HomeMy WebLinkAboutBuilding Permit # 6/11/2015 FORTHBUILDING PERMIT
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
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Permit No#: Date Received
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Ppp R5
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Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION A/5—
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PROPERTY OWNER /-/ S-
/ Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
TYPE OF IMPROVEMENT PROPOSED USE Machine Shop Villa7geytesno
Residbential Non- Residential
❑ New Building [Nbne family
0 Addition [I Two or more family 11 Industrial
El Alteration No. of units: El Commercial
El Repair, replacement El Assessory Bldg El Others:
El Demolition El Other
V 11, 141%01 rmasmx�igi�*Ifl awg,
� a r e. /f � >' r � � 1,,,, � ��,
DESCRIPTION OF WORK TO BE PERFORMED:
Ile ,1ezje &t4 4,4;10111;11e,&�
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.,$12 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
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Total Project Cost: FEE: $ 4,
Check No.: -� ta- Z Receipt No.:
NOTE: Persons contracting wi i nrontractors do not have access to the guaranty fund
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Plans Submitted ❑ Plans Waived ❑ Cerfified Plot Plan ❑ Stamped Plans ❑
FPrivatc
WERAGE DISPOSAL
❑ Tanning/Massage/Body Art ❑ Swiinming Pools ❑
❑ Tobacco Sales ❑
Food Packaging/Sales ❑
tank, etc. ❑ Pennanent Dw-npster 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
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;DEPARTMENT Temp Dumpster on-site, yes
Located at,124 MainStreet . rio``;
Fire.Department.srgr�ature/date
i
COMMENTS
,AORTH
Town ofE over
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BOARD OF HEALTH
PE �RMIT �T aw Food/Kitchen
Septic System
THIS CERTIFIES THAT ��S S BUILDING INSPECTOR
................. .............................. .. � .. .............. Foundation
has permission to erect .......................... buildings on ...... .:............
Rough
4
to be occupied as .......... .. `.. ....... ..... ........ &............. ................................ 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT I IN 6 MONT ELECTRICAL INSPECTOR
e
LESS CONSTRUCTI Rough
Service
................. .............................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Buildinga 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.
The Commonwealth of Massachusetts
F Department of Industrial Accidents
. . - 1 Congress Street,Suite 100
Boston,MA 021142017
• www.mass.gov/dia
l0A 5��v
Workers' Compensationlnsurance Affidavit:Builders/Contxactors/Electricians/Plum ers.
TO BE FILED WITH THE PERMITTING AUTAORIT'Y. Please Print Le ibl
A licant Information
Name(Business/Organization/Individual): �`/��`,
/Z.—
Address: �� 'Y�4
Phone#: 01City/State/Zip:
Are you an employer?Check the appropriate box:
Type of project(required):
(
1.❑I am a employer with employees to full and/or part-time).* 7. ❑New'construation
p y
2.F1 I am a sole proprietor or partnership and have no employees Working for me in g. 0 Remodeling
any capacity.[No workers'comp.insurance required.] 9, El Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 ❑Building addition
4.V,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 11[]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.F!Ro6f repairs
These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other
6.FJ 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.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
of the sub
tContractors that check this box must attached an additional sheet showing the name contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
wot•kers'compensation insurance for my employees. Below is the policy and job site
Yam an employer that is providing
information.
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lic.#: /
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.
Y do hereby certify and t epains andpe hies o jftyuty that the information provided is true and,correct.
Date:
Si nature:
Phone#: V �7
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
Phone#:
Contact Person:
�uKr y TOS'OF NORM ANDovEi P,
OFFICE OF
° °vpK °K :'X50D�JsgoocStzeeEBuilding4,Srte?36
n:
7�s�+atxa Fps 4t5 i 'N•oith Ando-Vox,Massadhusette 4l$4.5
C140
LI
A.Brown Telephorte(978)685-9S4S
hnspeetorof$uiidings fax (975)685-9542
,. 110104wMRMCBMEBXEYktION '
pleaseprL ,
DATE:
�OB LOCATfON:_,��,r A Ae-)i",z
Number Street ddress Map): of .
Name. . Monte Phone W orkMane
PRESENT AM6NGADDIMS � , iarc r . ..
Cm ��,„t, • StatP• -
zip Cod
The current exemption for”homeowners"was exteuaod to inelude owner occupied diveliags to t4va units or:ess and
fa allow suchomPa,rers to engage aa? diYidual•forhire who does notpossess a lice3tse,provided that the owner
acts as supazVisor)• BtafeDol ding (Code Section x08,3>S,h)
DF-MITION OYHOMEQ WNER. ,
Persons)who swns aparcel ofland on which,Ito/she reslaes or Mends to reside,on which thorn,is,or is i afended to
7�e,a one ox two faruily structures. Aperson.who constz-uots more,that onehoute in•at e-ysarperzod shall ztot be
causidered ahOMOownez
Tho undersigned"homeowzzez"'assumesxesponsibi ityfoxcompliauces wz Tz the Statel3uilding Codeand other
.Applicable codes,by laws,xales and-xegalatxons,
TbeUndersigned"komeowner"cert
,Res that he/she,&dergtaudgffi To"'
oof orth AndovsrEurtdingDeiiarEr�ent
n nimuzninspecfionpzoceduresandrequireznentsaudtbathtelshu -11 mplywith,saldpxoceduxesand
xegnirema ts, ,
3aOSVIEOWN'ERS SIONATM ,
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APPROVAL OF,I3TT,fz,DMCr OR.p'.ICIAL
Revised 7.200.9
FosznSomeowners Exemption '
EO.ARD OFA'PPEAM 688-9541 C01\1ma'AnoN 68&-9530Y
MUTH 688-9540 PLANNING 6889535
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6wt Easements O�S*ytD �y4 North Andover.Additional data provided by the Executive Office of
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F z--- definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
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# ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
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pRT3q Valley Planning Commission(MVPC)using data pr(
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'e �� Environmental Affairs/MassGIS. The information de
for planning purposes only. It may not be adequate
;f- definition or regulatory interpretation. THE TOWN C
MAKES NO WARRANTIES,EXPRESSED OR IMPI
THE ACCURACY,COMPLETENESS,RELIABILITI
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ASSUME ANY LIABILITY ASSOCIATED WITH THE
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Rail Line Wetlands Zoning
Interstates Sl Exempt Lands Busine s 1 District
UE Busine s 2 District Horizontal Datum:MA Stalepiane Coordinate System,Datum NAD83,
—I M Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack
M Busine s 4 District 14ORT14 Valley Planning Commission(MVPC)using data provided by the Town of
-- Roads M Gene. Business District 0 t`Kp , q� North Andover.Additional data provided by the Executive Office of
Ir�A Planne Commercial Dev ♦4 •�e a Environmental Affaim/MassGIS.The information depicted on this map Is
M1"r Easements .t b q
Corrido Development Dist L for planning purposes only.It may not be adequate for legal boundary
MVPC Boundary Y+ Comdo Development Dist 4 to definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER
&T Comido Development Dist �" .,
Municipal Boundary HAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
Zoning Overlay Indus(d I 1 District ,k * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
Industn 12 District OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
Adult Entertainment IndusM 13 District rF°o # ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
0 Downtown Overlay District M Industn I S District 1 '""*•' ti
0 Historic District 'o THIS INFORMATION
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+` Hydrographic Featuresde ce4 Disde ce 5 Dlstrri
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