMeORTANT: Applicant must complete all items on this page
LOCATION 44
Print
PROPERTY OWNER—— -cs-hu-4,
1:1rint 100 Year Structure yes no
M A P PARCEL:b�
ZONING DISTR'ICT: Historic District yes no
Machine Shop Village yes, no
TYPE OF IMPROVEMENT PROPOSEDUSE
Residential Non- Residential
El New Building El One family
El Addition El Two or more family El Industrial
El Alteration No. of units: El Commercial
El Repair, replacement 0 Assessory Bldg El Others:
El Demolition El Other
I 101DE A
DESCRIPTION OF WORK TO BE PERFORMED:
AaMj SI-42-d lo X6-�6
lInlica Plewse Type or Print Clearly
OWNER: Name: Phone: Z'09/ Atoxl
Address: A-- r,;-42�-AIV�4 -0�
Contractor Name: Phone:
Address: DIIIN Nj 2 42-1
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp.- Date:
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$1Z00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F.
Total ProjeGt GGSt: $ 060, FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unreg d contractors do not have access to the guarantyfund
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer 11Tanning/Massage/Body Art Swimming Pools ❑El
Well El Tobacco Sales El Food Packaging/Sales El
Private(septic tank, etc. El Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on signature
COMMENTS U"JI—Q, �o- 4.d"-A � C)0
HEALTH Reviewed on ( /,5Signatum"'111A
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OMMENT
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Zoning Board of Appeals:Variance, Petition No: -Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connectionisignature& Date Driveway Permit
]DPW Town Engineer: Signature:
Located 384 Osgood Street
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NORTH
Town of ndover
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No.
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COCKtC.a.,CK
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BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT ..........54j.-r........ . ..... .... .......................... ................. ..........
BUILDING INSPECTOR
has permission to erect Foundation
p .......................... buildings on ......... .. .. ......... � . .. .......
Rough
to be occupied as ..�l�j...., . .. ...........61-4011004A........ ........ ............ ..,... Chimney
provided that the person accepting this permit shall in every respect con f rm 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.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
Ape UNLESS CONSTRUCT T S Rough
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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
North Andover MIMAP May 26, 2015
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Interstates
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—SR Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83,
-Roads Me am Data Sources:The data for this map was produced by Merrimack
Easements f µoRtp q Valley Planning Commission(MVPC)using data provided by the Town of
1"3 MVPC Boundary 0�tt��o ra �iCl North Andover.Additional data provided by the Executive Office of
s
Environmental AffairstmassGIS.The Information depicted on this map is
Parcels 5* Op forplarmmg purposes only.It may not be adequate for legal boundary
10 definition orregulalory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
♦ * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
# OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE.OF
•'AopATW�TA`�ej THIS INFORMATION
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
d Boston,MA 02114-2017
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www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plum ers.
TO BE FILED WITH THE PERMITTING AUTFt0I2IT Y. Please Print Le ibl
Applicant information
Name(Business/Organizationandividual):
Address:
City/State/Zip: A
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑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
a capacity.[Noworkers'comp.insurance required.] 9, FJ Demolition
3,1am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole 12.0 Plumbing repairs or additions
proprietors with no employees.
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance. 14.0 Other
6.Q We are a corporation and its officers have exercised their right of-exemption per MGL c-
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.
all work
I Homeowners who submit this
box must it indicating lied ti additional e are sheegshowing h name of the sub contractohen hire outside rs and state whether or those entitrs must submit anew afridavit y s have such.
tContractors that check tlu
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 the policy and job site
information.
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lie.#:
' City/State/Zip�'�
Job Site Address:
;, ;� /^ v L
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
lation punishable by a fine up to
Failure to secure coverage as required under Mc.15 inthe form of as 25A is a criminal
ViO RK ORDER and a fine of up to$250.00 a
and/or one-year imprisonment,as well as pen
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 cert'y u der the pai and penalties of perjury that the information provided above is true and.correct.
Date:
Si ature:
Phone if:
official use only. Do not write in this area,to be completed by city or town official.
Permit/License#
City or Town:
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#:
Contact Person:
TOWN
OF NORTH AND OWR
OBFICE OF -
�Q.j1 YCcutniY..%S�6 •�
Xcdh Anaavar,Massachusetts Qx 845
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Gerald A.Brown � telephone(978}688-95 5
nspeetorofBuildings �'a� (978}688-9542
�. MO .EQN •:. RLICENSE EXEM !. XON .
1'leasepiint
DAM 6 �C
BOB L0CATfDN,-
dumber treetAddzess Map/Xot '
OMMOMNER nAn_ 0 `
7a ae. ROn70Phone Wbr1cl'hone
ut,To 'Pop,
Po -
zip codo
TAe current exemption for"homeownexs"Wase tended fo Glude ownex occt%pied d�ve1vgs to t4vo units or less and
to a11oW su� oanPo;)uers to engage an 1JdiViaual•fCrhire�yno e7oes nopossess a 7icG3ise,pxo videtl tliate owner
acts as supezp?sox. State3uizding (Code ueot?on Zo8.3.5,
DEFM-I,rlo 7 OYHOMEO'W M ,
Person(s)Who awns apazoel or intends to reside,on Wiclx there is.ax as xnfendeci to
'bb,aone ortwo family sfzaetuzes. ,personw�oconstcttcfsmorethafonehomeina a- earp�r�oclshaTlnoE�e
eozIsidered alZomeowner.
Tlio undersigned".h,omedwne ,assu�tesxesponszbiIi y ozcomp7iances wifh the Stato Budding Code and of ger
Applicable codes,by-laws,pules and-Xegalataons.
Thalmdersigued"homeowner"cart lies that fie Town of Tozfb Andover3uilding�e attmenf
msnimum xnsper,f ion procedures and requirements and that helshe,will comply With said procedures and
requirezrients, .
APPROVAL OV 33D) .DU)'tr OFFICIAL
Revised 7.2009
x'oxzn Romeowners Bxem�tion '
30ARDOF'APPEAM688-9541 CONTSEVA.'1'1ON688'-9530 TMAL.TH689-9540 PLANNW06899535