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Home My WebLink AboutBuilding Permit # 11/20/2015 %AORTH BUILDING PERMIT "(,FD ;6�`I'o TOWN OF NORTH ANDOVER46- ®� APPLICATION FOR PLAN EXAMINATION - . ..'._ gg Permit No#: - B Date Received �I " I AcmUs`�� Date Issued: IMPORTANT: Applicant must complete all items on this page % r/./ I / // r r,.//✓i r. ! %„ All r.. I r , / /, /„ ,% i,,(,�� lv/ r 11// r /r ,�/,/ „r %Jl /�//1 rr �,/ �//r/' /✓r//�r �'�,.:a/JJ,,.,.,/,,,.rr� r'i� ' " /, ,,,,r// ✓// /% ./// //i r Hill, r ,r r r r/ i/ � r r, arc r ✓ / r/ /,/ r/ rr,. f / OPERT r i� ll 11: J ✓/. r( 1 ,//, i. / 0%Yeah #ru r / ,/ J IM l ,,.A ll�. ,/, :.r,., rort,r/• a: /o I / r r/ / r r !:/ // / // /'r , ra/r //r / /// ,,,c r /. r, ri< rr/ r .< / "o i ,,,- ,� r /././� ,rr,i✓/ ., ,.it ,✓/,.r,_. c„ ,,�, ,,,,,,, �J�/i/rrr//j///%/rims✓//�/��/1/�//r/i/i, /r /✓ r/%��/ //�r / r✓/r r, ,,,,,!/:;iG., ,,. r, ,,,rr,,,...piri�, ,;.g,o„L/,r,�,, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building done family [I Addition 11 Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other / /rr /❑Se %� ;Watershed DIStr�ct fr ; � ,; ,,Flood lain:/ ,❑Wetlands Well r r / r, r,tIC , ❑ r �r ,, r�,� / r�,ro, ,//,o/ ,/ / rr /�// .i r/ r /::.rjr Jr//O+j„/, rr, /✓„ri;r/, :r r,i�//� r..�J i% ,�/, ,r/;,,n„; ,r ,,,,,// / ///(( s//c r r %ri%�l/„!/�/ /, ,,,:.,r/, ,,, ,,, ;:.. / r r/,ii/,,,,;,✓-//i✓/n%///rr � / ,r.////r//�✓%p%r //// r/:.: // / „a;,r // ,,;�j/ '// r / / ,/r%, ❑,Water/Sewer; DESCRIPTION OF WORK TO BE PERFORMED: . .I ,Identification- Please'Type or Print Clearly OWNER: Name: K C i art ! Phone: ' Lf `t"2 Address: c lc�. /r/r /fir./!i r% / /iir✓i r//!1/rr% / r / / r °Contractor,Name' Phone rr r r r r r r r /a� r,r r/ / r/r 1, / „/ // vi / r i ,/ u / ✓ lr ,, //� /i / ,rrr � � /// pry ✓ /a StrUG¢Ion.LIC i1S �e/c,��,, ,� „G////r,„<�� r.,,,,a� .,,; /r Jrr,EXp ��r�//. r r / / r /, r r r r✓.r / r/ i i r r r , //r r /r / r/ .. r//. I/...I// r, � / l, ✓ r. r //,./ /. � � �� r.o , /r ./r ,� ./r / //i �✓ r %�s/lri///r ///l/✓Ir /�r�///, /". <EXp /Date ,�`, .,/G>%/��r��,//.////,l rs�///l//r//r,. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDIN T. $12.00 PER$9000.00 0= FkITOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: C) FEE: $ �' Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature of Agent/0-wner Signature of contractor Flans Submitted ❑ Plans Waived_❑ Certified Plot flan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinuning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORINT PLANNING & DEVELOPMENT Reviewed On _ ( IJ ,4/� Signature_ COMMENTS CONSERVATION Reviewed on l/ 11(o 47" Si nature vo 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: Ali Located 384 Osgood Street FI0E,0E0ART,MENT -'-T Dumpster on site yes no Located a1 124`Main Street i Fire Dep 't' signature/date CORAKAFNTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) Ld LJ Notified for pickup Call Email Date Time Contact Name .................. .......... .................... Doe.Building Permit Revised 2014 IOTA ttORTH 1, 0", w1it 01 y' 00 O T httje.6 o �„K� ver, SS' IVA 6 COCKIC.t WtCK S U BOARD OF HEALTH Food/Kitchen Septic System P � R =M= D AINW% Aft 'So THIS CERTIFIES THAT ................... . .. . .. ...... .... .. ................................ BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .. . .... . .. .... ..��1M�............. ................... ® Rough tobe occupied as ...........................................,......... . ........................................................................; Chimney provided that the person accepting this permit shall in eery 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 ITEXPIRESMO"'T U S ELECTRICAL INSPECTOR UNLESS CONSTRUCS TS Rough Service ........... t............. ............... " ""' Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to OccupV Building 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. °� NaRTH TOWN OF NORTH ANDOVER OFFICE OF - ~: A BUILDING DEPARTMENT ° 1600 Osgood Street,Building 20, Suite 2035 North Andover Massachusetts 01845 �SSACHLU)5E� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: ®V- 16 2 U f S JOB LOCATION: �j U L k L rk Ay-,&oyea-, (D I d 14 Number Street Address Map/Lot HOMEOWNER A K-c AN K H L N , `t 5 , 6 2 Name Home Phone Work Phone PRESENT MAILING ADDRESS Scw 6k aLoye — City Town State Zip Code The current exemption for"homeowners"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 HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or 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 farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department oflndustria/Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 .�:`�t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0bly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Areyou an employer?Clreckthe appiopriate box: Type of project(required): L❑I am.a employer with employees(full and/or part-time).* 7. [�New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. 9. F1 Demolition am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be 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.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other oyees.[No workers'comp.insurance required.] 152,§1(4),and We have nQ�41 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnatiorL t Homeowners who submit t}nis affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box mustaffached 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. lam an employer that is pi oviding ivorli ers'compensation insurancefor nzy employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: fob 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. I do Hereby certify under•the pains andpenalties ofpeijury that the information provided above is true and correct. Sign rc. 4-'kaY Date: No 16 Zb 1 S Phone#: 61 -,�t R ' q,1 S- 65 Z 3 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 Contact Person: Phone#: