HomeMy WebLinkAboutBuilding Permit #621 - 198 LANCASTER ROAD 4/6/2006L
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
9SSACHUSE�
Permit NO: Date Received:'
Date Issued: AF
IMPORTANT: Applicant must complete all items on this nai2e
LOCATIO
PROPERTY OWN
MAP NO.: V'l PARCEL:
TVPF. AND ITSF OF R1J11,n1NC_
Print
Print ®
ZONING DISTRICT: /C:i'S
AiCTl1Di!' "1r C'TD71r1gr vr, o n
TYPE OF IMPROVEMENT
PROPOSED USE
Resioential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Commercial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Moving (relocation)
Other /!d 7-'7-
❑ Others:
❑ Foundation only
ut,ok,mirr i i"IN Ur w UKIt 1 U tsL rKtrUKTVIhU
Supervisor's Construction License: _ 47x;39 Exp. Date: i/7lo?
Home Improvement License: �Exp. Date: W
ARCHITE /ENGINEER !WAW- l Name: Phone:
Address*;9�a �/Lr � r C7—. Reg. No.A Vot. 3137o/
FEE SCHEDULE: BULDING PERMIT: 510.00 PER x1000.00 OF THE TOTAL ESTIMATED COST BASED ON
$12x.00 PER S.F.
Total Project Cost :$ x10.00—FEE:$ ��(]
Check No.:�n p Receipt No.:7
OF SEWARGE DISPOSAL
POE
TYPE
v
Tanning/Massage/Body Art ❑
Swimming Pools
Public Sewer
F1Tobacco
Sales
Food Packaging/Sales Ll
Well
Permanent Dumpster on Site f�
Private (septic tank, etc. Ej
NOTE: Persons contracting with egistered contractors (to not Nave access to are guarana
Signature of Agent/Owner _ Signature of Contra or 16
Plans Submitted e PPlans Waived ❑ Certified Plot Plan *Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATI
i COMMENTS
DATE REJECTED
❑ ❑
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
REJECTED
DATE APPROVED
DATE APPROVED
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision:
DATE REJECTED
❑ ❑
Comments
Conservation Decision:_ Co
Water & Sewer connection signature & date
Temp Dumpster on site yes—no— Fire Department s
Building Permit Approved and Issued by:
DATE APPROVED
(6)v 91�j
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required Provided
123'
/M /Ae
> �� -,I
DIMENSION
Number of Stories:
Total land area, sq. ft.: X50
Total square feet of floor area, based on Exterior dimensions.
NOTES and DATA — ( For department use)
Dix: INSPECTIONAL SERVICES DEPARTTMI:NT:BPI 0RM0 5
Created JNIC hn.:000
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
❑ Debris Removal Form
❑ 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
❑ Form U
❑ Surveyed Plot Plan
❑ Debris Removal Form
❑ 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 Pen -nit Application
❑ Form U
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses j
❑ 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 DEPARTMEN'T:13PFORN105
L -o -r- 41
;. CERTIFIED FOUNDA TION PLAN
LOCATED. /N
SCAL-E DATE" r2 g3
2
jScott G. G//es R. LkS .
50 Deer, Meadow. Rood
North Andover, Moss. u
1 /nlove
X1.1 4•
L_ dr 4
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DEC 2 2 1993 L-- A
L- Q-' 20
/ CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE Of
THE OFFSETS OF THE SU/L DING /NSPEC.TOR ONLY
. SHOWN COMPLY AND SUCH USE /S FOR THE
WITH THE ZONING _ DETERM/NAT/ON OFZONING '
SY LAWS OF CONFORMITY OR NON- CONFORM/TY
WHEN CONSTRUCTED.
WHEN BUIL T.
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
_ i"
RegISOB00
zn: 105485
117/2006 -
Type Supplement Card
SOUTH SHORE GUNITt POOL & S
116KRT FISKE
7 Progress Ave.�.,�
Cheb»sford, MA 01824 Administratof
✓/. �o?,�n�,t,,.�a/,tl o�,iT�l�aacluaei#
BOARb OF BUILDING, REGULATIONS
License: CONSTRUCTIbN SUPERVISOR s
Number: CS 076339
Birthdate: 07/07/1946
007 Tr. no: 15233
Resp 00, ,
RO13ERT J. FISI(t
5 TANtsLEWOOLI WAF K co,
HAVERHILL, MA 01830 C
CommissbneY
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y, \ The Commonwealth of .Massachusetts
Department of Industrial Accidents
'I Office of Investigations
600 Washington Street
a ri Boston, ,VIA 02111
W W W. niass.go vld l a
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(13usinCss/Orzanizatioll/111(liVidllal):
Address: � � �� * —
City%State/Zip: 64,e�,,_o Phone #:
Ael
u an employer? Check the appropriate box:
I .am a employer with go 4• ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.]'
have hired the sub -contractors
listed on the attached sheet. i
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
$. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I .❑ Plumbing repairs or additions
12.❑ Roof repairs
13.E 'OtherZeff AVO? *5
*;\ny applicant that checks box 9 1 must also I'll out the section below showing their workers' compensation policy information.
y 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.
1 um an employer that is providing workers' compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:—__ /Xr11V'—wlw�--- ---
Policy'? or Self -ins. Lic. #: 9la�<3Y S q 31 Expiration Date:_L=- Z6 4s --
Job Site Address://�/R` ' i��—_ CityiState/ZipAir/�OU�iC
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 IvIGL c. 152 can lead to the imposition of criminal penalties of a
tine Lip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the forth of a 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 certify a er to pttins and penalties of perjury that the in ormation provided above A trate and correct.
Phnnr� .. "Rev i
O/ficial use only. Du not write in this areo, to be completed by eity or loon g1ftcial.
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 #:
Location I I �1140
No. 6clv Date
TOWN OF NORTH ANDOVER t
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee pooL s
TOTAL
Check # bo
9(,86 Building Inspector