HomeMy WebLinkAboutBuilding Permit #832-11 - Exception 6/8/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
9,9z , //
Permit NO: C� tz Date Received
Date Issued:
fMPORTANT: Applicant must complete all items on this paize
MAPNO: (0'-1CPARCEL: 3) ZONINGDISTRICT: Historic District
Machine Shop Village
yes
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
VNew Building
0 One family
El Addition
El Two or more family
11 Industrial
El Alteration
No. of units: 1
11 Commercial
0 Repair, replacement
El Assessory Bldg
D Others:
El Demolition,
El Other
D Septic D Well
0 Floodplain D Wetlands
0 Watershed District
<�$Water/Sewefr--)
DESCRIPTION OF WORK TO BE PERFORMED:
L 14-()w L7T lnwNb��)S& rtR.&M& 5-MUC7&R& (rr-Y)&D1TJ13A) 0 �&Y)
Type or PArint Clearly)
OWNER: Name:
Address
AA
CONTRACTOR Name: r -O "I hud LC Phone: '7?9-49 Za�-'
A U A
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: PIA. Exp. Date:
ARCH,TECT/ENG,NEER(Ol Sdr, I... Phone:
.A &nk4l
Address: SM LJ�a2N!�t A. -A kAl tlZr
R 162 Reg. No. 60
-.77
FEE SCHEDULE: BULDING PERMIT. $12.00 POW10'00.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
4
Total Project Cost: $ FEE:$ too
Check No.: �Q-o �'
NOTE: Persons contracting'with qpne
'Signature of Agent/Owne
Receipt No.: ��J "7',? —7-0
do not have access to the oya�
S . ig nature - of . contracib r�
(f . 4�
.217
Location 27
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
vs CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2
/BuildingTdspe�cto-r
Plans Submitted �$- Plans Waived 11 Certified Plot Plan El Stamped Plans El
TYPE OF SEWERAGE DISPOSAL
Public Sewer
TanningfMassage/Body Art
Sw'rnm'ng Pools 11
well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc. El
Pennanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS �J 1A, -Z8
CONSERVATION Reviewed
COMMENTS
-#?-q2-
DATE REJECTED
0
DATEAPPROVED
'El
HEALTH Reviewed on Siqnatullre
COMMENTS (h-0 " MA 40,01.) NIA
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Zte— ill V Comments
Water & Sewer Connection/s
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Ternp Dumpste'r
Located at 124 Main Street
Fire Department signature/date —111L�
COMMENTS
Dimension
Number of Stories:- Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.: 3o Z ok< - —
ELECTRICAL: Movement If Meter location, mast or service drop requires approval of
Electrical Inspect A Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21 A —F and G min.$100-$l 000 fine
NOTES and DATA – (For department use)
Doc:.Building Pennit Revised 2008mi
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
• Certified Surveyed Plot Plan
• Workers Comp Affidavit
c3 Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Crossection/Elevation Plan.Of Propose d Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
i'�OYE: All durripster permits require sign off from Fire Department prior to issuance of Bldg Fermit
New Construction (Single and Two Family)
• Building Permit Application
• Certified Proposed Plot Plan
Li Photo of H.I.C. And C.S.L. Licenses
Ei Workers Comp Affidavit
Ei Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
Li Mass check Energy Compliance Report
u 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
rnust be submitted with the building application
Doe: Doc.Building Pennit Revised 2008mi
$M4
(U
;00
m
(A
W
C/)
0
1 -11
g
M,
u
0
S
T�3
u
co
E
0 1.:
ts
CD
CA
E
cm
ca "0
co
M
E ca 'm
CD
cc 0
a- CM<
ca
4-0 C cc
—J -0
0 0
co ts
co
C.3 CO)
cc
cc
CL
CA
LLI
ul
U)
LU
19
LU
LU
U)
t4
0
0
V.
Cf)
Cf)
00
w
�2
x
0
CD
x
�2
U)
cli
W.
�2
co
V.
9Q
U)
0
C/)
C/)
0
1 -11
g
M,
u
0
S
T�3
u
co
E
0 1.:
ts
CD
CA
E
cm
ca "0
co
M
E ca 'm
CD
cc 0
a- CM<
ca
4-0 C cc
—J -0
0 0
co ts
co
C.3 CO)
cc
cc
CL
CA
LLI
ul
U)
LU
19
LU
LU
U)
CD
ca C.)
CLc
m CID
CD
C42
co)
E.S
tv):
Lm
CL
co
`7S
ca
CA
C2
as
0
0
0
cc
cm
Sm a
:a
CA
r -L
cc
CL
cm
Co-4D
CD
L-
0
C L:
.40
COD
4—
g.
CD -s
CD
Z:5
LU
M
. C,
=
= :5
A is cc
go
E
CL=
= 4-
Z
cS
C-3
CL
0-0
CO2
0—
m 9 go=
C)
0 C- :a �
L.- 12
5
C/)
0
1 -11
g
M,
u
0
S
T�3
u
co
E
0 1.:
ts
CD
CA
E
cm
ca "0
co
M
E ca 'm
CD
cc 0
a- CM<
ca
4-0 C cc
—J -0
0 0
co ts
co
C.3 CO)
cc
cc
CL
CA
LLI
ul
U)
LU
19
LU
LU
U)
V.
ILJ
LO
Ems
kjz
I
zo
co
;gl
:2 t
Li o
41
=
M 0 -
WK
P.
------------
I
0
SMO
r- j ;,4
-,V(WAI Jo
11 'A 0�
go'
vit
V %
ji.
ZI,
- ---------
Y7e COnnWnweizfth ofKasmahusem
DePar'Ment 0frJUWStrW. A ccidentr
Office of J-nvest�.,
Wasiz
ins -Ion Stred
Boston, AL4 02111
www-Mass-goovIdia
Workers' Compensation bnwrance Affidavit: BuRders/Contra
20licaut Information ctors/Electridans/plumbers
Name (Bm=inmW0wmi�:onIflkn&v"iduaI):
U
r -mase rrMt Lmibly
Address:
City/SUW4 A A
10Ar Phonek
Are you an employer? Check the appropriate box:
�
�� 4
LO I am a=Tloyerwiffi 4- F] I am a general cOmbactor and I
-Pat-time).*
[2.
o
T7ype of Project (reqWred):
emp
employees (M and/or have hired the sub-��
11 am a sole
6- KNew'construction
IF
proprietor or par=- listed an the aft&ed sheet t
ship and have no employees These sub-cantactors have
7. E) Remodelhig
Working f
W Mr. m any capacity. workers, C<)MP. iaMrance.
[Noworicizs'comp. insurmce s. El We area coVorfiou and its
Demolition
9- El Building additicin
3.E3 require&] officers hatre exercised ficir
J
10-0 Electrical Mpairs or additiong
am a homeowncr doing an WO& right of !!�c:mpfion per MGL
Myself [NO work=1 comp- c. 152, § 1 (4)1 and we have
I LEI Phmbing repairs or additions
no
insurance required.] t employem- [NO *o*=-
12. n Roof repairs
comP .
- mMIrMncc require&]
am bcm#1
13.0 OfiW
who =bm&*- gffi&ft _&_tig OM d=;,n --It-.d IhM'bMUd,-
9. d-* 6. W. -M IMIdd . addhiaoW shea dw,*gAh, aff&VK nh=,Ig awk-
of d- ftb-co� mid
pofiry fi&wmzfi0ft.
lam an employer mar&Pr�ar�wwkersl compms.&. hzsWwzcef0r JUY MWIOY= Below is *epormy
.hrforma"L
djob
bsurance Co� Name
Policy # or Ser -ins. Lic.
Job Site Addrew. EXPiration. Date: ------------
AtIR& 31 COPY of the workers' compensation Porwy declaraden page (showing the Policy number and Opil-tio. du4
Failm to secure Wverage; as required under Section 2SA
of"MC3L c- 152 cam lead W.&C imposition acrinfillal penatim ofa
RuC Up W S1,500.00 auftr oW_yc2rbWdsomCnMIt, as well as civn Penalties in Ihe f0rul Of a STOP WORK '
of up to S250-00 a day against the violator. BeAvise ORDER and a fine
luvcsfigafions of the DIA for - d the a c9TY Of ft sMt=cdt my be; hrwapded tD the Office of
30surance covey(ge Acd&-afton.
I do haro cat.15, �mk I NEWS! 111111
006*7 &&a &C ntformaftn PVFt*.bov d
/.a COMM
0fi7,6'Id UW oidy- Do JW wr&- in &is area� to be compkW 4
I*Y Or tom offaiid
City or Tor,,= Pernlivucense #
bsumg Authority (arde one)- -
L Board of Health 7- Building Department 3. City/Town Clerk
6. Other 4- FAectricW hupector 5. Plumbing inspector
Contact PerOXI:
Phone Ar.
I _xx -
-mewg- Mas.sachusett.% - Department of Public safetv
Board of Building Regulations and Standard*s
Construction Supervisor License
Expiralion: 45=2
TrX: 21090