HomeMy WebLinkAboutBuilding Permit #764 - 29 BEAR HILL ROAD 5/18/2007Permit NO:
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
'Repair, replacement
❑ Demolition
PROPOSED USE
Residential
❑ One family
❑ Two or more family
No. of units:
❑ Assessory Bldg
❑ Other
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
RIPTION OF WORK TO et PKt1-UMMt:U: ,
✓' %, o41 ry U/ndD / SI✓JlA,, - ly`'�
fzc
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULD/NG PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
X
Total Project Cost: $ SFEE: $ i Z- ---
—
Check No.: 73 7 Receipt No.: C�0 23
NOTE: Persons contracting with unregistered contractors do not have access to Mguaranty fun j
Signature of Agee
ri
Location C>I
No. s,r %G K Date - I'd-' 0-9—
TOWN
T
TOWN OF NORTH ANDOVER
Q ,taao ,a
Certificate of Occupancy $
sAemustA Building/Frame Permit Fee $ �f
Foundation Permit Fee $
Other Permit Fee $
2T_O_TAL $
Check # -?3 T
2a2�O
'A—Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools U
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
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
CONSERVATION ❑
COMMENTS
HEALTH ❑
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
Comments
Conservation Decision: Comments
Water & Sewer Connecti
Located at 384 Osgood Street
Zoning Decision/receipt submitted yes
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 21A —F and G min.$100-$1000 fine
NOTES 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
0
.-Q mp i
a Flo*PjAn Or Proposed Interior Work
U Engi ring Affidavits for Engineered products
NOTE: All dum 'ster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
L, Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
a Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
u 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 In Accidents
OVIee of Investigations
600 Washington Street
Boston, MA 0211,
Workers' Compensation Insurance Affidavit Bui dere/Contractors/Ele
ADD licant Information ctricians/Plumbers
Please Print Le bl
Name (Business/Organization/Individual): �S r �/ � %� �rS
Address: %j 5X
City/State/Zip:I (� (nJ �3 Phone #: 3 OS
3-- S=
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I Type of project (required):
2.Xemployees (full and/or part-time).* have hired the sub -contractors 6. ❑ New construction
I am a sole proprietor or partner- listed on the attached sheet x
ship and have no employees C] Remodeling
These sub -contractors have 8. ❑Demolition
working for me in any capacity, workers' comp, insurance.
[No workers' comp. insurance 5. ❑ We are a co 9. C] Building addition
required.] corporation and its
Officers have exercised their 10•❑ Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work right of exemptibn per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp, C. 152, § 1(4), and we have no
insurance required] t employees. [No workers' 12.r❑] Roof repairs
comp. insurance required.] 13. 1]' Other 2,r t„06,bp��r•
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this amdavit 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 showing the name of the subcontractors and their workers' comp. policy information.
am an employer that is providing workers' compensation
information. insurance for my employees: Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration e (showing the Policy a p number and expiration date).
Failure to secure coverage as required under Section 25A of MGL . 52 can lead to the imposition of criminal penalties
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORT{ ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offic of a
Investigations of the DIA for insurance coverage verification. a of
�- •,, � � -«suy, unaer me pains and penalties of perjury that the injormati°on provided above is tape and correct
i na re:
D te•
hon #: tT 3® 5_3
Official use only. Do not write in this area, to be completed by city or town ujjiciaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other 4. Electrical Inspector $. Plumbing Inspector
Contact Person:
Phone #:
Charest Builders
PO Box 1288
Plaistow, NH 03865
Name / Address �]
Tom Beck
29 Bear Hill Rd.
No. Andover, MA 01845
9 K X/M CEJ�0
Date 5/1012007
Estimate # 7
Description Qty Rate Total
Removal of water -damaged wood on exterior of
home.
Replace all water -damaged wood and use proper
methods to help prevent future water damage.
All job debris will be placed in landfill (LL&S, Inc.)
1
Charest udders
charestiisa@yahoo.com
603-303-3539
0.00 0.00
5,500.00. 5,500.00
Subtotal $5,500.00
Sales Tax (0.0%) $0.00
Total $5,500.00