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HomeMy WebLinkAboutBuilding Permit #808 - 1478 GREAT POND ROAD 6/1/2011 TOWN OF NORTH ANDOVER j� APPLICATION FOR PLAN EXAMINATION Permit NO: `" Date Received I Date Issued: r / IMPORTANT:Applicant must complete all items on this page LOCATION y7 &Au-67�FJ D -/ / " Print PROPERTY OWNER /`EN + LA.v fie- A ?q P-KS ��yy Print MAP NO: PARCEL: �(J ZONING DISTRICT: Historic District yes no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building >6bne family 0 Addition 0 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 'Septic Well O Flood`1'aii `Wetland`s ! '} Watershed�IDisfrct. Water/Sewer ` DESCRIPTION Or WORK TO BE PERFORMED: ,p LA-G� I r I T. � V eTS N 5 13 1 / " , CO U re,-- --t- FLoO 10C !�e t A,CGS 7o 1/1esc5 e lzl, hu-it eotl (Identification Please Type or Print Clearly) OWNER: Name: KE'0 Phone: Address: CONTRACTOR Name: Illt-slem " rJ�rid•�/ Phone: Address: 1r3 3 AYA S' /0. of /Ji�'G,- Ad- Supervisor's d Supervisor's Construction License: 1/6 -7 0 Exp. Date: Home Improvement License: D 2-6 Exp. Date: ARCHITECT/ENGINEER �— Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. F:5-�D .C Le Total Project Cost: $ / /t FEE: $_T-� a Check No.: �J o �� Receipt No.: d NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature'of1Agent/Owne_ _�gnature of>RIZ contracto `' �: . 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 Camp 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 ❑ Photo Copy of H.I.C. And C.S.L. Licenses ® Copy Of Contract o Flo or/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products MOTE: 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 o 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: Doc.Building Permit Revised 2008mi i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: 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 Ll Notified for pickup - Date Doc:.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Piot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well / ❑ Tobacco Sales * 11 Food Packaging/Sales ElPrivate(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS H1EALTH 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/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location No. d e Date TOWN OF NORTH ANDOVER 9 t �. •; Certificate of Occupancy $ ' .�_:.. JACMUSEt� Building/Frame Permit Fee $ Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ Check # 7'2 3 Z 24 � V4 Building Inspector r The Commonwealth of Massachusetts Department of IndustrialAceldents Office of Investigations 600 Washington Street Boston,MA 02111 �,„ s�• www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 5 /l el4A COX,/S,,__ / Ci Address: r_3 3 //L-/ S�' - q -) —&,e" City/State/Zip: �( _ � lD iIV G' Phone#: �7U 7f SO P-0 4 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• E]Building addition [No workers'comp.insurance 5.*We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] o 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 1311 Other comp.insurance required.] *Any applicant that checks box#1 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 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.Liic.#: G /' p',, 'D p Expiration Date: Job Site Address: ( Y�0 6 . �'`'��'�C City/State/Zip: /��' XM_1 YT 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 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. I do hereby certify under he pains an penalties ofperjury that the information provided,above is true and correct. Signature: Date: / Phone#: �Z - [l G 7 YIYl 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): I.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: pRT1y , TONM of . _ 6 over No. yy - o dover, Mass. Y Q LAK 1 COCHICMEWICK I. 7�AQRATED S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT / ................A .l�-s'........................................................................................... •••••• Foundation has permission to erect........................................ buildings on ../..v .1ew T. 6n0.•.....0.-...... Rough / p Ch to be occupied as.......... z ........7 ....... .a.. . ............�'LC . t.. ��...C✓..�go4g .. Chimney �...... e provided that the person acce tin this permit s6i in every respect conform to the terms of the application on file in Final P P P 9 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 CONSTRUO STARTS 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 SODE j Smoke Det. o rrs.rchu. g fetts License: CsruC on SugperV,rtinn`�inr/hl,C S;1&tl. Jp 4p8j0 s°r Licen ettnU.trr/s. HN'/136 Hq N,%Z)o RHEM�R R Mq 1845 Expiration. T 71112p13 17261 ' � .� ✓>'ie 'COory�rnreaozusec�� o�✓�Caodar�uael�6 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: ;..:,116025 w Expiraton:_ 571'072012 Tr# 294721 Type:;?, _Privafe ---poration HASHEM CONST INCA:`= JOHN HASHEM JR t 133 MAIN ST y N. READING, VlA 01 ii`64` Undersecretary1 i f Hashem Construction, Inc. 133 Main St. No. Reading, Ma. 01864 978-664-4191 Home Improvement Contract Home Improvement Reg. # 116025 I Owners: Ken & Laura Parks 1478 Great Pond Rd. No. Andover,Ma. 01845 Contractor: Hashem Construction,Inc. John J. Hashem Jr. Pres. j Job: 1478 Great Pond Rd. No. Andover,Ma. Start Date: Approx. 10 days from building permit and complete approx. 60 days from start. Permits to be obtained by contractor.Owners who secure their own permits are excluded from Guarantee Fund MGL Chapter 142A. Contract amount: $ 39,850.00 Payable $13,000.00 upon signing, $ 13,000.00 when windows installed and $23,500.00 upon substantial completion. All Home Improvement contractors and subcontractors shall be registered, inquiries directed to: Office of Consumer Affairs and Business Regulation 10 Park Plaza, suite 5170 Boston, Ma. 02116 617-973-8700 Cancellation rights: Owners have no later than mid-night on the 3rd business day from signing of this contract to cancel and receive a return of all deposits. All workmanship is warranted for one year of installation. Contractor not responsible for performance of products and shall deal with manufacturer.