HomeMy WebLinkAboutBuilding Permit # 11/19/2015 ® g.�OR'B'Ib
BUILDING PERMIT O�'J"FD
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#t: Date Received nreo
�SSACHt!`�E�
Date Issued:
O�IRWTANT: Applicant must complete all items on this page
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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
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T B PERFORMED:
fDESCRIPTION OF WORK �� IT � ��� r
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Identification-, lease Type or Print Clearly
OWNER: Name: Phone: AQ
Address:
Address: r1\ "t
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ARCHITECT/ENGINEER I "hone: r I ��)
Address: cb � Q '� Ah 2'al '- Reg. No. (0
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No
NOTE: Persons contracting it registered contractors do not have access to the guaaanq fund
Signature of Agent/Owner Signature of contractor
Plans Submitted.❑ Plans Waived-0 Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tanlc,etc. Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
P NNING & DEVELOPMENT Reviewed On (��i�' Signature_ Nkww
COMMENTS
YNSERVATION Reviewed on 3 Si nature
COMMENTS VIZ CEJ vA Ob,
H LTH Reviewed on IL 60(5 Siqnature��411 )V
COMMENTS I
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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
,FIREr�{ '`�,.� ,�.�:' ',.�� r"_r,r ," � t ? u r' ��,r;�kPr�,w,,,%,�� ���r,�,r„�a J"�.�l�y✓r���r�z tr�"''`7`G,r'r"rl,�i�yfrrs rut �
DEPAR�TMENTf��Temp�Dempster on site yes, ". h�� ,,� �r� ,� f ,no � ��{° ��J } >� ,�rt
r�..'�r^$:��"�^u "'�- m ;lr; `u' .�rP{fr I�sr`✓ �rA sf r� r� Ir✓ri�f ,";r..xr�� to r;?/`�,Irr �JY >r rr`r kr r,... � �;
Andover
Town of
C, LAKE h ver' ass,
COC MIC Kf WICK
04 AriE c)
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BOARD OF HEALTH
Food/Kitchen
Pr. RMJT T LD Septic System
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THIS CERTIFIES THAT . .� .. , ............................... BUILDING INSPECTOR
411111111111111111 Foundation
has permission to erect ....... .............. buildings on . .lb�....... ....... A � ...... ..........
Rough
go
to be occupied as �... ...... .. .. ... .... ............am..'... . ............................. chimney
provided that the person accepting this permit shall in every respect conform to the t he application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Insp ion,Alteration and
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Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
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Final
PERMIT EXPIRES I T ELECTRICAL INSPECTOR
AL AL� UNLESS CONSTRUC N TS. Rough
Service
........ .... ..... ...... ........................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place Ont the Premises — Do Not Remove Final
No Lathingor r
Wall '1 oBe One FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
t%ORTII TOWN OF NORTH ANDOVER
OFFICE OF
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BUILDING DEPARTMENT
1600 Osgood Street,Building 20, Suite 2035
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North Andover,Massachusetts 01845
�ssgcHUS
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION: 17 1-ci dl�q 4, �te� /�61-70 AAJJAf e cz #1 � _
Numb Street Address Map/Lot
HOMEOWNER ��bA)
�W &�e 9,
Name Home Phone Work Phone
PRESENT MAILING ADDRESS—
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,ni:ovide
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 I O.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 understands the Town of North Andover Building Department
minimum inspection procedures and require ents and that he/she wil 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
North Andover MIMAP November 12, 2015
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Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83,
—I Meters Dala Sources:The data for this map was produced by Merrimack
—SR NONTN Valley Planning Commission(MVPC)using data provided by the Town of
Roads Ot 7tac r "qti North Andover.Additional data provided by the Executive Office of
IMq Easements 2 Yui a*s GQ Environmental Affairs/MassGIS.The information depicted on this map Is
Parcels 3 L for planning purposes only.It may not be adequate for legal boundary
N definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
41 * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
♦ 't +if OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
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M-7-77-7Project Name: Mixon Residence Addition
Sitverwatch Architects, LLC
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xxx 201 Fam—Road Architecture'Engineering'Design'LandPlann(ng
Project Address: NMh And—,Ma59sch—US lss l-oodo„demaoad WinM m,Ne Hampsh(reosoer
m�e. tmta�ls Sheet Title: Main Floor Plan wl.sv+.++so vmw.vty w.ra.coa
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Issued for Foundation Permit:10\22\15
n`a""` 3oS Project Name: Mixon Residence Addition
�� : TAI TAI Architects, LLC
r"m` Prepared For: Tom Mixon
xxx Architecture'Engineering'Design'Land Planning
xxx 207 Pamum Road
PfU eel Address: Nonh Ande—,Alassach—u, N nsP
Scale. IlJ'=1'-0' � 155 LmdMder Raad Wir�am,IIeH Ha shire 03087
mm: ImlJt15 Sheet Title: Basement\Foundation Plan wl.e°J.aso —savumnus.cou
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Issued for Foundation Permit:10\22\15
sqtnom,.,,: ,DS Project Name: Mixon Residence Addition
A�yxo,,—, ,ns SAverwatch Architects LLC
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xxx Prepared For: Tom Mixon
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xxx 207 F'nrnum Raid hitecture'Engineering'Design'Land Planning
Project Address: noun nodm.r,n,asocnr,5.us 155Lwawwarry RoadMM ,newnampzhtre03087
m1z: 1014\15 Sheet Title: Main Floor Plan aoI.ava uw w.rnssnxwnra.can
Pm M No.: SA-58-15
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seg n""n` ms Project Name: Mixon Residence Addition
Silverwatch Architects, LLC
Prepared For: Tom Mixon
xax Architecture'Engineering'Design'Land Planning
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Project Address: Zor Fam,un Road
1 North Andorer,hl-ac wows 155 L-d-le"Rmd WNR—,fl wHampshire 0308]
nal.: tmlmts Sheet Title: BasementTotmdation Plan ws.av9.9m wnw.vcWmvarcH.coss
'm No: SA-SKIS
The Commonwealth of Massa chusetts
Department oflndustrialAceldents
r
1 Congress Street, ,.Suite 100
r Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ,? Please Print Le ibl
la1ne (Business/Organization/Individual): AA 0 Y
Vddress: t �C b'
;.ity/State/Zip: k,4JJ ��� 5 Phone Y#: s< 7�O. �
Are you an employer?Check the appropriate box: 'Type of project(yequired):
1.❑I am a employer with___employees(full and/or part-time)." 7. []New construction
2. 1 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling
any capacity.[No workers'comp.insurance required.]
° 9. F1 Demolition
. . I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
4 R1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 U4 Building addition
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.Q Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.F1 Other
152,§1(4),and Ave 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.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
4:ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
e,n iloyees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I c m an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
1.,t�brmation.
h surance Company Name:_
Policy;#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
F; {lure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
a d/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
&t.,,against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
c. icrage verift I
I"do hereby ertify ungler'- a gins a penalties ofpeijuiy that the information provided above is t u and correct.
t�
Si nature. l jDate:
Phone#:
i
7fftcial 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):
i.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
0.Other
Contact N.7son: Phone ll: