HomeMy WebLinkAboutBuilding Permit #540 - 24 COVENTRY LANE 2/16/2006OSHORT„
O
° p TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received:c�"/&-' 0(
Date lSSUCd: -�1' V/.— O&�'
IMPORTANT: ;Applicant must complete all items on this page
LOC:MON_____21q COVErJTi�-�/ LSE
_ Print
PROPERTY OWNER fVVC4-0 -r- BATULd A24CJ,- j3/
/, Print
MAP NO.: __b___PARCEL:�i3� ZONING DISTRICT:
TVPF ANP IICF. OF RUMBING
HISTORIC DISTRICT YES ❑
i TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
Addition
_ . Alteration
)'One family
- Two or more family
No. of units:
Industrial
_ Repair, replacement
i Demolition
- Assessory Bldg
- Commercial
Moving (relocation)
Other
- Others:
_! Foundation only
L
DESCRIPTION OF WORK TO BE PREFORMED __/ 96 T4 L -L /6) IIi/V.KZ-
P—/ r9C m i"T"' wi NoDws lj9 tiff
0
Identification Please Type or Print Clearly)
OWNER: Name:,&j0C'6"j " ApegAzv 9ACk_,5—c/ Phone:
Signature a .
Address:
CONTRACTOR Name: 'Pic —K.4 �ezyp Phone:'360' 7J
Address: 113 Cr -OP --O ST lyliL-60,0 /f?J°, ®/2S7
Supervisor's Construction License:
Exp. Date:
Honlc Impro,cnlctlt Liccnse: 1�20q�46 Exp. Date: 7 ""
ARCI IITECT, dame: I'llone:
:Address:
eg. No.
FEE SCHEDULE: BC-LDLVG PER,VIIT: 510.00 PER $1000.110 OF THE TOTAL EST131ATED COST BASED ON
S 125.00 PER S. F. 00
Total Projcct Cost x`10.00 -FEE:$
Check No.: Receipt No.: /
,�-�.� --
Location �'-
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $'4 td
Check # //7 zd
18982
/ Building Insp ctor
l%
TYPE OF SEW ARGE DISPOSAL
Public SeNver
well ,
Private (septic tank, etc.
Tannin-/v1assage Body girt Swimming, Pools
j
Tobacco Sales -- Food Packaging, Sales
Permanent Dumpster on Site
NOTE: Persona contracting with unregistered conlructors do not have access to the ;;uuran{j fund
Signature of Agent/Owner
Plans Submitted
Signature of Contractor
Plans Waived E Cerci tied Plot Plan 1-i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Stamped Plans
DATE REJECTED DATE APPROVED
i
❑ Water Shed Special Pen -nit
�J Site Plan Special Permit
Other
DATE REJECTED
CONSERVATION - ❑
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED DATE APPROVED
0 D
Zoning Baird of Appeals: Variance. Petition No:_
Zoning Decision, receipt submitted yes
Plannim,, Board Decision: Comments
Conservation Decision: Comments
bVater & Sewer connection signature , date
Temp Dumpster on site )�es___no _ Fire Department sivnature.'date
Building Permit Approved and Issued by:
Building Setback (ft.) I
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided
DIMENSION
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
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 Debris Removal Form
u Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
j Copy of Contract
u Floor Plan Or Proposed Interior `'York
Addition Or Decks
u Building Permit Application
u Form U
u Surveyed Plot Plan
u Debris Removal Form
u Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic
Calculations (If Applicable)
u Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
Li Building Permit Application
u Form U
u Certified Proposed Plot Plan
j Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic
Calculations (If Applicable)
u Copy of Contract
Mass check Energy Compliance Report
lu all cases if a I ariance or special permit was required the Town Clerks office must .;t,amp the decision from (lie Board of
#ppeals 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: I\SPEC*noN.kL SER% ICES DEPAR'r%IE\T:RPF0R\NI5
�ls(�am�.u»zcuea�t!./�%caaoacLuaPlta '
Board of Building Regulations and Standards. License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
7, Board of Building Regulations and Standards
Re i 456 One, Ashburton Place Rm 1301
oos
c
Boston, Ma. 02108
v piement Card
611 -RAY Al: -UM
PAUL GARY K�
40 ELMQN7?U
ELIVIDNT 1+11 � � 003 :Administrator Not valid without sig141,
/_1
?'tie Comm
onweajaz of Massacl
Depart*e.Yzt..qfIndustrial AccL
office, of bzvestigations
-00 WStreet
ashington
Bosion, MA 02.111
g
www.mass,ov/dia
Workers' -Compensatian Ilmsm-ance Affid-a-wt: -BuRdeirs/C
Name (BEzsinesSfozggai
A
01
City/ Phone,
ers
Please ?'tint-Le2ibl-V
ire you an employer?-Checkthe'zn ro'
p priate box -
I.% I an , employer with
4. -ED fam a general contractor and 7
employees (Bill and/or part-time).*
have hired-the.-za-cont tactors!
I un a sole proprietor or partner -
listed on the attached sheet
shp and have no emplq7ers
These sub-contractorshave
worldmg forme many capacity.
workers', comp. =zurance.
.No wormers' comp insurance
5. ❑ We area corporation audits
officers have exercised their
reqLdred-I
3. ❑ 1 am a homeowner doing all'work
right of exemption per MGL
Myself N -O -Work=' COMIP.
c. 152,;.§ 1(4), and. -we liaveno I
instuance req died j t.
employees, [No workers'
msurancq required_]
comp.
Type of prdje
6. No1 'cc
.-W
7.
8. ❑ Demolj
9. ❑ BL�_M
10:7 Electii(
I
12. ❑ Roof rl
I
13.:E] Otheg-
(required):
addition
I repairs or addbions
repairs or additions.
-Any applIc=rtbat checks box rj must also nu ointne secuon ociuw z.Luuw,u6
T H=eown= who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new i �ffidavit indicating such.
tCont-actors that check this box must attached an additional sheet showing -the -n—e of the sub -contractors and their workers' c0IIrP- Policy infmanation'
I am an. employer that isprovidingworkers' compensation insurance for my employees. Below is tIr'policy and job site
hM=Mc_- Company N,,Z4V 62-1
Policy or Sedf-iu& Lic. #.. W
#_ r_ 3 6 B#jcatLonDate._
I& . Site A&h—
-kttachacopy ofthe workers' cdm-pens Jon policy declaration page (showinithe' policy nMUI
FaDure, to secure covara:ge as retpimd -ander Section 25A of MGL c. 152 can lead to the imposition
tine up to 51,500.00 and/or
one-year -rmpr onment, as well as civ -Il penalties in the form of a STOP
ofUPto 5250.00 a day against the violator. Be advised that a copy of this statement may be forwar
Investigations G; tfle DIA- for ins=0e coverage Ve r—i fl- catiOP.
ofperfury- that the informationprovidad above is
I do hereby certify under the pains
0 w I c
Of use-only..Do not rite in this area, to be completed by city Or town Offi'aL
City or Tow -m
Issxdng ATrth rity (circle tiic2i Inspector 5-
El
4
Clerk. ec
one)-
1. Board of Health 2. Bmildbag Department 3. City/TownJ
6.Other
Contact Perso Phone
— ef
and expiration date)_
criminal penalties of a
:)pa ORDER and a fine
to the Office of
ue andcorre--J-
� 0
:pmbimag. Ins-peztor
n
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