The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #467 - 12 MIFFLIN DRIVE 12/18/2006 TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXAMINATION 0 ,,-go 16— OL o A Permit NO: Date Received toc— Date Issued: fT -(� ��SSACHUs��y IMPORTANT:Applicant must complete all items on this page LOCATION p� PROPERTY OWNER f/Y Print Me r �2y Print MAP NO.: I PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: epair, replacement ❑ Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving(relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRI TIO OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: ��`� f'96 /V Ph 9e�/z 7e3 Address: //,l—L/n' y/Z lild Afsepa U6 R, /t/-/#- CONTRACTOR Name: IV4, 40AS11 a✓ stilts Phone77k-4 Af -i�n7 Address: Supervisor's Construction License: �� U Exp. Date: _ Home Improvement License: l 4.. ��" Exp. Date: ®� ARCHITECUENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING/,IIT:$12.0 $1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ 4,'IT. ,,�j`j FEE:$ 4->-®' / yr Check No.: �f Receipt No.: y Page W4 4 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 o 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 Addition Or Decks ❑ Building Permit Application o Surveyed Plot Plan Li 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 ❑ Certified Proposed Plot Plan ❑ 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 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 DEPARTNIENT:BPFORV105 Page 4 of 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools 11Tanning/Massage/Body Art E] g Public Sewer ❑ Well Tobacco Sales ❑ Food Packaging/Sales ❑F ❑ ❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 4D Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ S amped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer connection/SiQnature& Date Driveway Permit 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. Total land area, sq. ft.: NOTES and DATA— For department use) Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENTUTORM05 O cat ed WC..Ian'006 Location�� M No. Date ��Lam_ MaRTM TOWN OF NORTH ANDOVER • i : : Certificate of Occupancy $ Building/Frame Permit Fee $ s�cwus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 Check a 19879 1"' Building Inspector AORTH 1 Town of Andover O Y.w •f o �` dower, Mas sop O COCMIC.EWICK I 7� 0RATEO �i BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • Aft BUILDING INSPECTOR THIS CERTIFIES THAT L ....1I�!��!1�.f�........... !......... .............. .. 1.................... ................... Foundation has permission to erect............ .................. buildings on ..J.. . ........ 1... � �. � •...... Rough . ...... ........ ................ to be occupied as...t.3.........� C. .... ......4J�.1.�h.d,,Q. 1.,#�....... Chimney provided that the person acceptingf�is ermit shall m eve respect conform to the terms of the lication on file in P P P every P PP Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU Rough ............ ......... ....................................................... Service .. . ... . BUILDING INSPECTOR 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. . Pae# of Proppol CS.# 022680 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 55 Pleasant Street 1-866-AJWALSH North Andover, MA 01845 Proposal Submitted.To• � S�%��;� C fob Name �t�� Job# Address Job Locatio� R Date Date of Plans —06 Phone# Fax# Architect f0 Fherebybmit specifications and estimates for:.___..._____._.___— rWe propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: /(0 fU , 114 _IZ?5_� Dollars , with payments to be made as follows: Any executed only up aviation from above specifications involving extra sts will be Respectfully executed onl upon written order,and will become an extra charge over and submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn'4 us if not accepted whin days. Zicceptance i f Vropogal The abode prices,specifications and conditions are satisfactory and are Signature „ hereby accepted. A-S epted.You are authorized to do the work as specified. /! (J Payments will be made as outlined above. Date of Acceptance Signature ISSUE DATE(MM/DD/YY) CERTIFICATE OF INSURANCE11/08/2006 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Samuel J Durso Insurance DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Agency Inc Agency Ave Suite 10113COMPANIES AFFORDING COVERAGE North Andover, MA 01845 INSURED Arthur Walsh COMPANY A.I.M. Mutual Insurance Co dba A. J. Walsh&Sons LETTER A 55 Pleasant Street North Andover, MA 01845 COVERAGES THIS IS TO CERTIFY THAT ^ T THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIOr, LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ LAIMS MADE[::�] CCUR PERSONAL&ADV.INJURY $ OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ ::,NON-OWNED AUTOS (Per accident) GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ MBRELLA FORM AGGREGATE $ THER THAN UMBRELLA FORM WORKER'S COMPENSATION AND X wC STAMI OTH ER EMPLOYERS'LIABILITY TORY LIMITS 7014648012006 11/14/2006 11/14/2007 $ ' A THE PROPRIETOR/ INCL EL DISEASE—POLICY LIMIT $ 500,000 PARTNERS/EXECUTIVE $ 100 000 OFFICERS ARE: X EXCL EL DISEASE—EA EMPLOYEE OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE;HOLDER ; :;CANCELLATION. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town Of North Andover MAIL DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 fVashington Street Boston, .MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Con(ractors/Electricians/Plult113ibers Please Print Leribl- A )licant Information Name (Business/Organization/Individual): Address: -� S�/�� -� City/State/Zip: Are you an employer? Check the appropriate bo Type of project(required): 1.❑ I am a'eniployer with 4. l am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on die attached sheet. t �� E] Remodeling ship and have no employees These stub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[:1 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions 3.El 1 am a homeowner doing all work on g p myself. [No workers' comp. c. 152,§1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] 'My applicant that checks box t11 must also fill out the section below showing their workers'compensation policy information: t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such tCentraclors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 4, ,WI�41AL m5 Policy#or Self-ins. Lic. #: �6/G/� 7 e 1,A 6 0 7 Expiration Date: Job Site Address: /A/0�}r ��U�/� Cit : �`'//�/��/�� •�/� ��' 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 crittunal penalties of a fine 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby ce► ') under he pains and penalties of perjury that the information provided above is true and co►•rect Si ature: G��F Date: �� — Phone#: �Z Oficial use only. Do not write in this area,to be completed by city or town official. City or Town: Pernrit/License# Issuing Authority (circle one): 1.Board of health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5.Plumbing luspector 6. Other Contact Person: Phone#' �/e �ommooul�i t/ aaaac�u�aella Board of Building Regulationd Standards - HOME IMPROVEMENT CONTRACTOR Registratiotrs-1.03358 Ex p lratiort. 7/7)2008 Type: Private Corporation A J WALSH& SON$JNC: f Artnur Waish,dr 55 PVeasant St N Andover, MA e 4 Deputy Administrator 018 5 P Y • II � r7 juQ�ss: cc�srr�va� �� ' oum�- OWN IN 'm it