HomeMy WebLinkAboutBuilding Permit #820 - 315 TURNPIKE STREET 6/6/2011Permit NO•
Date Issued: (P `
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
IMPORTANT:
Date Received
must complete all items on this
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MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
11 Addition
El Two or more family
❑Industrial
❑ Alteration
No. of units:
❑ Assessory Bldg
❑ Commercial
❑ Repair, replacement
❑ Others:
❑ Demolition
Other
Well
�Q`Floodplam . Lt�'Vi7etlands #
' 'Watershed++District
_
_ f
DESCRIPTION OF WORK TO BE PERFORMED:
72 C3 ' USE? P -f - 40rUiy1 on/ wV LKe"ND
Identification Please Type or Print Clearly)
OWNER: Name: �41-(e5 644,v2l Phone: bc)777
Address:QOX '409 "L"'10 IJ A'*( C' 135.
CONTRACTOR Name: n�� 4Fivre` Phone:
Address: ^ . ezk /Y7Q /__Ar ,rro.1# AVN C).7Ps t
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: FEE: $
Check No.: ' 9 05 Receipt No.: P4,), t
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner : Signatu�e:of contractor ..A.:
t._.
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
E
WERAGE DISPOSAL
❑ Tanning/MassageBody Art ❑ Swimming Pools❑
❑ Tobacco Sales ❑Food Packaging/Sales ❑
c tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
.COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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
NUI to anu uKim-11
® Notified for pickup -
Date
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i
Doc:.Building Permit Revised 2008
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
❑ Engineering Affidavits for Engineered products
NOTE: 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/Crossection/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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
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
❑ Engineering Affidavits for Engineered products
MOTE: 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
Chat 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: Doc -Building permit Revised 2008mi
Location f/7f/1yy/%9G
No. v Date 41
TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
'�s���, s ct•' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 4 18
Building Inspector
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P.O. Box 478, Newton, NH 03858 O grja.w
Toll Free 1.888.APEXTENT ,'A 0) Z
(1.888.273.9836)
Phone 603.382.1777 • Fax 603.382.2177
Ak www.apextent.com
TENT RENTAL
RENTAL CONTRACT
Customer Name l U.Alf^4A 1 1 rP a, -W A A 4 —
� `ck
Contact Name email
Street City
'-u W ( -"
Phone 9— 8- 53-7 - 5119 Fax
Scheduled Date of Function TV -W 1 D 111 D Set Up Date
Tent Sizes & Descrintion
Statey� Zip O) $t{ S
Am^11"+
X K/
-
Tables:
8' Banquet 6' Ban uet _ 30" Cocktail
60" Round 48" Round 36" Round 72" Round
Chairs:
White Pol fold White Padded Garden
Green Pol fold Gold Chivalri
Linens
Dance Floor Number of Sections:
Lighting
Heaters
Misc.
Rental Terms & Conditions
1. Renter agrees to not cook under any Apex Tent Rental structure.
2. Renter is responsible for any and all damage to Apex Tent Rental property.
3. Apex Tent Rental equipment is guaranteed to perform the functions designed
by the equipment manufacturer.
4. In the event of severe weather situations, renter should evacuate all tent
structures and seek shelter indoors for safety.
5. Apex Tent Rental is not responsible for damage to renters' property or injury
sustained by renter or guests.
6. Apex Tent Rental employees will be allowed on the property at any time in
order to set up, maintain or dismantle Apex Tent Rental equipment within
the dates agreed upon In this contract.
7. All deposits are NON REFUNDABLE.
Subtotal $
Delivery Charge
TOTAL $
Less Deposit $
BALANCE $
Must be paid in full before set up
I have read and agree to the above contracted fees, terms and conditions.
Customer Signature Date
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): /4P& -t, -r6^4--
Address:
r6^ --
Address: %'b a-�A �17g
City/State/Zip: &✓ ,c/K 03658 Phone #: I03- ?aS -/777
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.�'I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
[No workers' comp. insurance
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
1011 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*Any applicant that checks box A 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address:
City/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. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK 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 Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenayies ofperjury that the information provided above is true and correct.
'3- 588 -
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. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
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