HomeMy WebLinkAboutBuilding Permit #708-14 - 8 Bixby Avenue 4/14/2014O`NOaoT
BUILDING PERMIT 3?
TOWN OF NORTH ANDOVER °
(�� APPLICATION FOR PLAN EXAMINATION -
Permit NO: Date Received 'LA0 '" ;—
Date Issued:
RTANT: Applicant must
LOCAT
all items on this
J Q_s`'1A_k
t Print
PROPERTY OWNER DlAkK
Print
MAP NO: PARCEL: ZONING DISTRICT:�H' one is `. yes no
.01
Machine Shoo Vi
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑One family
❑ Addition
TWO or more family
❑ Industrial
❑ Alteration
No. of units: 3
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
uf\li *ao Mloor 6aft1fI701M (QikNQT1J_eD(' 1't ��PI�� ?►LP SUf(�U -pGWi1t
Identification Please Type or Print Clearly)
OWNER: Name: 1'�lflrc ���'�� Phone:
Address: Zb (_N�q,�wm Rt) AV.11°DUeg yo�
CONTRACTOR Name: kK E CW_gR(Actlov Phone: 9)i3
Address:
33 N4L k p_2 pD "I H &/o,0vhE hm
Supervisor's Construction License: CS- 093bExp. Date:
r�� _ �i�ITbis
Home Improvement License: Exp. Date:
�17�3� Ioll6fZvly
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED T BASED ON $125.00 PER S.F.
Total Project Cost: $ 4,0401 (70 FEE: $
Check No.: 0!�'_:2 Receipt No.:
NOTE: Persons 4'--L"fig wrth unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner l/� �'v�%i(. Sinature of contractor
_�_
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this p
LOCATION.
Print. .
PROPERTY OWNER-
- Print 100 Year Old Structure yes no
MAP NO: _ __ .__. _ :PARCEL: ZONING DISTRICT: 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
El Septic ❑ Well
❑ Floodplain ❑ Wetlands
0 Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO HE PERFOKIVIEu:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
A rJ r4 roc e
r auvvv.
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.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature=of Agent/Owner _ S�r��af�re of cof contractor..
Plans Submitted LJ Plans Waived 11 Certified Plot Plan 11 Stamped Plans
a
Location V61
No.
r — 1 `/ Date l ( c
�_
t
®- TOWN OF NORTH ANDOVER
4b �,
Certificate,6f Occupancy $ r
Building/ Frame Permit Fee $
r]Foundation Permit Fee $
°� .t^- Other Permit Fee $
to r. TOTAL $
Check # I U
27445
Building Inspector
Plans Submitted ❑` ..: `Plans Waived ❑.:
.,-,.Certified- Plot Plan ❑
Stamped Plans ❑
'TYPE Ol SEWERAGEDISPOSAL
-
Public Sewer ❑
Tanning/Massage/BodyArt ❑ ..
,Swimming Pools ❑
Well ❑
Tobacco.Sales 0
Food Packaging/Sales ❑
Private:se tic tank etc._
p � `-
_,. ❑
=Permanent D'iiinpster on-site
THE: FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF U FORM
t
DATE REJECTED -
PLANNING & DEVELOPMENT ❑
COMMENTS
-CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision:
fi
Comm
Conservation Decision: :Comments
Water & Sewer Connection%Signature &Date Driveway Permit
DPW Toiv;! Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTINI: NT =. Temp Dumpster on site yes.. no
Located at 1 4;Mair, Street: -
"Fire-D6paitme?rtsignature/date~
:.
COMMENTS �' ,
--Dimension -
Number of Stories:
,-.Total- land -area,- sq. ft.:
Total square feet of floor area, based on Exterior dimensions.__
ELECTRICAL: -Movernent.of Meter locationmiast 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
Doe.Building Permit Revised 2010
r.—
Building Department
-The following is'a-list of retiuired.forms to be. -filled ouffor.:the.appropriate. permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building PermitApplication
La Workers Comp Affidavit
o Photo Copy Of H.1.C. And/Or G.S.L Licenses
o Copy of Contract
u Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off. from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
a 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
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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 apt),: -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Building Permit Revised 2012
AX
The Commonwealth of Massachusetts , -
Departinent of l'ndustrialAccie%�ts
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dza
,Workers' Compensation Insurance Affidavit: Buildens/Cont°actors/Electricians/Plumberrs
Applicant Information Please Print Legibly
Name (Businesstorganization&dividual): PAM UA/ (1(h W
Address: 3 3 1NLilc�t2
City/State,/Zip: Phone #•
Are ydu an employer? Check the appropriate box:
Type of project (required):
1. I am a employer with 3_
4. ❑ x am a general contractor and I
6. ❑ New construction
employees (full and/or part time) *
have hired the sub -contractors
7• [Remodeling
2. C] I am a sole proprietor or partner-
listed on the attached sheet.
ship and•have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers'. comp. insurance.
g. [] Building addition
[No workers' comp. insurance
5. ElWe are a corporation and its
10.❑ Electrical repairs or additions
required.]
3. El I am a homeowner doing all work
officers have exercised.their
right of exemption per MGL
I
11. [] Plumbing repairs or additions
myself. [ffoworkers' comp.
c.152, §1(4), and wehavono
12.❑ Roofrepairs
insurancerequired.] i
employees. [No workers'
13.[] Other
comp. insurance required.]
'Any applicantthat checks box#1 must also fill outthe section below showingtheir workers' compensationpolicy information.
t'Homeowners who submit this affidavit indicating they ge' doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that che&this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
-Taman employer that isproviding workers' compensation insurance for my employees Below is the policy and job site
information. K
Insurance Company
IM
Policy #or Self411s.Lic.#: V WC too — G004S560Z Expixat[onDate: /0 ((,0( �l'y
Job Site Address: 9 City/State/Zip:k.. IhAe-r Cx8
Attach a copy of the workers' co pensationTolicy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a
fine up to $1,50 0.0 0 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 cert& under the
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 official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 41000.00
m
$ -
$
48.00
Plumbing Fee
$
6.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
6.00
Total fees collected
$
160.00
8 Bixby Avenue
708-14 on 4/14/2014
Minor Bathroom Remodel - Unit 8
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