HomeMy WebLinkAboutBuilding Permit # 10/5/2016 O�
BUILDING PERMIT poRrh
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received 1.�R„r��
�SSAC t]$F�
Date Issued: _ C
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ;z,One family
❑Addition ❑ Two or more family ❑ Industrial
❑Ageration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
�Septic��❑Well ,'L3 Flaodplarrl ❑Wetlands < � �,p
WK
❑1NatrlS�wer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Cle ly r
OWNER: Name: Phone:
Address:
7.
r i
Cantractor<Flame At,2Pllone
r r k ��
Erra1l z a.L'� r rix ✓
L1d1e.50 r z /'. a ✓! fir"
uperrrsor� Cbnstruct�o�n License f Fw
l Name im-raverrlen lrlcer�s� f . . ,.Exp ``Dai ' ;.. 3
ARCHITECTIENGINEER 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- $ 00 FEE: $_
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyefund
Signature'of AgentlOwner �gnature,of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Piot 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 ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed Onwk Signature_
COMMENTS
CONSERVATION Reviewed on (C) Si nafiure
COMMENTS
HEALTH Reviewed on
Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
;Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Si nature& Date
Drivewa Permit
DPW Town Engineer: Signature:
FIREEPART Located 384 Osgood Street
MENET Dum ste n safe 2no
Locata 124 Mabee} Tempi p r p Yes ,
^r:�veaN ^;�F-..�' i�' ..,Wr �"fn-S� n t �: �� i va r S✓,� xM� a. . ,„,,,,
Fire
P. Sigmatureldate
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COMMENTS
4
vo40RTk
Town of z s _ ,kT 6 ndover
O tri
No.
�O IR h h ver, Mass, I0 r • OI
gyp_ coc.a[riCwK.. ti'
e2
S U
BOARD OF HEALTH
PERMIT TFood/Kitchen
��rr LD Septic System
CERTIFIES THAT . 9.14. T',� w!4 BUILDING INSPECTOR
THISC ................... ....... . . ...,.........,....,..............,.....................
Foundation
has permission to erect .......................... buildings on �d X W nD .........
.............. ......... ....................... .,.�.. Rough
tobe occupied as ................................................................................................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR
UNLESS' CONSTRU N STA S Rough
Service
.. . .... . ......, ........... .................... ..
. .
BUILDING. INSPECTOR. Final
GAS INSPECTOR
Occupancy Permit Required t® Occupy Buildin Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fina'
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
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We hereby propose to furnish the materials and porforin taro labor necessary for the Completion of __ .......-_..._... _ ._-
W,
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All material is qu aranteecl to lac ear w,iaec;iGic cl,arrcl tlac cat:arave;wwcau°k tca loo,laurtcarnaert iar ace,crN➢aNrace wwiVUn tkat itraauuilarts rXnci a lra;a�tic atiraras submitted or sataove arwca '„ttttcl
r,raun letert irr.a substantial workinonlike rnannei for [be,swot et. ......
C � � with payments to bo m actc as follows.
Dollars
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n¢:de¢uRRs,ar ddayx beyund Issas collimIMI.
peN -..-.--....
_. 110ty ..uli s prop osai naaay he vdih(ta,awn by us it nrA acr,oprled trahhin days.
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"I lie above,prpGN,;a,,�,l'ar;a,lflca[ions,,and colrctilioii s o-aro satisfactory and al tobya accetated. YOtN aal�c au.ttticariwa;�tra rtaa ttra;vwcaria pas yarar;uGia,cN. I'°rayratUuN:aa aurfl ktr�,rraatcla;aar;
outlined above.
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Do Not remove
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j CJI
ne Commonwealth of Massachusetts
_ Department of Industr^ial.A.ecidents
z100 eel Smite
.� Congress street,
�ostoft,MA 02114-2017
we wWw.rnass.govldia
' M Sys Workers' Cow pensationUsurance.Affidavit:BrdldexWContraors ' C�'
ctlectr ciaus �z?��ers.
1:OSE-RILED WITHTM']?ERM'NT�NG AT3TF OSS ]X. Blease Print Le 'bl
A licant Informatiax�
Narac. (Susines10i9an zation/lndiv'aual):
Address:
Cztyltatelzp: Phone 4:7-1
opriate box:
Type of project( ecluired),
Are you an employe'?Cheep the appr
employees(£uI1 and/or parttime).
7. E[Newd6nstt& on
1.❑I am a employer 71a,
olegropzietoor putnership anal have no employees vVorkurg forme in . ❑R.emoacity.jNoworkers'camp.insurance required.] 9, Q Deznolitiozlomeowner doing all workmysel£[Pia workers'comp.insurance required.]t 10 Building addition
d.QI am alromeowner and will be bung contractors to conduct all work onmy property. 1 wilt i 1❑piecixieal repairs or dditions
ensur,that all contractors either have workers'compensation insurance or are sole ja g repairs or additions
pzoprietors with no eiriployees.
5,❑l aryl a general contracfior and/have hired thosub-contractors listed onthe attached sheet.
13-.Ej Rbof repairs
These sub-contractors leave eiployees and have workers'camp.insurance 14." Qther
g•❑We are a corpozatiori and its,offrcers have exercised their right of'exemption per MGL c.
152,§1(4),endive IiaYe no empl6ydes.tNn workers'comp.insurance required.?
Any applicantthat cheeks 6bx,#1 must also ill oue s are deing1a11 work andtben hire outside cshowingthoirw s, montraetozs must subzrn'pensatfun policy t a crew affidavit indicating such
i Homeowners who submit this afffdavit indicating y
tContraotors that clrecktivs Bo.k must attached'an additional sheet showing the name of the sub centractors and statewheYher orpafi those.entities ave
employees. Sfthe sub-cantradois bave employces,they must provide their workers'comp.policy number.
to er Haat isproviding workers,coMpensation insurancefor"my employees. Below is thepolicy and)ob site
Xam an erre P
information.
fm8urance CoropanyName:
Expiration Date:
policy##or Self ins.Lic.-9 .
City/State/Zip:
: t o number and exp
Attach a copy of Me !ration date).
Job Site Addressyyorlrers' compensatio;=t policy declaration page{shavPibg the Policy
paiiuxe to secure coverage as requixed under MGL e. 1.52,§25A is a criminal violation punishable by a ine, f p o $ 50.00
and/ox one year imprisonment,as well as civllepe ma be forwarded to then Of e of ORDERons of'the IDSA for ins-Wanc�a
day against the violator.A COPY of this state n y
coverage verification.
f do hereby cert" under thepains andpe lti s fperjury tizat tine information provided above is trWc and,correct
. �._. `.—
Si afore:
t
Phone
al use on . Do not write in this area,to be completed by city or town official.of.�ci'
• permit!'License#�
City or Town'
Issuing Authority(circle oRe): '
1..Board of wealth 2.$xxilding l3epaz tman� 3.CitylTown Clerk 4.Electrical inspector 5.Plumbing inspector
G.Other
Phone#:
Contact Person-,
Massachusett's -Dep,t' s?f public Safety
Board of Building Regulatirins and Standards
E>•ilttifiFi
License; CS-090863
JOHN E TRULLI
149 COTUIT ST y
NO ANDOVER MA 01 t
is
' xpiCatloF
•GornI1lissiOner, 01113I2017 !
ru ofConsumer.4fru.�rs-&&rsine:rs Rcu)niioi
5'hOME 1VIPRO PRO, CONTRACTOR
egistrat175283 `
1 %Exprratlon' 5112017-i Type
Individual
.JOHN TRULLi
JOHN -rR.ULL1
149 COTUI'T ST.
NAN9OVER, MA 01845 :
' Undersecrctary� �; ���
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