HomeMy WebLinkAboutBuilding Permit #479 - 217 BEAR HILL ROAD 2/13/2008Permit NO: !1h. i
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
FO A
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
— ne family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
e ra riri a laceme
Assessory Bldg
Others:
Demolition
Other
Septic Well .. `
Floodplain 1Netlands
1/atershed aDis#rict
Wa. ter/Sewer . . ,...:,
PTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: b 4YID K6LEA Phone: g7J-687-1572-
ARCHITECT/ENGINEER
I:!�T•m1
Address: Reg. No.
Location �f` r 2 t PL `" ti
?. U
No. G ` Date . ZJ /
NORTH TOWN OF NORTH ANDOVER
� 9
s ; ; Certificate of Occupancy $
cMus S Building/Frame Permit Fee $
s�
Foundation Permit Fee $ j
Other Permit Fee $
TOTAL $ +
Check #
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
ti
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Dimension
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 2 1 A —F and G min.$100-$1000 fine
NU I E5 and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
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
❑ 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
❑ Floor/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
NOTE: 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
❑ 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
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The Commonwealth- of Massachusetts
Department.of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www-massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieianslrtumbers
lame usiness/OrVmizationitndividual): Pel' W 44Ow-s CA IL .104-s 1^�
Ld&css: qS pond',
;i /State/Zip:, A%;ec MAr oW31it i> � ���r �R���Z—�S•%2S5
re you so employer'. Checkthe appropriate box: :; .: t
Type -Of project (requittd):
I am a employer with 2'S
4. ❑ I am a general contractor and 1 '
6. ❑ New construction
employees (full and/or part-ttme).'�
hired tfie sub-Fontraxtors
listed on the sheet_:
❑ RenOcling-
❑ I'am a sole proprietor or partner-
ship and have no employees
aftachtd
Thest sub-coraactots have
8 ❑ Danolition: '
working for me in any capacity,
(No workers' comp. imurance
workers' comp. insurance.
S. ❑ we are a corporation and its
9. ❑ Building addition
10.0 Electrical Tepairs ar additions
required:]
❑ I ata a homeowner doing ali.work�
officers -have exeicised their
right of ex r MGL
ton per
11.0 Pltlmbtng repairs -or additions
myself. [No workers' comp. '
='ct 152, § 1(4), and we have-nb
12.0 Roof Main
insurance required.] 1
employees: [No workeis'
13.❑. Oder
comp. insurance requiisd.j
ay sppliunt d�st'etucb box 01 must also fill out the section bdow showios `� Umpau8i�►poli1Y ibfom►atian"
lom js wbo mbmit Ods affidavit indicWa j ibey ate doiss all week atd dken bice .outside ooatradots must submit ! neN► a>tdavit indigtiag such.
oatracto� thst check this box must.attached an additional soca showing the. name of the sub-c*Wnc m aid rheic ++��• °01°p policy in[oematioa
un an CMIyer Mat is provtidinr-ivorkkers'.contpensadon.inrts;gncc foritq► Below it the poGcy.and job. site .
%rrrtotion. - •any Name: �P` C0� � . Ci^ V r � {� . � • _ - " • - -
sur � comp
)Iicy * or. 5eif-ins. Lic. C Q%W G N L-_ 5 7&4 2 E,tpuation Date'
)b Site Address: City/Statt:/Zip: k .
date)
,teach a copy*[the workers' compensation policy -declaration page (sDowingtke policy number and eipiration .
ailitre to secure coverage as required under Section 25A of MGL c at lead do .152. cthe imposition of criminal penalties of a `
ine up to 11,500.00 hnd/oi one-year imprisonmeat, -as well. as c64l penalties in -the foriu of a STOP INORK ORDER. and a fine '
f up to $256.00 a day against the violator. Be advised that copjrTpf, fir stitanent may be forwacdcd on the Office of
nveitigations of the DIA for insurance coverage vetification.
' do kereby'certify under the peLw- acid penellies 'ofPcOury that the _information provided above is. true aced correct
'-6sS-'7155
Ops -C d -ase only. Do itot. lvrite• in this; Brea; to- be complete by city or town offieiaL .
City or Town- Pert�it/Licewe M
Inning Authority (ciride one): tot S. Ylnmbiag laipectoi
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CERTIFICATE -HOLDER CANCELLATION
r1oradi
dows SIG Doors, Inc. SOOMCI AWOfTME ABOVE 0E"CI100 PMX'XS Se C" r-* fo OEPORETNEE]I "TM"
Road DAE :TE ISSUM INSURER MlL VOWAV'OR TO WAX. TOoAYs W�lll, IVIA 01830 MOTICE TO TILE C&RM CAW "OUDER K"" TO TILE LEfT. BUT fAlk.URETO 00 io "MAIL
WOSE NO OwISAIM oft LINK T OF AW1010 UPON tNE> T13 A*"" OR
wTTilEL
AYINOItltEORE11�"EIITATIVE:,�.` :..............! .. • - • .
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R CERTIFICATE OF LIABILITY INSURANCE
mnlRoo7 111007 o9 -s6 '
,00ucat (300)125-1965
THIS CERTIFICATE IS ISSUED AS A MATTER'OF INFORMATION
ONLY AND CONFERS NO RIGHT$ UPON THE CERTIFICATE
rtvAC C. Cbufa
HOLDER. THIS CERTIFICATE DOES NOT AMEN, EXTEND OR
Il S�oe1
it Wel
ALTER THE COVERAGE AFFORDED OY THE POLICIES BELOW_
ivlA01eet
loa225-1e65
•
INSURERS AFFORDING COVERAGE MAIC E
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My" A. Haacva 1aAlnacc CNIVWX
Ua Wiodc!►s d�Doo/s. lac.
111st111Hta; T'wia Ciip Fsa kmmu Co. -
Fendi Road
,vutill, MA 01332-1302
•
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INwRERo:
'
suRER e - '
•
:OVERAGES
THE POLICIES OF M'IS.URANCE LISTED BELOW HAVESON ISSUED;; THE INSURED NAMED ABOVE FOR THE POLICY PER100•MrDICATED. NOTWITHSTANDING
ANY REQUIREMENT; TERM OR CONDITION OF ANY.CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY. PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THETERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN.REOUCED sY PND CLAIMS.
POLICY NUMOEII EliECTTi1E Pa ElQr1A11011 Lwnx
OENEIIAL ummM
' , EACH OCCURRENCE S1.000,000
X COMMERCIALGENEWLMIM"500,000
MIMEg
Cl IMS MADE MX OCCUR
MEO EXP. Woe an 10.0m
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—71
Z.BN9161107 1 IMI 7/112003 PEASONk 4, ADV M►AIRr 21.000.000
GOIEKALA 82.000.000
PRODUCTS, C0111pI AGO 6 2.000.000,
OEKLAGGREGATEUW APPUD ICBM
fWc.y ` . X LOC
AIITOaIOD"11AM►ITY
cohmolto SOME WIT '
i 1,000,000
AF*AUTO'
X ALL OWNEO AUTOS
f _
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scNEol><EDAUTes
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X MREOAUTOS
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At7�0OIAY. AOO
ucEssAr wlwllRY"
EAL110CC11ME?ICE• $ 9000.000
:X) OCCuft CLAIMS MADE
AGGREGATE 9,000,00.0'
A
UANe16"05 7/112007 71112003 s
.
aoUcnaE
- .
X RETENIflON
1NO 114M& COUMN"J"AND
w
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EL EAChACc1oET1T i $00000.00
BOMEAIET'ECUTIyE
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,
El 015EA"E - POLI�r uMIT' 500,000.00
OTH" .
pEaC111PT10NOFO►EIIAr10115/LOCATONi/VEINCIES/EkClU510MSADOEO�YETIOOIISEYENTI3[•ECIALMONi10Ni
CERTIFICATE -HOLDER CANCELLATION
r1oradi
dows SIG Doors, Inc. SOOMCI AWOfTME ABOVE 0E"CI100 PMX'XS Se C" r-* fo OEPORETNEE]I "TM"
Road DAE :TE ISSUM INSURER MlL VOWAV'OR TO WAX. TOoAYs W�lll, IVIA 01830 MOTICE TO TILE C&RM CAW "OUDER K"" TO TILE LEfT. BUT fAlk.URETO 00 io "MAIL
WOSE NO OwISAIM oft LINK T OF AW1010 UPON tNE> T13 A*"" OR
wTTilEL
AYINOItltEORE11�"EIITATIVE:,�.` :..............! .. • - • .
ACORD 2S (1001104) Q;�t B s96o ygt,3 07 Ot cx. Auto, WC fc eetieil O ACOIto CORYOgAT1oN 111164