HomeMy WebLinkAboutBuilding Permit #945-15 - 29 BLUE RIDGE ROAD 5/20/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Permit
Date Issued:
LOCATION
1?qPORTANT: Appli,
� A1,116? lfl�
must comDlete all items on this
Ir
PROPERTYOWNER 7Z-17Yf &,P1914—r
1/11' f Print 100 Year Structure
MAP PARCEL: ZONING DISTRICT: Historic District
Machine Shop Village
yes On
yes
yes
F 0-,;-,
TYPE OF IMPROVEMENT
PROPOSEDUSE
Residential
Non- Residential
El New Building
Xbne family
0 Addition
El Two or more family
El Industrial
Alteration
No. of units:
0 Commercial
El -Repair, replacement
El Assessory Bldg
11 Others:
El Demolition
El Other
OWNER: Name: -
Address: A
Contractor Name:
Address:
DESCRIPTION OF WORK TO BE PERFORMED:
I Ir -
=M
Identification - Please Type or P int Clearly
la, -1 V,4 Phone: F7t- ?7-57-65,6-7
&- h ";
on� hone:
Supervisor's Construction License: <51r— 67aY613 —Exp. Date: -
Home Improvement License: Exp. Date:_
ARCHITECT/ENGI NEER
Phone:
46
Address: Reg. No.
FEE SCHEDULE. BULDINGPERMIT.'$1200 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ 74P�9 FEE: $ kL47
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have ac -cess to the 9"Uarantyfund
-v-1
Location C�q
Date
Check #
80 3
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $Z�
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Building Inspector
Plans Submitted [I Plans Waived 11 Certified Plot Plan [I Stamped Plans 11 ..f
TYPE OF SEWERAGE DISPOSAL
Public Sewer 11
Tanning/Massage/Body A -it
Swfiming Pools El
Well El
Tobacco Sales El
Food Packaging/Sales El
Private (septic tank, etc. El
Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on - Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision:
Comm
Conservation Decision: Comments
Water & Sewer Connectionisignature & Date Driveway Permit
]DPW Town Engineer: Signature:
a-
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.si oo-si 000 fine
NOTES and DATA — (For department use)
LJ Notified for pickup Call Email
Date Time Contact Name
.............
Doc.Building Pen3ait Revised 2014
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 0.
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract V
4. Floor Plan Or Proposed Interior Work
,t Engineering Affidavits for Engineered products
IOTE: 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/Cross Section/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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two -Family)
,4� Building Permit Application
,4, 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Doe: Building Permit Revised 2014
—jo
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
S 53,780.00)
M
$
$
645.36
Plumbing Fee
$
80.67
Gas Fee 100 comm.
$
110,000
Electrical Fee
$
80.67
Total fees collected
$
906.70
29 Blue Ridge Road
945-15 on 5/20/15
Kitchen Remodel
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Tanya Gould
29 Blue Ridge Rd.
DEXISBOUCHER CONSTRUC7yoN
13 PLEASAJVTST
GROTON
, AIIA 01450
978-250-9493
North Andover, Ma 0 1845
H(978)975-0657 cell (508)320-6179 tanyagouldl@gmail.com
We hereby propose to furnish material and labor for the completion of
KITCHEN REMODEL:
Proposal
04/01/2015
job type: Kitchen Remodel
Page No--I_ofl__I—.Pages
I - Remove all cabinets and tile floor.
2. Install new wood flooring chosen by customer (allowance $3,300.00).
3. Install owner supplied cabinets.
1. Extend kitchen ceiling approx. 12" to include 5" crown moulding.
5. Install new granite tops (allowance $5,000.00).
0. Plumbing will be to code & include hook up of owner supplied appliances and new sink and faucet (allowance for
sink and faucet $1,200.00).
7. Electrical will be to code and include hook up of owner supplied appliances and new fighting (allowance for lighting -
recessed cans & rope and labor, $1,000.00).
3. Remove wallpaper in kitchen area and paint all walls and ceiling.
). Install 3" black granite under fireplace.
0. Install owner supplied backsplash tile.
1. There will be a $600., 00 allowance to work with heat issues.
2. Retrim cased opening between kitchen and front entry.
3. Does not include cabinets or appliances.
4. Remove all debris from job site.
�T PROPOSE to furnish material and labor -complete in accordance with above s cifi ons for sum of -
pc cati
Fhirty Three Thousand Seven Hundred Eighty
3%mentTo Be As Follows:
$ 10,000 AT START OFJOB AND BALANCE PAID UPON COMPLETION
U material is guaranteed to be specified. All work to be completed in a
lbstantial workmanlike manner according to specifications submitted,
-r standard practices. Any alteration or deviation from above spm
volving extra costs will be executed only upon written orders, and will
�come an extra charge over and above the estimate. All agreements
intingent upon accidents or delays beyond our control. Owner to
un
ny fire, tornado and other -necessary insurance. Our workers are f y
�vcrcd by Workmen's Compensation Insurance.
Authorized
$33,780.00 )
Note: This proposal may be withdrawn by
us if not accepted widlik_3Q_days.
CCEPTANCE OF PROPOSAL - The above prices, specifications and
)nditions are satisfactory and hereby accepted. You are authorized -to Signature
the work as specified. Payment will be made as outlined above.
ATE OF ACCEPTANCE— 015 Signature—
Commiffed to Excelknee
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Name
I - -
The Commonwealth ofMassachusetts
Department ofIndustrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
. . . . . wwwmass-gov1dia ctricians/Plumbers.
Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Address: / 3 1111�1'nma__
bl-,o 7-0,A2
-5-;r,
Phone #: 7 7J P- S e 7 -2 - -7 5'0Y
Are you an employer? Check the app�opriate box:
lXj am a employer with --/—employees (full and/or part-time).*
2.F1 I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.F1 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no bmployees.
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insuranceJ
6. n We are a corporation and its officers ' have exercised their right of exemption per MGL c.
152, § 1(4), and we have no epployees. [No workers' comp. insurance required.]
Type of project (required):
7. E] New construction
8. ;KRemodeling
9. 0 Demolition
10 F1 Building addition
ME] Electrical repairs or additions
JZ. El Plumbing repairs or additions
13.E] Roof repairs
14.E] Other_,
I ation
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy inform -
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub-contiactors have employees, they must provide their workers' comp. policy number.
-&—y . --tion insurance for mv employees. Below is thepoliCy andjob site
I am an employer that is proviuIrIg WO -f,
information.
Insurance Company Name: -
2– Expiration Date:
Policv # or Self -ins. Lic. #:
7 - 7 J- /3-
,a City/State/Zip:
Job Site Address: ;2 ell olicy Weclaration page (showing the policy number and expiration date).
Attach a copy of the workers' compensation P
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under thepains and Ities ofperjury that the information provided above is true and correct.
'00177 natp. -r — / .5,— /"P -
Phone#: "0?
official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
issuing Authority (circle one): i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: — Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emp�loyees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual', partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city ' or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required" to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured' companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write �'all locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiv�r or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking - the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city pr town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required I to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write �'all locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
The Commonwealth ofMassachusetts
Department ofIndustrialAceidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
. . . . . . www.mass-gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PEP.MTTING AUTHORITY.
Name
Address: 13
-r;r,
0;i-%r/V,tnfP./7in- Aoolo-o 7-a,49 /" ,
Phone#: 77,P- Se -Z - -7 swy
Are you an employer? Check the app6priate box:
X., am a employer with __L_employees (full and/or part-time).*
In I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ i am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. n I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.F1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.:
6. n We are a corporation and its officers ' have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. E] New construction
8. MRemodeling
0-
9. [1 Demolition
10 n Building addition
11. E] Electrical repairs or additions
12, Plurribing repairs or additions
13. E] Roof repairs
14. E] Other,
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not, those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
6 B 11 1 cy
I am an employer that is providing workers' compensation insurancefor my empl yees. elowist epoi andjobsite
information.
C, XTAme: L
hisurance, onw—.7
Policy # or Self -ins. Lic. #: _W627 Expiration Date: 7-
4e City/State/Zip:
Job Site Address: elil /) 4r,
Attach a copy of the workers' compensation policy Teclaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisoninent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and Ities ofperjury that the information provided above is true and correct.
T)nf�
Phone#: — 9P 7"q. - se�z -Y
Official use only. Do not write in this area, to be completed by city or town official,
City or Town:
Permit/License #
issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person: — Phone#:
AR
INFORMATION PAGE
Issued.by LIBERTY MUTUAL FIRE INSURANCE
Policy Number WC2-31S-368214-014
RENEWAL OF: WC2-31S-368214-013
Account Number 1-368214
1. Insured and Mailing Address
DENIS P BOUCHER DBA DENIS BOUCHER
CONSTRUCTION
13 PLEASANT ST
GROTON, MA 01827
INS*6RANCE
175 Berkeley Street Boston, MA 02116
16586
Issuing Office 016C
Issue Date 08-15-14
Sub Account 0000
RISK ID 260525
Status 01 -!-' INDIVIDUAL
Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE
2. Policy Period: The policy period is from 07-31-2014 to 07-31-2015 12:01 A.M. standard time at the
Insured's mailing address.
3. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of our liability under Part Two are:
Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06B
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required below is subject to verification and change by audit.
Code Premium Basis Total Rate per $100 Estimated Annual
Classifications Number Estimated Annual Remuneration of Remuneration Premium
See Extension of Information Page
Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 2,749
Premium will be billed ANNUAL
Producer 0004-010038
BROWN & BROWN INSURANCE OF NEW
HAMPSHIRE
3 HOLLIS STREET
PEPPERELL MA 01463
WC 00 00 01 A 1987 National Council on Compensation Insurance,Inc. WC 00 00 01 B (NJ)
Ed. 07/01/2011 All Rights Reserved Page 1 of 1
Insured Copy
&N -
Boston, Tviassachuse s 02 116
Home Improvement Contractor Registration
Registration: 114800
Type: DBA
Expiration: 10126/2015 TO 244685
DENIS BOUCHER CONSTRUCTION'
DENIS BOUCHER
13 PLEASANT ST
GROTON, MA 01450 .. ....
U p
date Address and return card. Mark reason for change.
Address n Renewal [:] Employment n Lost Card
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
SCA 1 0 20M-05/11
Office of Consumer Affairs & Business Regulation
@OME IMPROVEMENT CONTRACTOR
Registration: - 1-1A890 Type:
xpiration:-.--_Jq�?,q�2 -1 DBA
DENIS BOUCHER CONSTRUCTION
DENIS BOUCHER
13 PLEASANT ST
GROTON, MA 01450 Undersecretary
W*
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
ot vali utsignature
Massachusetts - Department of Public Safety
Board of Building Regulat ions and Standards
Construction Supen-isor
License: CS -004613
DEfM P BOUCH"
13 Pleasant St
Groton MA 01450
Expiration i
Commissioner 0311912016
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5 170
Boston, Tviassachuseus 02 116
Home Improvement Contractor Registration
Registration: 114800
Type: DBA
Expiration: 10/26/2015
Tr# 244685
DENIS BOUCHER CONSTRUCTION,
DENIS BOUCHER
13 PLEASANT ST ---- --
GROTON, MA 01450
U date Address and return card. Mark reason for change.
ent 0 Lost Card
R Address F] Renewal [-] Employin
SCA 1 0 20M-05/11
License or registration valid for individul use only
office of Consumer Affairs & Business Regulation before the expiration date. If found return to:
ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
1,14800
,91 Type:
pgistration:
Suite 5170
DBA 10 Park Plaza
xpiration:
Boston, MA 02116
DENIS BOUCHER CONSTRUCTION-
DENIS BOUCHER
13 PLEASANT ST
ot Val'
GROTON, MA 01450 Undersecretary ar ut signature
W
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: C"W13 1-1�
Is t 44
DENIS P BOUCH"
13 Pleasant St 0"
Groton MA 01456
Expiration
Commissioner 03119/2016
2
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
U Notified for pickup Call Email
Date Time Contact Name
Doe.Building Penuit Revised 2014
M
Plans Submitted 11 Plans Waived 11 Certified Plot Plan [I Stamped Plans 11 .70
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art 0
Swi=ning Pools
well
Tobacco Sales 11
Food Packaging/Sales 11
Private (septic tank, etc. El
Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature*_
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
�oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
It
Planning Board Decision:
Comments -
Conservation Decision: Comments
Water & Sewer Connection
DPW Town Engineer: Signature:
Located 384 Os.qood Street
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
10TE:
Building Permit Application
Workers Comp Affidavit 0.
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
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
i6 Photo Copy of H.I.C. And C.S.L. Licenses
,;6 Copy Of Contract
4. Floor/Cross Section/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*
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
,;6 Building Permit Application
4, Certified Proposed Plot Plan
4, 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
10TE: 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: Building Permit Revised 2014
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
LOCATION 97
TANT: A
9/1/& llfl�
must comDlete all items on this
51
0
6— Print
PROPERTY OWNER 7Z4Y,-f ez,,�V-
1/11' Print 100 Year structure yes on(�
MAP PARCEL:— ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
Kone family
El Addition
11 Two or more family
El Industrial
Iteration
No. of units:
El Commercial
El Repair, replacement
El Assessory Bldg
0 Others:
0 Demolition
0 Other
f S5.i ig Q�Wel:
0 -'epj
in, Em"Vol.
-0 AW mr/%
Am
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or
OWNER: Name:
Address: A gr
FIN
Contractor Name:
Email:
Address:
Clearly
Phone
Supervisor's Construction License: eS-- aaYb1-7 —Exp.. Date: ., 3 -11'*' -1&1-- —
Home Improvement License: Exp. Date: 4�7
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEESCHEDULE. BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00PERS.F.
Total Project Cost: $ -160/ 74pv FEE: $
01
Check No.: ooe_o_-Ol Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the gou'arantyfund
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