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Home My WebLink AboutMiscellaneous - 130 APPLETON STREET 8/3/2015 OORTH BUILDING PERMIT 0 + TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received A .V AC Date Issued: 5 1 IMPORTANT: Applicant must complete all items on this page LOCATION 15eq m 'Sty— A-A,`4b 11-1Print ........... PROPERTY OWNER Print 100 Year Structure yes(no MAP PARCEL(�C ZONING DISTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 010ne family 11 Addition 0 Two or more family 11 Industrial L1 Alteration No. of units: [I Commercial P Repair, replacement D Assessory Bldg Li Others: 11 Demolition D Other qr; DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name. Phone: Address: 13e> 4 Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED C BASED ON$125.00 PER S.F. a- Total Project Cost: $ 3 P-6 FEE: $ Check No.: "53) Receipt No.: 2-- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund .............. 6f- "- --- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/Massage/Body Art ❑ Swimming Pools 0 Well ❑ Tobacco Sales ❑ Food Packaging/Sales 0 Private(septic tank,etc. ❑ Pennanent Dmupster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature 4- COMMENTS... '.I') 10N, 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 FIREiEPAR' ,'T'M'E' NT -,Tbmp,,Dump teron,site-yes Located at 124 M'bin`,',S' tree't'— Fire,Department sighatureldate V, COMMENTS FORTH Town ofa _ � E '' Andover VA L �O LAME h h ver, Mass, CO[NICNl A0,?A r S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System , THIS CERTIFIES THAT' t 1 • `� BUILDING INSPECTOR ........ ..... .... ...... ............................ .. . .. .. .. .. .... .. Foundation has permission to erect ........................... buildings on ..... ...... ........,, Rough to be occupied as /� ��,,� � ..... ... .. .... .. . ..�4��,Ki/.!.... ...................................................................... Chimney provided that the person acc piing this permit shall in eve espect 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION-UA Rough Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildinz 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. Qf�aar� � TOWN O�`//''�`y�7��O;;��(.'77��.',��'}AND ta i R (16;iv lit .1600 DsgoOC I7t G�L�T1t�dT?lg �� `t7f.�i:—9-36 r 7 hOR3 ➢Fp�t.t - , •Nbith Ando vox -Massadhasetta o1845 Gerald A.Brown '�e1epItorte(978)699-9145 lnspeeioro $uttdzngs -Fax (97-8)6$8-•954.2 pleasepr3nt ()B LtdCATfDN: .� �► ' " �� /� Lazne. HomoPhoneWozltMone . TRUSENT MAT1iItTGADDRrES, .. TAe euzxent exeznptzon fox"iorQeo rets"'teas extan4d io i.OZLICIa owner-o 0,61pled divel'Rgs iD Ivo unify�r��ss and 'LQ llOw 5 7c D�]eO uexs LO e3gage x717 Cj VdEL"al.f'orb"r,-WftO C70eS Rut:ODBOSS a.71GG3180,PSo-Vi*dedffia ffit'owner acts as sLlpezv?.sor). gmWeBuildxng (Code ection lD&,3.5, 1 - bEFINITI N OYHO OVW , Pnrson(s)who towns a parcel onwid.on blr7iio L ltelslle xesxcle8 or intends to reszdo,on wMch thoro xs,ox zs .fended to ��a one or Gwa areily sfzuctuzes. Apor'3011who r'ORstctLefsworeffiai.oROhomein-a tffo yearpoziod shall ztotbe coalszdered a lIomeDwnez; The undersigned"Romeowaer"assumesrespDnszbilityxoz os�znpliances-with the statORU11CRug Codeand oger APplzcable codes,by-18W9,tales andxegulatdons. Tho rzudexsrgned"homeowAex"cert esthat I.eblhetutdexstaudsIdleTown ofNorth Audoverl3ujtcliug.De�Mtznent uuuxa inspsotiozl procedures and x-OPIrOments and tTiat helslze will comply wlz;sazd pzacedures and z'ec�ulrezlients, APPROVAL Cali 33U.ILI3MG 011FZCIAI; ' �eyise[i 7.20Q9 'oxzn�omeowners�sxem�[ion � ^ ^ xr O.ARD OF'.A.PP•EAKS 688-9,541 CONTSFaWRON 699-9530 b,•a,, The Commonwealth of Massa chusetts F Department of IndlustrialAceldents X Congress Sheet,Suite 100 Boston, 111A 02114-2017 www mass.gov/dna Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FMED WITH THE PERMITTING AUTHORITY. Applicant Information �1 Please Print Legibly Name (Business/Organization/Individual): - 6YiL • C ~j Address: 136,) ,9 b n le City/State/Zip:&0 41-) cu-c t. eyKTPhone#: 4 Std _. 1;�/ -2 Are you an employer?Check&e appii•opriate box: Type of project(required): 1.❑l am aemployerwith : 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.] . am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 3. 10 ❑Building addition 4.❑I am a homeowner and will bo 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.❑Plumbing repairs or additions 5. 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. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other �e pro ,,Z_ 152,§1(4),and we have nq 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 submif#his 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-conlracfors have employees,%ey must provide their workeis'comp.policy number. I am an employer that ispi'oviding workers'compensation insurance for my employees.'Below is thepolley and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: fob 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 o. 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. I do lzerehv certify under the pains andpenalties ofpei;jury that the information provided above is true and correct. Sign e: Date: - f Phone#: Official use only. Do not write in this area,to he 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#: