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Home My WebLink AboutBuilding Permit #763 - 249 Marbleridge 6/8/2006� OF No oTH 1� ,SSACHUs�t Permit NO: Date TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 'G IMPORTANT:A must com Date Received: Z, all items on this LOCATION ^/1-4-446&00P �� Print PROPERTY OWNER �IJ691%(C� J f�it'P7' �F �4 Print MAP NO.: 3� PARCEL: AK ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE D—ao„*,�► I Non Residential ❑ New Building 00ne family ❑ Addition ❑ Two or more family ❑ Alteration No. of units: ❑ Repair, replacement ❑ Assessory Bldg ❑ Demolition ❑ Moving (relocation) C'Other ❑ Foundation only i 1 DESCRIPTION OF WORK TO BE PREFORM OWNER: Name: Address: �y CONTRACTOR Name: Address: a7c)`X��/ Id >Itification Please Type or Print Clearly) ❑ Industrial ❑ Commercial ❑ Others: �Z P�/� fP� Phone: r f l% /7Sa�D/1l� Supervisor's Construction License: 67 3� % Exp. Date: �" 0 Home Improvement License: /U� � Exp. Date: 7--1;2'O6 ARCHITEC /ENGINR_ 1146 Name: Phone: EE i k" Address/ G5%� !er✓�i/ d2i`" Reg. No.'6' 3/37 FEE SCHEDULE: BULDING PEWHT. $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASE ON $125.00 PER S.F. Total Project Cost x10.00=FEE:$ �— Check No.: rp Receipt No.: Page I of 4 S 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 Dor. INSPECTIONAL SERVICES DEPARTMENTMFORM05 Page 4 of 4 TYPE OF SEWARGE DISPOSAL Tanning/Massage/Body Art ❑ w i Smmin g Pools Public Sewer U�' V Well ❑ Tobacco.Su[al,es ��` El ' Ii -"'J Ly' Food Packaging/Sales 11�.Gl Private (septic tank, etc. ❑ Permanent Dumpster on Site Ll. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty Signature of A ent/Owner g g Tl �ec� Signature of Cont Plans Submitted L� Plans Waived ❑ Certified Plot Plan Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT DATE REJECTED DATE APPROVED ❑ � COG 0 ater Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS l>`ou, X' -e f / , A—", .-t ^at� DATE REJECTED CONSERVATION11 COMMENTS L& v, k i6 o o+ 6'X�z - 7-n 1 DATE REJECTED HEALTH A IVA ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer connection signature & date Comments Comments Temp Dumpster on site yesno_ Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 Q DATE APPROVE DATE APPROVED f� Building Setback( Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided ofl � li1.1VILINNION Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. NOTES and DATA — (For department use) Page 3 of 4 Doc: INSPECTIONAL, SERVICES DEPARTMENT:DPFORM05 Created JMC. Jan.2000 Location— `= 9—? No. A3 Date f &ORTPI TOWN OF NORTH ANDOVER • , Certificate of Occupancy $ b�•n '��(i CHU Building/Frame Permit Fee $ u Foundation Permit Fee $ Other Permit Fee $ $ TOTAL Check # 111�2 4s� 19381 Building Inspector Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Re9iSi"_. 1SU85 Expiration - - _ IZ-1/17/2006 - s T j. ype Supplement Card SOUTH SHORE GUNITE, POOL &,S MRAT FISKE,' 7 Progress Ave. Chelmsford, MA 01824 Administrator BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 076339 Birthd1W, 07/07/1946 Exp1na6: 07/07/2007 Tr. no: 15233 Restricted: W ROBERT FISKE 5 TANGLEWOOD PARK DR. HAVERHILL, MA 0'183D' - Commissioner I .4 \ The Commonwealth of Jlassaehuselts Department of Industrial: lccidents ^.`8'►;: i' 1 Office of Investigations ti El r / 600 Washington Street Boston, ,V14 02111 .., -, • www.mass.gvv/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information rPlease Print Legibly Name( BLISil'ICSSA h'CUIlliAlfit) Ili Ill (I k iklllill ;address: 7- Ale, _ City: State: Zip: �ial�,,,4W 0 018af Phone #• gem 4,y9 BjSD ,kre y u an employer? Check the appropriate box: ' 1. 1 am a employer with -9� __ 4. ❑ 1 am a general contractor and l employees (.full and/or part-time).* have hired the sub -contractors 2. ❑ I 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. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §l(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I .❑ Plumbing repairs or additions 12.❑ Roof repairs 13.[Other /AISIU111AsVA A ` any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. + Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating :arch. Contractors that check this box must attached an additional :;beet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance fir my emplgyees. Beltrw is the policy and job site information. Insurance Company Name: __-- Policy 'l or Self -ins. Lic. 4: kC966 _ Expiration Date:_ i �% lob Site Address:, w'? � Gi2�9� Ay City State/Zip:/Y' %OdeV7 , 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 %IGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one-year imprisomnent, as well as civil penalties in the form of STOP NVORK 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 DLA for insurance coverage verification. / du hereby cer ly underjke7 Tins and penalties of perjury that the inj�rmation provided above is true and correct. S i" I'hone // Date: S --Ig- e6 !1/Jirird apse r,uly. 1)u rrot write rn this r,r��a, !u bc:•nrnplcted h4• r.rll� r�r tr>ty» uJ�e•ial City or Tnwn: :Permit/License 4 Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk d. E!ectrical ? nspector Flumbing Inspector 6. Other CoMact Pcir on: Phone #: m m m m YI m mm CD H d C •C Cos Cl) 'v O CD C) Z y CD 0 O.a. y v CD CD o Q CD o CD C O CA �. CD CLO y C S v CACD O oCD 0 A O C y 0 0 d Z m co an am n m n .O.a .+ W K O N. T �v1 x R': O O N� CJ AY CO . O o %=x: O O O N m l 1i� O N lw' : V N a cr now CL o � � a N �1 0 m '^ V) y N r� O O !1I • m w N BSmi'�`: rn ?wam A �C om o z god � CD S P .d � cnm 1 m N •�• d =m: m m : 1 O CD: cn cn w ~ b z ,w',t1 c7� o M M '�1 �1 n5► O z � / D o a G7 r- O r� n c r c o O O • CL 0 c