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Home My WebLink AboutBuilding Permit #215 - 15 BUCKLIN ROAD 9/22/2006 TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXAMINATION oq'u'o 6 �6 ryry 0 to Permit NO: Date Received o 4q Date Issued: —C)t'p �9SSAcNus��y IMPORTANT: Applicant must complete all items on this page LOCATION Z PROPERTY OWNER Print MAP NO.: PARCEL: �� ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building 9-0ne family ❑ Addition ❑Two or more family ❑ Industrial ❑ Alt 'on No. of units: R'kepair, replacement ❑Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving(relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Prin learly) OWNER: Name: AIYVeleSU/y Phone: Address: CONTRACTOR Name: Phone: Address: y! �L �}�'�J`/ �/ ��,/7/�`�GfG' •�- ✓' 14 Supervisor's Construction License: Exp. Date: e Home Improvement License: 3 Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULD/NG 10,M/T:V2.00 Pge$1000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ dG� FEE:$ D_ a•i �� - Check No.: / -� Receipt No.: 17 � Page W4 4 P A it Location `� �'� No. ,r-4 151 Date t)(p 1 = 1 TOWN OF NORTH ANDOVER o c IA F e 9 , Certificate of Occupancy $ �ssACHust<� Building/Frame Permit Fee $ ,, Foundation Permit Fee $ Other Permit Fee $ t TOTAL $ Cl 1"� Check # 1.960 Building Inspectd, I TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. F] Permanent Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner 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 ❑ -1 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 Temp Dumpster on site yes no Fire Department signature/date t Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided- Dimension rovidedDimension 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 DEPARTMENT:BPFORM05 Created IMC.Jan.2006 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 o 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 ❑ Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Floor/Crossection/Elevati on 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 ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 DEPARTMENT:BPFORM05 Pape 4 of 4 4 NORTH Town of , . g L over No. 2`� -- �`y z dover, Mass., - T O = LA E COCHIC M£WICK A0RA7ED PPS\ BOARD OF HEALTH PERMIT ' T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT........................... ............ .................................................................�......... .................... Foundation has permission to erect........................................ buildings on ..I3....... . Rough to be occupied as ...................................... Chimney provided that the person acce ing this permit shall in every respect conform�to the terms of the application on file in Final this office, and to the provis' s 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 �0 • owm� PERMU EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR STAR S Rough ........................................... .............. Service ,n BUILDING INSP CTOR 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. I The Commonwealth of Massaehuselts Department of Industrial Accidents { Office of Investigations 600 Washington Street Boston, ,VIA 02111 ^ �t www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (tausiness/()rg.nliz;,tir,n/ln(liviLitttll): Address: �3 pn'�SH H 7 S� — City/State/Zip: / 140)YNQ�e)e( Phone 4: Are you an employer?Check the appropriate box Type of project(required): 12.[] .❑ 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 1 am a sole proprietor or partner- listed on the attached sheet. < 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ 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' 13.❑ Other comp. insurance required.] Any applicant that cliccks box 3l must also fill out the section below showing their workers'compensation policy information. i 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 slowing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy end job site information. > /�j} Insurance Company Nam � e:__ /9L//V/0`�`Z ty� 1r 4 _ MIS v -- Policy `f or Self-ins. Lica #: Expiration Date:_ G � ./"/ Ci iState/Zi :__ � ty P Job Site Address: 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 I,1GL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a tine of up to 5250.00 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 cert ' under the pains and penalties of perjury that the information provided above is true and correct. Si mature: Date: 7 olficiul use only. Do not write in this area,torr,to be completed by city or town g1ficial. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: CS # Pae# of pages 022680 � 978-688-6737 HIC# 103358 A. .!. Walsh A Sons or 55 Pleasant Street 1-866-AJWALSH North Andover, MA 01845 Proposal Submitted To' Job Name Job b; � "A"4 Address / /�� B Job Location 41d A f� Date / /ly I lo6 Date of Plans Phone# Fax# Architect We hereby submit specifications and estimates IWO - �,--- - 3 ....___._......_........_._�___._...___-.___. 7�Wepropose hereby to furnish material and labor complete in accordance with the above specifications for the sum of: �iCS`DD Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully '' executed only 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 withdrawWby us if not accepted within days. 2cceptance of The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified. 1 Payments will be made as outlined above. Date of Acceptance Signature BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR �4 Number: CS 022680 • �-- Birth40e:-x06109/1939 ExpUe8 06/09/2008 Tr. no: 28249 Restricted: 00 ARTHUR J WALSH,JR 55 PLEASANT ST N ANDOVER, MA 01845- �� Commissioner TiLC �O'IILlIL4IblLCl000IL 6�.-C�i'asru;`ivaetla Board of Building Regulations and Standards lug HOME IMPROVEMENT CONTRACTOR Registration: 103358 Expiration: 7/7/2008 Type: Private Corporation A VVALSH& SONS.INC. ,,rmw Walsh,Jr 55 ?leasant St N Andover, MA 01845 Deputy Administrator