HomeMy WebLinkAboutBuilding Permit # 8/13/2015 i
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IJIL I PERMIT ®��"rD ,dpMa
TOWN OF NORTH
APPLICATION FOR PLAN EXAMINATION
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Permit No#: Date Received
�RaTeo
�SSgCHUS��
Date Issued: ,
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER_ � '' � ) '�� " ' " "> W� ✓ c �� c ,,
Print 100 Year Structure yes no
MAP 'Vr PARCEL: SZ ZONING DISTRICT: R " 'L/ Historic District yes no
Machine Shop Village yes no,,
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other Poke %,)
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// Flood lai // � rWetlands /,, ,/,, r�❑ W e s e � t c� //, „,, ,
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DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone: (I,Y<,
Address: P 1,ki
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:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ -c :�r. FEE: $ 6 c) ,-,
17
Check No.: z3 3 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
m -
d
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISP.OSA
Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dulupster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
i
C SERVATION Reviewed on 6 Signature
VCOMMENTS
HEALTH c 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
FIRE DEPARTMENT -.,Temp;Dumpster on site., yes no
Located at 124 Main Street
Fire Department-signature/date .
COMMENTS
i
%AORTH
A*"kver
' town of
lictu
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y .
® LAK h ver, Mass,
COCHIce<ewecx T �3 241T
S
BOARD OF HEALTH
P �E IT T D Food/Kitchen
Septic System
THIS CERTIFIES THAT . . IRS!!. 'e 3 s �........,,.,�,R,�l(. �. .. ........... BUILDING INSPECTOR
......... .. ...... ........ ... ......... ..
has permission to erect .... ... . ........... Foundation
.......................... buildin s on .. �.....
.................................................................. Rough
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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
. UNLESS CONSTRUCTION ST RTS Rough
.. . . Service
.. / ......................I........ .. •• Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy BuildanRough
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 Approvedy the Building Inspector. Burner
Street No.
Smoke Det.
Tow OF j�opuff AND OVER
�ry R• im F-�r+✓�JJ'.s-.l S.Ja �J.Y.A.&..V�.'.1
• z = -r n6 +,dy.;C ' ,e• CI�L� 8 'DDC tStroatBuffdhlg20j-Sv-ajto206 r
"�'�#�x'SYxA F p�'{5 ,•'XOitL1^".I dD'vbx,,J.YJ.asmhusotta 01845
e
Gerald A.Brown _ Telaplr ozze(978)68 8-954S
nspP-utorofBi ldings Wax (97-8)689-9542
pleaseprin-E _
DATE:
�()B LOCATION:
. �um'bez' t;lzeet.Address �Sap/�ot
Name. Rome Phone work J?kane .
zip Cx?.ila
Tke euzrent exemption fax"komeol ?exs"was oxtenaW to:include owner❑cc1%p'zed d�vellin s to tvo units•ar;gas and
fo�allowsub homco:;mem to engage au?udzvhhal•t'orhire-WitodoesnotpossessalicGaise,pxovldedMat theowner
acts as supazv?.soz), 9 atoDullding (Coda Seaton.ZD8,3<5.j) -
DMMITION OFROMEOVMER.
Pexson(p)who rjas apaxcel oflud. oz'zuufeuds to reside,ou wkiclz tkere is,ox zs xnfended io
b�,a nueorttxaFamilysttuetures. A.porsmwho constmcfsmore tliat.onohome xaatwoyearperXodshall uotbe
conszderedako�eownex
The tmderszgned"b o�ste�s wnex"'assuzaes Yes.ponszbil:(y foz'GompHauces w! tho State:3nzlding Code anti other
.A.p ,pJica'ble codes,by Zawo,niles anti-xegajatlons.
Thou tdersigned"homeowuex"cexi es at 4hailnde19tau the Town of NolffiAndolverDallft Do&ffmGnt
minimum 7nspeoi3on procedures andre ' e eats and at eyLL c4lrip y�tt7l;saidzacedures and
zec�nireznents,
' s
A-PP.ROVAL Ov BMDWG Ol3liICIAz,
ieyised fi 244 .
�oxzn.'�ozneovrners�Sxercap[ion ^
BARD OFAPPBAKS 688-9541 -.-
The Commonwealth of Massachusetts
(2 Department of lndustrial Accidents
v4Y . 1 Congress Sheet,Suite 100
.Boston,MA 02114-2017
qct www.mass.gov/dia
ctors/Electricians/Plumbers.
Workers' Compensation Insurance Affidavit:Builders/Contra
TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl
y.
A licant Information
Name(Business/Organization/Individual):
,//Address: - .
ty/State/Zip:
Phone#: �S/
Are you an employer?Checic the appropriate box:
rO
f project(required):
em to ees full and/or part-time).* New construction
1.❑I am a employer with P y
2,F1 I am a sole proprietor or partnership and have no employees working for me in Remodeling
any capacity.[No workers'comp,insurance required] 9, ❑Demolition
3,Q I am a homeowner doing all work myself:[No workers'comp.insurance required.]t 10 ❑Building addition
4.®I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs Or additions
ensure that all contractors either have workers'compensation insurance or are sole 12.n 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.[]Roofrepairs
These sub-contractors have employees and have workers'comp.insurance$ 14.Q Other 2 t
tion per
6.Q We are a corporationwe haven employees.rs have exercised their[No worker'comrght insurance required]MGL a
152,§1(4)> p
*Any applicant that checks box#1 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 anew affidavit indicating such.
tContreo Homeowners
that check this box must attached ti additional sheet showing the name of the sub-contractors and state whether or not those entities have
comp.policy number.
employees. If the sub-contractors have employees,they must provide their workers'
loyees. Below is the policy and job site
X am an employer that is providing workers'compensation insurance for my emp
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
Failure to secure coverage as requir under
MGL c. 152,penalties inthe form of a STOP is a criminal violation
ORDER and a fine of up to$250.00 a
1
and/or one-year imprisonment 1 p
the 'olator.A his statement may be forwarded to the Office of Investigations of the DIA for insurance
day against
coverage vexi c tion
I do hereby e tify der pains and enalties of perjury that the information provided above is true and cat•rect.
Date'
Si ature
Phone#:
L[, S
only. Do not write in this area,to be completed by city or town official.
n• Permit/Licensehority(circle one):Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
Phone#•
rson:
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North Andover MIMAP August 5, 2015
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0 MVPC Bo
Interstates Horizontal Datum:MA Slaleplane Coordinate System,Datum NAD83,
Meters Data Sources:The data for this map was produced by Merrimack
—SR NQR711 Valley Planning Commission(MVPC)using data provided by the Town of
-Roads Of t*4�o r qb North Andover.Additional data provided by the Executive Office of
Bap Easements = a0 p Environmental AffairslMassGIS.The Information depicted on this map Is
Parcels 3 G for planning purposes only.It may not be adequate for legal boundary4010
— ' definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
$ ! y THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
rF t ^ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
x ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
O^AT,O'ppm THIS INFORMATION
CHUS�t
1"=51ft °