The URL can be used to link to this page

Home My WebLink AboutPermits Permit # 6/9/2015 l ®� BUILDINGPE 4e 1T e►LED 1 b0 yWR� D.:v, xa�d TOWN OF NORTH ANDOVER - APPLICATION FOR PLAN EXAMINATION ® ' AATED Date Received `�RpD ` Permit IVo#: �ssAew„s�` Date Issued: 4PORTANT: Applicant must complete all items on this page LOCATION / Print PROPERTY OWNER Mc Print tO Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition Nrtwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ... ,,..... �r- a r�a ,a xrai . , ,r., i �� • irtrnu ��u�,u'giV... w �,� ,i de�'rr ik f��(t1,"r1'y�VOfil kVl�'(f'6"'✓1�4i i., °,r,.,. a sur�I .riy�n�"�'�IE"iEp1DWV��wiF�Jl'VV'NW ?ify'f9ilr( i,,i�glr��","(.7flIW��' �..,, � yJ-�s ri e� �� r e l w � �9� v11�� rs�ed, ��►s"�I�� ' U DESCRIPTION OF WORK TO BE PERFORMED d Identiifieatio - Please Type or Print Clearly OWNER: Name: °' Phone: c35] '2 '. Address: Contractor Name: Phone: Email: Address: i Supervisor's Construction License: Exp: Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $_ � � _FEE: $ e4- Check No.: v Receipt No.: NOTE: Persons contracting tla u registere co tr rs do not have access to the guaranty fund 50 ti Plans Submitted [I Plans Waived [I Certified Plot Plan F1 Stamped Plans 11 TYPE OF SEWERAGE DIP-0-SAL J_Se Public Sewer ❑ TwmingrMassage/Body Art ❑ Swimming Pools El Well El Tobacco Sales ❑ Food Packaging/Sales El Private(septic tank, etc. El Permanent Durapster on Site El THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed OnSignature_ III COMMENTS CONSERVATION Reviewed on /�Sii nature COMMENTS 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& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street I R Eg,b t 0"AA ster lm 1�,��,llt% , s ite;,'N j �W,1115y 7-"TP,"i'M",Tu" 'ARTAY �.........11,11,0�X,` 944 Located btlllo 2, ....... F /,D INg mo I- cb ' k tkORT H Andover Town of 0 to S_ I _n i^�E h ver, Mass, COC HiC„fwKK S t1 BOARD OF HEALTH P �E R� IT Food/Kitchen Septic System THIS CERTIFIES THAT ......... ,4!. .... it „ .. ........ BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ... ... ........... . ... .. to be occupied as 42on .......wow ......... .. .... .. .. .......... .. ..�.,.' .�.`.... ....� chi ne e tin is a shall i res ec con orm to the Perm of the application provided that the acc p ry p pp 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 PERMITAa I IN NTHS ELECTRICAL INSPECTOR ® CTI A Rough Service .............. .... .... ................................................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final o Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. tkORTH T T AnclOver O . . ® - �^�� h Ver, Mass, COC NIC Ml WICK ��• AERATED S U BOARD OF HEALTH Food/Kitchen I T Septic System THIS CERTIFIES THAT .......... . ....... .... . ,,,,, „�, BUILDING INSPECTOR has permission to erect ............ buildings on .:. Foundation .............. ........ ... Rough to be occupied as . .... .. .... .. .. .......... .. moon,........................................ Chimney provided that the on acceptin is a shall i ry respec con orm 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES 16 M NTHS ELECTRICAL INSPECTOR ® UNLESS C® STCTI A Rough Service .............. .... .... .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay 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 28, 2015 i y, I l I I tAidd��seX 5�ree Interstates y —SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAO83, Roads Meters Data Sources:The data for this map was produced by Merrimack pORTH Valley Planning Commission(MVPC)using data provided by theTown of y"ti Easements f q North Andover.Additional data provided by the Executive Office of 0 MVPC Boundary �O`�t4tu °'aQ Environ mental Affalrs/MassGIS.The Information depicted on this map is Parcels for planning purposes only.It may not be adequate for legal boundary O — rn definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER � ~ MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING {t '! >w THEACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY '.. 4Lt ^ OF THESE DATA,THE TOWN OF NORTH ANDOVER DOES NOT �►0 4� x ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF '.. *Ao��rrc Of",fah THIS INFORMATION �SSACHU5�t V=19ft The Commonwealth of Massachusetts F Department of IndustrialAecidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 o^M 5y www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH•THE PEF"TTING AUTHORITY. Please Print Le I AM!___4-Information Name(Business/Organization/Individual): Address: 41 - 31). C4 City/State/Zip: 1 ''._— hone#: c °� Are you an employer?Check the appropriate box: Type of project(required): em to ees full and/orpart-time).* 7. ❑New'construction 1.0 I am a employer with P Y ( 2.❑I am a sole proprietor or partnership and have no employees working for me in g. [1 Remodeling any capacity.[No workers'comp.insurance required.] 9• ❑Demolition In I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.F1 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.FJ Plumbing repairs or additions proprietors with no employees. S.F1 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.t 14.[❑Other 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL e 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information, homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 worlrers'compensation insurance for my employees. Below is the policy artd job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: City/State/Zip: Job Site Address: ompensation policy declaration page(showing the policy number and expiration date). Attach a copy of the workers' c a Failure to secure coverage as required as civer il penalties enalties i x the form of STOP GL c.152,§25A is a criminal violation ORDER and a fine of up to$1,500-00 a and/or one-year imprisonment,as w p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eerti y under the pains andpenalties of per jury that the information provided above is true and.correct. '/ Date: Si afore• hone# Offzcial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: o4K err TOS'OFO .M ANDOVER OFMCE OF -BU MD- G I)FPARTM T • ' �Q Bey .1600 CJs OOd Siwe � Building,2Q,-S-aitt�,?36 7 s �r<b wp"`��`� i •NoithAndmr,Massaohusettq 01845 �Ft�{-1119$ Gerald A.Brown TeZeVhozza(978)68 9-95 InspOctor of,Buildings _ a (978)685-9542 8 CPE `s- W LIC r):Ox pleasepr3nt . . '' DATER . _ 3 - , .Numb or Map)zot DL 7&q Tazae. . HOMO Mone WoxTt�'hone a . zip Cori TAC cuzrent exempfion fox"bomeownexs"was extended to?nchlee ovinex oactillied af�e Ings to t�vo units-DYT-099 anal fa s as Susuch ornea:7uexs to enga e an-+ acts assUv;auax for biro Vto does aotVossess a 71cmgo,provided that the owztex pext»sox), ,�iate3uiXding (Codeuectian.ZOS,3<5.�,� DEMITION O:FHOMEO'WM , Pmsau(s)'tXrho V4s a parael ofZana on 1 Ih'01,"'Bl xesides or intends to reside,an which utero is,ox is infeuded to bb,a one oz twoaMily stntctazes. A persozl who canstcaats more t7iat one home in a Ewaeaxllerioa sba71 ztot be owisidawd a ho�steo�l�er , TF1euudersigned"�onzeownez"assumesresponsibiliy oxcoznp aztces-Waft tieStateBuiidiagCodeanaoffer Applicable,codes,by Jaws,roles and-xegaiations. The aarsigned"bameownex"cextx; es thatdieTown of�7ozEht�aa�er�3uild%ng�]e�az�ezzE nv`n7muxninspeafionPTO csauzesand requiranenfsaMthat 11018 tewillcomplywithsaidpraroduresanal xequixezzlents, �,..-„ . , L7.O.1.Yf n.0�'Y.L'(.L'RS rS1011T'.C3.'ZME ,,� ,,.,..... .�,,,. ..... • APPROVAL OF I3ZT.CC DMG OFFICMx. Revised 9.2009 � " 'FozmomeawnersBxempCian - x� 3OA}{D OF.AITBAT 698-9541 CONSBR•F'.t3.MN 688-95,30 MAL'IH6$5-9540 -PLAT7NIN06$9-953! .