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HomeMy WebLinkAboutBuilding Permit #518 - 109-123 MAIN STREET 5/3/2006 f NORTN 1 p TOWN OF NORTH ANDOVER � . ,>•��' APPLICATION FOR PLAN EXAMINATION 9SSACHUSEt r Permit NO: /� Date Received: Date Issued: 4-3-6,6 IMPORTANT: Applicant must complete all items on this page LOCATION /C1 -A43 IVI' "'y 6?' Print PROPERTY OWNER �-.��}d a-le=z1 r Print MAP NO./ PARCEL ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑One family ❑ Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Repair, replacement ❑Assessory Bldg KCommercial ❑ Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Tyne or Print Clearly) OWNER: Name: Sig) Yt-) Ar W4 Y IZ-S7r Phone: 277— go�S-W,-3 S�iggnature Address: P '6�13 IfAl) 5/ % 57ZF- .J A/0- hAA,167- CONTRACTOR Name: ao ,0�i1 d C P Phone Address: (5F 108.7-449 'cl 6 Supervisor's Construction License: ©e4U'`4,' Exp. Date: 1r :Z7 -40a7 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$10.00 PER$1000.00 OF THE TOTAL EST/MATED COST BASED ON $125.00 PER S.F. Total Project Cost :$ ?f/0-00", x10.00=FEE:$ JO Check No.: Receipt No.: TYPE OF SEWARGE DISPOS Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer Well Tobacco Sales ❑ Food Packaging/Sales 1:1❑ ❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. NOTE: Persons contracting withJelrr istered con a rs o not have access to the guaranty fund Signature of Agent/Owne Signature of Contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection signature&date Temp Dumpster on site yes_no_ Fire Department signature/date Building Permit Approved and Issued by: i Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: Total square feet of floor area,based on Exterior dimensions. I Total land area,sq. ft.: j NOTES and DATA—(For department use) Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created IMC.Jan2006 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 ❑ Debris Removal Form ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Form U ❑ Surveyed Plot Plan ❑ Debris Removal Form ❑ 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) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Form U ❑ 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 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 DEPARTMENTMITORM05 Location /� �`�% ✓ No, �/�' Date NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ Buiiding/Frame Permit Fee $ s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 18959 i�. i Building Inspector V40RT own , of Andover No. Y40L C" dover, Mass. LA or ATED P"' WARD OF HEALTH Food/Kitchen PE T D Septic System Z2BUILDING INSPECTOR THISCERTIFIES THAT ................................. .. ....................................................... . Foundation has permission to erect........................................ buildings .......................................................................... Rough tobe --4/..... . .......... ............. ....... Chimney occupied as.. a........................................................................................... provided that the person accepting this p shall In every respect conform to the terms of the application on file in Final 4"i'�iioi this office, and to the provisions of the C es and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES N 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ..............Mee' Service .............. ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing -or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. RTI, Town , of Andover No. Cdover, Mass., C;2 OL IC EE ICK A 1E 11 0"?ATE WARD OF HEALTH Food/Kitchen PE T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT ................................1%4,00F................................................ ....................................................... Foundation has permission to erect........................................ buildings on ./ ............. Rough to be occupied as....,/..... . .......... ............. .......W.. ........................................................................................... Chimney 0--10 " provided that the person accepting this p shall in every respect conform to the terms of the application on file in Final 4"i4�i i this office, and to the provisions of theVi�Cs and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS. Rough Service .............. ......t ...... lwml ................ ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display, in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. VWA�ta . YI€L 55 �►lli�'fLAN�STREE tAWRFMC,F.MAf$43 SM # 03SBN TFLFPf/dN8# (�78� 688 6258 �� 3)e SU IN NATIONAL GRANGE MUTUAL RED INSLRANC,E COMPANY W 55 West Street, Keene, NH 03431 Telephone: 1-888-646-7736 CONTRACTORS POLICY DECLARATION; Y .sti'. Named Insured and Mailing Address EDWARD E VIEL DBA Policy Number: MPI66885 VILLAGE KITCHEN & APPLIANCE Account Number: CACI66885 200 SUTTON ST REAR BLDG NORTH ANDOVER, MA 01845 Agent: CHAS F HARTSHORNE & SON INC Producer Code: 200167 781 245 4300 POLICYHOLDER INFORMATION Named Insureds Business: CARPENTRY INTERIOR Entity: INDIVIDUAL Policy Term: 12 Effective: 09/20/05 (12:01 A.M. Standard Time at the address Expiration: 09/20/06 of the Named Insured stated above) in return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. See the attached schedules for Description of Premises, Property Coverage, Optional Coverages, Forms and Endorsements applying to this policy and Mortgagee Schedule if applicable. BUSINESSOWNERS LIABILITY COVERAGE LIMITS OF INSURANCE Liability & Medical Expenses - each occurrence S 1 , 0 0 0 , 000 Personal and Advertising Injury Limit 11000 , 000 Products-Completed Operations Aggregate Limit S 2 , 000 , 000 General Aggregate Limit S 2 , 000 , 000 Fire Legal Liability- any one fire or explosion $ 500 , 000 Medical Expense Limit - per person $ 10 , 000 Business Liability and Medical Expense: Except for Fire Legal Liability, each paid claim for the above cover- ages reduces the amount of insurance we provide during the applicable annual period. Please refer to section DA. of the Businessowners Liability Coverage Form. For policies subject to premium audit: Annual Audit Applies. Estimated Annual Premium: S 1 , 368 TOTAL PREMIUM AND CHARGES S 1 , 368 Countersigned: By: 64-5470 (9100) 09/08/05 RENEWAL MC NATIONAL GRANGE MUTUAL INS. CO. ZT EDWARD E VIEL DBA Policy Number: MPI66885 VILLAGE KITCHEN & APPLIANCE Account Number: CAC I66885 Agent: CHAS F HARTSHORNE & SON INC Effective Date: 09/20/05 Producer Code: 2 0 016 7 CONTRACTORS POLICY DECLARATIONS - LIABILITY SCHEDULE LIABILITY COVERAGES PROVIDED Code Premium Advance Premiur Classification No. Basis Rate Prems/Op & Produce STATE - MASSACHUSETTS CARPENTRY- INTERIOR 74231 41725 32 , 227 * PD DEDUCTIBLE = NONE 1345 PAYROLL ADDITIONAL INSURED 2 INCL MANAGERS OR LESSORS OF # INSD Total Estimated Liability Premium 1345 - LIABILITY PROPERTY DAMAGE DEDUCTIBLE PER CLAIM 64-N1BB-2 9/00 09/08/05 RENEWAL MC