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HomeMy WebLinkAboutBuilding Permit #677 - Exception 4/23/2007ARCHITECT/ENGINEER z �z Phone:___4 "o, 1- —2 FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: -0145-71 TEE: $ � Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,of.gertt/t inner gnafure of Plans Submitted ❑ Plans Waived ❑ 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 tank, etc. ❑ Permanent Dumpster on Site ❑ Ir .f THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS 0 CONSERVATION ❑ COMMENTS, ,., HEALTH COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED I DATE REJECTED DATE APPROVED ❑ ❑ 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 Located at 384 Osgood'Street 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 0 Notified for pickup - Date i Doc.Building Permit Revised 2007 _ — f 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) ❑ 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 1 Location boldo No. Date d MORTM TOWN OF NORTH ANDOVER � 9 Certificate of Occupancy $ �'� s'•••°' E Building/Frame Permit Fee $ "us Foundation Permit Fee $ Other Permit Fee TOTAL Check # �C 2G1�6 $ 4. Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (t3usincss/Organiration/individual): Address:_�� City/State/Zip: G. -O L7 % �, ALe--Phone Are you an employer? Check the appropriate box: 1. am a employer with �D 4.. ❑ i am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. ❑ New construction 7.einodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 I .❑ Plumbing repairs or additions 12.❑ Roof repairs 13. F1 Other *Any applicant that checks box # I 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. 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. Insurance Company Name: Policy # or Self -ins. Lic. #: LJ ?� �j Expiration Dater© 0 Job Site Address: d9 D D 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 tine 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 tinder the pains ani! penahies o erjury that the information provided above is true and correct. Phone It: (-?- -1,;2 �L c � 5` 7 2-2 2, 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 #: Mar 06 07 12:48p (ACM.. CERTIFICATE C N.v.mmns stvsv�uscE .. 1060 STAT MOMMWVMr41L 01645 woumm DOW11R'P F.X= .lWCS'Z CD., mc- PAIDOVM, M 01810 INSURANCE 6038900192 p.1 r""_ ons�ww�oon`rrrt cweuoE mac* ....,.�.. im sirs m anou�rm of�++ewao+r� o�scae� vouaeeee cox«,••• •�••..i .._.— .. ------- am �. THE usume tNsutM VAU VObiw— M rua i0 OATS vyFMFA NDT/CE TO TIE comwWAve MD1Dm noon m "6 uEFr. OUT FAIL m TO Do 90 Gimt - —.— — .w — ROM TIE OIIRWL t RS /lmms 0k BOARD OF BUILDING REGULATIONS _icense: CONSTRUCTION SUPERVISOR Number: CS 048040 Birthdate: 10/291/955 Expires: 1012912007 Tr. no: 8053.0 Restricted:. 00 GIEERT _ - Z DOW 175 BRADY175 RAVE SALEM, NH 03079 Commissioner IM4 ;00 O b �I N P, 0 H � v uj z CL c� CD N _\ ••d C I y y t 1 a� m • y� i Ea .m C _ ts 0 d G 40 1 C V •CD `S Of t H E OGy y :>3 r FA 37 Nl _m s to y G �O m 73 4D 0 cv .: o _ = O C1 cc .oma �t y Z `o as 0 co ca 0 CLc H 1!0C C io o_,,, 3 N H y • v ~ m COD _ C. •vyi atWG Z c� •Q ;E c x w o�z3 o IL m a L CD O di • L Z o. 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