HomeMy WebLinkAboutBuilding Permit #79 - 255 MIDDLESEX STREET 8/4/2006Permit NO:
Date Issued: s
TOWN OF NORTH ANDOVER
pORTFI
APPLICATION FOR PLAN EXAMINATION o` <t�tD q -
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Date Received L(
74 pR'TE D 91
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IMPORTANT: Applicant must complete all items on this page I
LOCATIONS " 2'
PROPERTY
MAP NO.: PARCEL:
TVPF. AND iTRF nF RITII,DING
ZONING DISTRICT:
RIWORIC DISTRICT VES fl
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
n❑epair, replacement
emolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
el-
Identification Please Type or Print arly)
OWNER: Name: ® ort s e- /f -c—&—/ Phone:
Address:
CONTRACTOR Name:
4 &4771- �
0
6�5 "_Yezo
Address: :7,0 4 J�F I r(IO4-e't r N64—e-tz k *—&2w ? /
Supervisor's Construction License: o q2 yc% 3 Exp. Date: 131 d /
Home Improvement License: j b -Z 0 Exp. Date: I 0
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
4
FEE SCHEDULE. BULDING PERMIT. $(p � 4 0 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ � x12.00=FEE:$
CheckNo.: ��� Receipt No.: �.
Page I of 4
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
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Paur. 4 of 4
TYPE OF SEWERAGE DISPOSAL
Art ❑
Swimming Pools 11r]Tanning/Massage/Body
Public Sewer
❑
Tobacco Sales ❑
Food Packaging/Sales 11
Well
❑
Permanent Dumpster on Site ❑
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner '\-l' Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition N
Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
DATE REJECTED
❑ ❑
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
DATE REJECTED
El
Comments
Comments
Q
DATE APPROVED
DATE APPROVED
DATE APPROVED
Water & Sewer connection/Shwature & Date Drivewav Permit
Temp Dumpster on site yes_no Fire Department signature/date
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Re uired
Provides
Required J Provided
Dimension
Number of Stories:
Total land area, sq. ft.:
NU I ti i and DATA — (For department use
Total square feet of floor area, based on Exterior dimensions.
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC. Jan.2006
Location DW - 3\��''
No Date ,
NORTH
TOWN OF NORTH ANDOVER
0� ..Ie .0., 0
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Certificate Occupancy
$
of
s�cNus
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check��
19320
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?IN
The Commonwealth of Massachuselts
Department of Industrial:leeidents
(` I 'y'
Office of Investigations
600 IVashington Street
' , � ix id
Boston AM 02111
www.mass.gov1dia
Workers' Compensation Insurance ,affidavit: Builders/Contractors/Electricians/Plumbers
applicant Information Please Print Legibly
Name ll)usincssr(hganiialionilndiviJual):
ftp ,C
Address: 70
/ - -
city: Stater Zip:�I� ��f Phone # �j
Are you an employer? Check the appropriate box: '
1. ❑ 1 am a employer with 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2.& 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.] ocers have exercised their
3. ❑ 1 am a homeowner doing all work riffight of exemption per MGL
myself. [No workers' comp. c. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
3. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I .❑ Plumbing repairs or additions
12.❑ Roof repairs
13.0 Other __
°Any applicant that checks bore!4I must also till out the section below showing their workers' compensation policy information.
I Iomeuwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating :;uch.
Contractors that check this box must attached an additional sheet slowing the name of the sub -contractors and their workers' comp. policy information.
I am tin employer that is providing workers' compensation insurance fur my emph�yees. Below is the policy and job site
in%urmation.
Insurance Company Name:% ----- --- ---
Policy It or Self -ins. Lic..=1:
Job Site Address:
Expiration Date:
C ity%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. 153 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 andor one-year imprisonment, as well as civil penalties in the form of a STOP NVORK ORDER and a tine
Of up to $250.00 a day against the violator. Be advised that a copy of this state vent may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains
Si.
penalties of perjury that the information provided ab eve .,s Irue uric/ correct.
9 L -f f o
!Yjiichd use only. leo ,rut write in this orea, to be conipleted b): cq, rir town gfflcial.
City or T,)% n: P,,rmit/License 4.,
issuing ,authority (circle one):
I. Board of Health 2. Building Department 3. City/To%n Clerk d. E?ectrical Inspector Plumbing Inspector
6. Other
cf)'Itact Person: Phone #: