HomeMy WebLinkAboutBuilding Permit # 8/26/2015 t9UILUINU FLKMI I c `_
TOWN OF NORTH ANDOVER
n r APPLICATION FOR PLAN EXAMINATION i
''-{'�i-< Date Received -
PermitNO: V •cc •°
ACMeSE 4z
Date Issued. •�` s;
IMPORTANT:A licam must com lete all items on tivs aQe
LOCATION �CZCJ�13c¢t�'�WOo Ccr
PnOt
[PROPERTY OWNER M A 1
LOCATION,
� Print
MAPNO:�PARCED ZONING DISTRICT Historic.District yep n0
Machine,Shop Villageye no
TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential
11
(New Building ❑One family
Addition a Two or more family Industrial
❑Alteration
No.of units: ❑Commercial
F,Repair,replacement )Assessory Bldg 311 ❑ Others:
❑Demolition Other
Septic -Well D Roodplain F Wetlands 'Watershed District
WaterlSSewer (}
Sedgy bJ��O'. a �t�X ��411
PN YOr 5d1yoJPc '1b6 1
/�o f4 Vtrs Std bacK rc�oic�os, �a}
Y�aS JPPsa ('o flSS eO� 1I (_ f �r/s ry
e v
Iden ifecation Please , e or Print early)
OWNER: Name: Im 6�a BfP4 Phone:
Address
[Home
TRACTOR Name. /r Phone
ess: t) Y?n7 S�Wt t4hre ":
rvisor's Construct n License: Exp, Date,
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$125.00 PER S.F.
CC
Total Project Cost:$ 5_ o®® FEE:$ XOD
Check No.: 12` Receipt No.: %� 1
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of AgenUOwner—�–_—`–� ature of contractor
Plans Submitted❑ Plans Waived❑ Certified Plot Plan❑ Stamped Plans❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer JJJy�y�y�'''\ TanningX—age/Bcdy Art ❑ Swirmning Pools ❑
Well a Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dmnpster cn Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
PLANNING&DEVELOPMENT Reviewed Ongak5 Signatui
z
COMMENTS Ilio 0// �
C , r
CONSERVATION Reviewed on /"- Signature'
COMMENTS--f\'Q---) k a cL w) f� t no'
rt
HEALTH Reviewed on lU, S Si nature L
i
COMMENTS (Y
Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
�,oncervation Decision: Comments
[Wafter&Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer:Signature:_
Located 384 Osgood Street
FIRTempE�DEPARTMENT Dumpsteron site yes ;nor at s
`FireDeparYmentsrgnatura
e
COMMENTS,
Town of 'Anuover
ver, ass
PERMITU B ARD OF HEALTH
THIS CERTIFIES THAT 77T�� Y�r.W. BUILDING INSPECTOR
provided that the person accepting this permit shall in every respect conform to the terms of the application Fi-I
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 mthe Zoning or Building Regulations Voids this Permit.
Fml
PERMIT EG
= n IN 6 NTHS ELECTRICAL INSPECTOR
UNLESGCON
.............................................
FmI
BUILDING INSPECTOR
GASINSPECTOR
Occitpancy Permit Required to Occupy Buildin2 R..gh
Diop|oyinoConopiouousP|unoonthePmmi000—DoNutRomovo
NoLathing orDry Wall ToBeDone FIRE DEPARTMENT
Until Inspected and Approved bythe Building Inspector.
TOWN OF NORTH ANDOVER
°�° OFFICE,OF
u otl Y,..,
BUILDING DEPARTMENT
1600 Osgood Sheet Building 20,Suite 2035
�''_�,,,,�.:.�z� North Andover,Massachusetts 01845
Gerald A.Brown Telephone(978)688-9545
IuspectorofBoddnrgs Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Pleas Tint
DATE:_
JOB LOCATION: 200 �revs�waa c
Number Sheet Address Map/Lot
HOMEOWNER -Tin odd MecwFe R7g-835-39as-Q,11i
NameHomePhone Work Phone
PRESENT MAILING ADDRESS 00- -B-e l e,"D 0—
/1)04k
iNn:k /,,Ave- 'X'fV+ 0l8115
City Town State Zip Code
The ancient exemption for"home—eys"was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to Engage an individual for hire who does not possess a license,provided '..
that the owner acts as supervisor.
DEFINITION OF HOMEO WNER
Person(s)who owns a parcel of land on which he/she resides cur intends to reside,on which there is,or is intended to
be,a one-or two-family dwelling attached or detached structures accessory to such use and/or finm structures.A
person who cmutructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR
Section 1I O.R5.1.2)
The undersigned"homeowner"assumes responsibility for emnpliance with State Building Code and other applicable
codes,by-laws,mles and regulations.
The undersigned"homeowner'certifies that he/she understands the Town of Nortb Andover Building Department
inspection procedures and requirements and that he/she will comply with said procedures and
minimum
requirement,
HOMEOWNERS SIGNATURE
APPROVAL OF BUII.DING OFFICIAL
REvo d 82015
Fenn nom—Axono nw.
BOARD OF APPEALS 638-9541 CONSERVATION 688-9530 ETALT11688-9540 PLANNING 688-9535
The Commonwealth of Massachusetts
Department offndustr^ialAceldents
W.—I
1 Congress Street,Suite 100
Roston,MA 02114-2017
www.massgov/dia
Compomation lnsnrance Affidavit:Builders/Contractors/S}aotrlcians/Plnmbers,
TO BEFIL);D WITII TM PERMJTTMGAUTTIORITY.
Arnl'' tTnform tion q� Please Print Leeibly
Name(Business/Organizattoa/Individusl): 7"'mod /"(P rSRI-P2y_
Address: „200 :e�J-wgaedl C;,�
M[y/State/Zip: ,4 dryti/��cl'Wa�/l�✓-_Phone dl':__ °77Y-b'3rJ•`3$�3 5'
Arnyon a.cmployarz etiarkttie appioprinea hnx[ Typ fpr'oJee6(;guu'od):
1.01om aempioyaxwith_ _employees(&ll avd/orpsrUfimo).T 7.54Nm—wk. 5kcp
2.�Iam eola pxopvotox orpa,mazshtp endhaven,plcyees workLg lbr mom 8. Rcro.&dg
any capacity.[Noworkers comp.ivsuran mqufied.] g.Q Demoffon
3Q Lam¢homeovmardaing all warkmyeel£[No workers'comp.vumanaexequired]t
10 E]Building addition
4I am a homeowner and wil16e hiring c,ntraclnrs to c,udvel all work mi my property.I wi II
methat ah contranmrsaid,oxhavn workers'„mpenaallon inaarance orama,t, Il.❑Electrical repairs or additions
p.Poaom with.,employees. - 12.0 Plumbiug repairs or additions
Ism ageneffi contractor and I haw hiredthe sib-cwrtmctorslistedon pre attached sheet. 13.0 Roofo paim
Thos=svb-wnhac whave eniployeesandhave w,dcens'c, ?.inmvanrut
6. Weare aco ditso car exemisedtheirnght,f'exem'ion MGL e. 14.Q Other'
❑152,§I(4),andwe have nq em�pl¢yLaveegs.(,No workers'comp.insurance inquired.]
`Any applicant tLat checks liarkl mustalso fill out the sectionbelowsMwtheirkeeloomponsarionp,licyiufoxmetion.
T LIemeownemwfio submittlile affidavitindicatingthey me doingaliw,rk=avdthenWae ovtsido coNmctom mustsubmitanewaf£rdavitindicaf gsncL.
iContractoxs that checktlilq boxmvsk'attaehedanadditionai sheetahowwgthe name of thesubcontmetors avd state whether,root thoseeviitics have .
nmpleyces.If the eu6conlr'aoNm liavee ploycee,ilicy moat pxovidefhelr wod¢is'comp.polioy'mm�bor. '
I am ax employer tFiatupjovjdj gworkcns'compensatdon iusurancefor•ray empin'yees,Below is lhepolicy andjob site
hz�rmolion.
Tnsmance Camp yNarne:
Policy#or Sal£-ins,Lie.#: _ _ EayirafionDate:_
Sob Site Address:_. - _. __City/State/Zip:
Atfaehacopy ofthaworkers'campeneat[onpofcy dedarafon page(showiog thepolieynnmber and expiration dot).
Failm'e to secm'e coverage as requiredunder MGL o.152,§25A is a criminal vielafonpunishable by a fine up to$1,500.00
and/or one-year imprisonment,as well os civil penalties inthe form cf.a STOP WORK ORDER and afine ofup to$250.00 a
day against the violafor.A cepy oftWc statement may be forwarded to the Off—offuv tlgafons of the DTA for insurance
coverage verifi-ii—
Idoherebycertifyuuder•tlze rdus andpenadties ofperjury t/sat the injornrationpxrovde7zdabowedsC true/-)0/madr corveet.
c -'`-- Date: FO
5ienatme: —.. '.
Phone#:
officdal use only.Do notwr&e ba this area to Be c ydefed by t3fy m•town offacdal.
City or Town: Fermit/License# _
7esuingA.th-ty(&ole one):
1.13...dof Wdtn 2.B.ddingDeportment 3.City/Town Clerk 4.Elect ical inspector 5,Plrwbingbrspe H.nr
6.00wl —
Contact Person: _ Phone#:_
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