HomeMy WebLinkAboutBuilding Permit #48 - 371 Blue Ridge Road 7/20/2011■
Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
IMPORTANT:
Date Received
must complete all items on this
Lvl,l-� l iviv c� r �
rmt /
PROPERTY OWNER Unit #
, ,,_�_ Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o
Machine Shop Village yes o
100 year-old structure yes no
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
❑ Repair, replacement
❑ Demolition
❑ Septic ❑ Well
0 Water/Sewer
OWNER: Name:
PROPOSED USE
Residential
Non- Residential
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Commercial
❑ Assessory Bldg
❑ Other
❑ Others:
❑ Floodplain ❑ Wetlands
❑ Watershed District
ON OF WORK "1 U BE FhKti UK1v1r v:
(Identification Please Type or Print Clearly)
—Wo M
Address:
CONTRACTOR Name Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home 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.
Total Project Cost: $ FEE: $ ::� ®--_
Check No.: �
Receipt No.: 9L15gC
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
;Signature of Agent/Owner Signature_qoc+otractorF'
Location z9` `L `
No. Date
MORTM
TOWN OF NORTH ANDOVER
2
Certificate of Occupancy
$
sAC
Building/Frame Permit Fee
$
14
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tannin Swimming E)g/MassageBody Art ❑ g Pools
Well ❑
Private (septic tank, etc. ❑
Tobacco Sales
❑ I Food Packaging/Sales ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed
COMMENTS , j
DATE REJECTED DATE APPROVED
❑ ❑
HEALTH Reviewed on
Si nature
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision:
Comments
Water & Sewer Connection/se
Q iveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dempster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
yes
no
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
NU i t5 and DATA — (For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition or Decks
❑ Building Permit Application
o Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
a Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
µORTH
TOWN OF NORTH ANDOVER
OFtt�eo �6�4,
d_!e �. _a 0L
.
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please.print
DATE:
JOB LOCATION: fie'
Number Street Address
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Telep one (978) 688.. 45�
Fax (978) 688-9542
Map/Lot
IJOMEOWNER m �Chd c l - �D'ZS�"—/(v 3 `l C� � � `�� Q
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town
ml
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Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units -or less and
to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who Qwns 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 structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the 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 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 6994)Sli .
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
U www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information +� I Please Print Legibly
Name (Business/Organization/Individual):
Address: 31 � 0 I Jew gt e -d
City/State/Zip: P( -40L) tr 1Y) Phone #: 6 3 /
Are you an employer? Check the appropriate box:
.1 -El I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. N4 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance 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).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 pAs andpenalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town of
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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Date.. '� 13 A, ........ .
TOWN OF NORTH ANDOVER
PERMIT FOR GRAS INSTALLATION
This certifies that...7x-!.-./.�..<........................
has permission for gas installation .. U. r. rr .. jz c ../7/(:.. .
in the buildings of ...///-I.1. (...............................
at... /.7.... B I.,, ..P. r. d. .......... , North Andover, Mass.
Fee. ..... Lic. No. I... ...... i..,::N..
GAS ' INSPECTOR
Check # C/ c / 4h
MASSACC�TTS U� APPLICATION FOR PERMIT TO DO GASFITTING
Mass. Date CaL/ 20 // Permit #
Building Location Owner's Name 1417
3 i `% - F 6 Type of Occupancy ,
New V' / Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No LLQ
G
Installing Company Name
Address 31 s k- S Check one:
I e� W44 (Corporation
Business Telephone /— 75- ' $ -Z f 4 ❑ Partnership
Name of Licensed Plumber or Gasfitter 117&W— /9gjjj �rr—cco ❑ Firm/Co.
Certificate
32 GG . ,
INSURANCE COVERAGE:
I have a current liability ' urance policy or its substantial equivalent which meets the requirements of MGL
Ch. 142 Yes 1P No ❑
If you have checked yes, please i 'cate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by Chapter 142 of the MGL, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true
and accurate to the best of my knowledge and that all plumbing work and installations performed under the
permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State
Gas Code and Chapter 142 of the General Laws.
Byype of License:
Title (lumber ❑ Master Signature of Licensed Plumber/Gasfitter
City/Town ❑ Gasfitter ❑ Journeyman License Number
APPROVED (OFFICE USE ONLY)
PLEASE COMPLETE REVERSE SIDE --0'
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SUB -BASEMENT
BASEMENT
FIRST (1 ST) FLOOR
SECOND (2ND) FLOOR
THIRD (3RD) FLOOR
FOURTH (4TH) FLOOR
FIFTH (5TH) FLOOR
SIXTH (6TH) FLOOR
SEVENTH (7TH) FLOOR
EIGHTH (8TH) FLOOR
Installing Company Name
Address 31 s k- S Check one:
I e� W44 (Corporation
Business Telephone /— 75- ' $ -Z f 4 ❑ Partnership
Name of Licensed Plumber or Gasfitter 117&W— /9gjjj �rr—cco ❑ Firm/Co.
Certificate
32 GG . ,
INSURANCE COVERAGE:
I have a current liability ' urance policy or its substantial equivalent which meets the requirements of MGL
Ch. 142 Yes 1P No ❑
If you have checked yes, please i 'cate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by Chapter 142 of the MGL, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true
and accurate to the best of my knowledge and that all plumbing work and installations performed under the
permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State
Gas Code and Chapter 142 of the General Laws.
Byype of License:
Title (lumber ❑ Master Signature of Licensed Plumber/Gasfitter
City/Town ❑ Gasfitter ❑ Journeyman License Number
APPROVED (OFFICE USE ONLY)
PLEASE COMPLETE REVERSE SIDE --0'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
UV. www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ,, a / Please Print Legibly
Name (Business/Organization/Individual): / � !/� A � /V I P GD
Address:
City/State/Zipa k4n, M-6: Phone #: /L- � � � -s'6 - Z71'07
Are you an employer? Check the appropriate box:
1.�am a employer with P .
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. +
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6..F ew construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. j
Insurance Company Name: C / 4/n,
Policy # or Self -ins. Lic. #: d �S IAl
'" U Q 15_ 3 3 90 Expiration Date: dA L /(
Job Site Address: 3 / 7 a4A—_ ,e_ jet) 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided above is >true and correct
Sip–nature: 4;7� lej Date: A�
Officlul 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