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HomeMy WebLinkAboutBuilding Permit # 6/9/2015 BUILDING PERMIT Of VkORTII TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATI;�..' ell 11 IL to c I 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 z . � t ........... �710111R- gh'a III)7filf�//00411 rlrri4,1mi,1111011111 r `-7nqV VV 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 'do ( s "k'(2 OMMENT VIn 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 0RA" P 5Psite, ies 1i p a.L ji �1,p m"-M"I'&orated nz Y 1 M11 Q9 R T1JY,q1Y9R I fV/"","///�,/,/�,/1'­ C MMN, ) E NORTH Town of ndover O to No. �O LAKE h h ver, Mass, COCKtC.a.,CK S U 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 II it I I r i ?r q 3 7 � " Interstates —I —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 �sSACHUS 1"=45ft " e / / ( ' . � � � / / i / � � � � The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 d Boston,MA 02114-2017 ��b SJ•�� 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 y ' 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