HomeMy WebLinkAboutBuilding Permit #447-15 - 17 MILLPOND 11/16/2014 • �t V Q. HORT#{
BUILDING PERMIT 3� 6,, r. ._.. 6 0
TOWN OF NORTH ANDOVER 1 �
APPLICATION FOR PLAN-EXAMINATION
Permit NO: Date Received
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Date Issued: L
I W ORTA'NT: Applicant must complete all items on this page
LOCATION / L_L. ofIi C,9A1,0u xn1" 11;�, -A C 7
Ptint
PROPERTY OWNER /'J 7-- k:-7 IL -zrY T
Print
MAP NOPARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Resid ial Non- Residentigr_
❑ New Building V,6ne family
❑Addi ion ❑ Two or more family ❑ Industrial
N4�Iteration No. of units ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
AlJ, l /lam (� �" 1 ✓l j /1d�ft j / j.5.%f/`j �lI Ud r/wz/ "l Vc
Identification Please Type or Print Clearly)
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OWNER: Name: 6 /A/ �' �-� A ?J -r'� Phone:
� Address:
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CONTRACTOR Name: Phone: 0 3 L/ ®1 S L% /
Address: -3 t2I) 57 L E cM
Supervisor's Construction License: Exp. Date:
� �� Z Z1 -s--
Home Improvement License: Exp. Dater
102121Z-01 -S-
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
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Total Project Cost: $ FEE: $_ ,P 0
Check No.: /d _ Receipt No.:
NOTE: ,Persons contracting with unregistered contractors do not have access to the guaranty fund
ignature of Agent/Owner � - Signature of contractor 1
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NORTF
BUILDING PERMIT °� "" 's
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TOWN OF NORTH ANDOVER 00
� APPLICATION FOR PLAN EXAMINATION 4 _
Permit No#: Date Received gssgcHoss��5
Date Issued:
IMPORTANT:Applicant must complete all items on this page
j
LOCATION;
PROPERTY OWNER _ ____ _ _ _. _
"Year Structures yesno
j MAP PARCEL: _ ZONING+DISTRICT: Historic District yes no
j
Machine-
Shop Village yes, no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
El Addition ❑Two or more family ❑ Industrial
El Alteration No. of units: ❑ Commercial
❑ Repair, replacement [IAssessory Bldg El Others:
❑ Demolition ❑ Other
❑ Septic ❑Well, ❑ Floodplain ❑Wetlands ❑ Watershed District
j ❑Water/Sewer_
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly ,
OWNER: Name: Phone:
Address: `
Contractor Narno: P.hone:,�
Address _
Supe=rvisor's Construction License. .. .�_ Exp. Date _ Y _
Home Improvement Licenser,__
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of.Agert/Ow!ner Signature of contracta�,
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
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
u Certified Proposed Plot Plan
u Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
u Mass check Energy Compliance Report
u Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
Iri all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
tlx, at the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
na ust be submitted with the building application
Doc:Building Permit Revised 2014
Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
I
TYPE'OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH 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:
��P
Located 384 Os ood Street
FLREARTMENT - TempDumpsteron site yesLocatedat 124 MainStreet:, -
..Fire Department signature/date
COMMENTS ' t
�1
Dimension
S
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
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)
i
❑ Notified for pickup Call Email
i, Date Time Contact Name
Doc.Building Permit Revised 2014
NORT11
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Town _ ndover
O
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No.
07%0".-. "h ver, Mass,
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LAME
C0CNIC"1WICK 1_
7,95°R^rEo �PP��S
U BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT ......................(.f.. ....... �.(24.f t................... BUILDING INSPECTOR
has permission to erect ........ . ............. buildings on 1%a...`Pn�. ...l,,ovio... ... ... ,,, Foundation
��( Rough
to be occupied as .. ... :�r.:....C/.S� G�C,�l... -�'.:'`P .. !�:,�.. .....�;�. ... .. imney
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provided that the person accepting this permit shall in every respect conform to the terms of the applica ' Final
on file in 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
0 o Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION SZF! S Rough
Service
......................... .... ........
BUILDING INSPECTOR Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
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Smoke Det.
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��� E SiORT1� 1
ist�a° a°�a6
BUILDING PERMIT 3? b..;: '• o
TOWN OF NORTH ANDOVER ° w o
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
I I ORTANT:Applicant must complete all items on this page
LOCATIONAI/ L/ 10J•(/0 r,9N.Or,InI1411;, ' A ajtl i ,)
Pt� .n�J'L /llJl�
PROPERTY OWNER 1/f �Y
Print
MAP NOA.';-PARC€L-�ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Resid ial, Non- Residential'
0 New Building One family
❑Ad5dJMon ❑ Two or more family ❑ Industrial
I-Alteration No. of units: ❑ Commercial
0 Repair, replacement ❑Assessory Bldg ❑ Others:
❑Demolition ❑ Other
❑ Septic ❑Well 0 Floodplain 0 Wetlands ❑ Watershed District
0 Water/Sewer
it/ l l, �fY �' a� 1 J�j01 u f /'i< l S%i �t)l� ��-%� .►v�
Identification Please Type or Print Clearly)
NNER: Name: / 1 I- �� A '-rrz Phone: I
dress: L_ L P o 0-0 {
CONTRACTOR Name: Phone: t� 3 ` f /
if ✓�J }�12 t C kil /4(A J0
Address: / �J I2- /=,� >2 -5' L m NO 030'?
Supervisor's Construction License: C Exp. Date:
..� �� � �� 7-.9 Zit -s—
Home Improvement License: � Exp. Date:
zZgQ/
'
ARCHITECT/ENGINEER / �--- Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON;$125.00 PER S.F.
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Total Project Cost: $ 16-0062 FEE: $
Check No.:_ z Receipt No.:
NOTE; Pe sr on contracting with unregistered contractors do not have access to the guaranty fund
Si9nature g " �'Snature of contractor
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Mce off, pmec au f bn nate If found'rF.t4ra to,
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ME`I
Business Reguintion
- 9istra Type. -�o
xpiration
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THE( KE MkCHI�iJ Ix� r,
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SALE N 'tVH 639 �¢�: v Nb}valid tvitroiif signature
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PROPOSAL
PROPOSALNO.
SHEET NO.
DATE
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT:
NAME/' p� T ADDRESS
ADDRESS
DATE OF PLANS
PHONE N0.,.•� � __7 j / ARCHITECT
We hereby propose to furnish the materials and perform the labor necessary for the completion of
7—"--If,(' if Y1 � C f.2 l T'1- IS ti
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All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi-
cations submitted for above work and completed in a ubs `nlial workmanlike manner for the sum of
(/r )j r'�%A r ( i:......-f —Dollars�,�-------. ($ .�C�0 )
with payments to be made as follows.
0 0 ��- /��,<' ✓ Ula--T L Jrt C_c
Respectfully submitted
Any alteration or deviation from above specifications involving extra costs
will be executed only upon written order, and will become an extra charge Per
over and above the estimate. All agreements contingent upon strikes, ac-
cidents,or delays beyond our control. Note—This proposal may be withdrawn
by us if not accepted within days.
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work
as specified. Payments will be made as outlined above.
Signature
Date f 1'4 `'{ Signature
, 381850
MADEINPROPOSAL
MADE IN USAA i"
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: / 3 Z li d� �C /C
City/State/Zip: -)/Y N u' Phon�#: J� �� —Y01
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. I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• 9. ❑Building addition
[No workers'comp.insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees.[No workers' 13Other t I✓)��'
comp.insurance required.] C_.
*Any applicant that checks box#I 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/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 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 cern under the ains and enalties o Perjury t t the in ormation provided above is true nd correct
Signature: - 1 f / Date l
Phone#: &15203 �Z 10 / 7y/
Official use only. Do not write in this area,to be completed by city or town offaciaL
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#: