Loading...
HomeMy WebLinkAboutBuilding Permit #625 - 17 MABLIN AVENUE 4/7/2006OE NORTkt , p TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ,SSACNU`�Q4 //- ,— Permit NO: Com/ Date Received Date Issued: W-7/1, IMPORTANT: Applicant must complete all items on this Daae LOCATION 1/ M1 o lj lj d 1/ f, Prin PROPERTY OWNER :10 SC 4 A �i Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND IJSE OF BUILDING HISTORIC DISTRICT VFS n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial FKRepair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearo C,l V OWNER: Name:Phone: 4 8 Signature Address: 1p o % CONTRACTOR Name: -( � •fJS C �. Phone:q)g Address:/ 7 A, , L .l Supervisor's Construction License: 21% Exp. Date: Home Improvement License: Exp. Date: o� q ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULD/NG PERMIT: $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST A FD$125.00 PER S.F. Total Project Cost :$ 94 e, A 4 !H 's,� 1 , &x10.00=FEE:$ Check No.: (�o :2 -7 --1- Receipt No.: 0C Page 1 of 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 ❑ 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 ❑ Surveyed Plot Plan ❑ 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 ❑ 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 DEPARTMENTMFORM05 Page 4 of 4 s TYPE OF SEWARGE DISPOSAL Art ❑ i wmmn SiPools ❑ g Public Sewer 11Tanning/Massage/Body Well F1Tobacco Sales ❑ Food Packaging/Sales 11❑ Private ❑ Permanent Dumpster on Site (septic tank, etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the gua ty Signature of Agent/Owne -Signature of Contrac or Plans Submitted ElPlans Waived ❑ Certified Plot Plan ❑ Sta ed Plan ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS S HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition N Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: DATE REJECTED ❑ ❑ ❑ Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED DATE REJECTED Comments Comments Water & Sewer connection signature & date Temp Dumpster on site yes no—A Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 DATE APPROVED DATE APPROVED f JC� ` DATE APPROVED Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: Total land area, sq. ft.: NOTES and DATA — (For department use) Page 3 of 4 Total square feet of floor area, based on Exterior dimensions. Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC. Jan.2006 Location No. C.Q Date /47/"M-1! Check # (40 -�"? TOWN OF NORTH ANDOVER' Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee Pa. $ TOTAL 19090 Building Inspector 0 w V) w z a o w° U w w w°' w 0 a W w°' ) w a c� � C4 w a cA cn o cn s•. I f- O i �Z Eat N SNL 4:mc E Orr a m � o ��o � N N .� .: W 3 N cm m_.0 N N C C O O Em mo 4a acs o '= o CD �0� m f0.1N O 0- Z C o cm ` d C Q � : y m C O = m :ow3 N ~ +0.. y m rO. H m Vb W G c +- .15 GO 'az c Z O`r )•N O CD © co •n 0- z = any=CD F- 064" m � p U Q u O v Z CD CL O h D � a) Om c C V2 p 'C CO2 'i m m �3 � � O L cc O a CMQ ca c cc Q 'p a) CO2 Z CD V CO) c c • c CL CO2 cm LU D Y/ 0) 19 W LLI 19 W U) R. damrnwou�ea/�i aro Budding Regulatio and Standards j HOME IMPROVEMENT CONTRACTOR Registration: 101841 f Expiration: 6129/2006 f Type: Private Corporation I PAYETTE CONSTRUCTION CO., INC. Roger Payette E 17 MILTON ST. _ i Dracut, MA 01826 �` ° — Administrator M✓% ommzoor.���,a �• BOARD OF BUILDINGREGULATIONS License: CONSTRUCTION SUPERVISOR Number' CS 021304 Birthdate: U1/2U/1948 �. Expires: 01/20/2008 Restricted' 00 ROGER G PAYETTE 17 MILTON ST DRACUT, MA 01826 Tr. no: 14604 Commissioner The Commonwealth of Massachuselts Department of Industrial: accidents Office of Investigations 600 Washington Street Boston, A1.4 02111 www.mnss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information Please Print Legibly Name Il3usincss;Org;utizalionllndividtutl): `/� Q`'1Z9.� /� ©� Address: --- City/ StatelZip: ]Z Phone #: % d 3 pA Are you an employer? Check the appropriate box: .9�4 am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part -tune).* have hired the sub -contractors �. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, j 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other _ Any applicant that checks box,4I most also lill out the section below showing their workers' compensation policy information. + Ilomeowners who submit this aflidav it indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating Such. Contractors that check this box most attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 1 am an employer that is providing workers' c•ompencation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy "t or Self -ins. Lic. 4: Job Site Address: Expiration Date: C ityi State; Zip: ,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 %1GL c. 152 can lead to the imposition of criminal penalties of a tine tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the forth of STOP WORK ORDER and a tine Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby_$ r * under the painpd "Fralties of perjury thin the information provided above is true and correct. sil, Official use only. no not write in this area, to be completed by ci(p or town official. City or Town: Permit/License # /7,,4 Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk d. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: