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Building Permit #715 - 32 SECOND STREET 6/22/2009
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1- Date Received Date Issued: v / IMPORTANT: Applicant must complete all items on this page LOCATION G N r Print PROPERTY OWNER 4r- hE 0 1� Print MAP NO: PARCEL: '� ZONING DISTRICT: Historic District yes no Machine Shop Village ve no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alter tion No. of units: Commercial e air re lacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: '1-.� � oma-- PvRc* — K I Ili -r- tl-= OWNER: Name: Address: 3 -')- 15 x F ,o�-f �,) ;& fi�cationt \Please Ty i � r -ro t Clearly) €c c,*J b S'T 77,1� ��yF76 CONTRACTOR Name: 'T- Lf} 6V'l 0 Phone: 47 7E tf FcS 2 6'07 7 f Address: ? l �- _S -f-- P .a, A -P -.)D 6V E -k Supervisor's Construction License: :2 d 7 S Exp. Date: Home Improvement License: 1 t U Exp. Date: ,;Z7 1 ,;�-O / ARCHITECT/ENGINEER N Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. 1---- Total Total Project Cost: $ '7 F'U FEE: $ Check No.: 3 3 Receipt No.: r NOTE: Persons contracting with unregistered contractors do not have access tgegAarantyjfi nd Signature of AgenUOwner Signature of contractor h Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools 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 CONSERVATION COMMENTS HEALTH 'j COMMENTS u DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comm 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 NOTES and DATA — For department use ❑ Notified for pickup - Date 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 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 2.2008 Location 3Z.. No. % Date 01012 MORTh TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ s�cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 33 22 U _ Building Inspector 0 I- 9 O L O 0 0 O N c~j J O G co z Gz e v . O O Z In N O bu Wrn_ '(y 2 •= C o _o E CC LU N J r OE H N O W el N °� a o-a c� �, g �1 ci LO PC ,�• 'm C N3" 9 Ci' C N ii" Z Z 00 0o�hk,�- l emC 0 W W = Z Z A = xfrly+'t(yyx F- LU !1! W Z -i O Q 0 x F" m m Q W W o � � Z � Q Q m O Z O to Q � � Z i Page No. of I Pages r o a S a 4 ROr 'C C0 'F ,;FtIVOIN R . WDEli MG i9b,"Daff 1AA1:*c-ACH! ISET_'�S 3134E PROPOSAL SUBMITTED TO ---------- -- TPHONE DATE STREET -JOB NAME T - CITY, STATE and ZIP CODE JOB LOCATION -7- ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ............. ............................... ........................................ ................ .......................... ............. .......... ............. .......... ................................ .................. ........................ .............. .............. .............. ................................................................. ................ "I A 7- 1 C < I ............................... .............. ............................... .... .............. .... .......... .................................... . .. _i ......... ................. .............................................................................................. ....................................................... ................................................................ ...................................... . .................. .......... ....... .............. ................................................................ .............................................................................. .............. ............ ............................................ 0 1 4 ... .... . . .......... ...................................... ......................... �� ................................................................................. 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I ..................................................................................... ................. ................................................................................. .......................................................................... ............................... Ric proPOSC hereby to furnish material and labor —,:complete in accordance with above specifications, for the sum of: "AL __r A dollars Payment to be made as follows: #,j --A-- All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard Any alteration or deviation from above specifications; Authorized practices. Signature involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents' or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This proposal may be cinv.q withr1rAwn by ns if not nr.r.4-.ntP.d within Our workers are iuiiy covered by Workman s Compensation insurance. Arceptaurr of Proposal — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature proposal Page No. of Pages _......,79_ Jata Street X%::O IR, 'd SSACX1JS':7TS 018345 •• r PROPOSAL SUBMITTED TO /,:,4 TH j C F.) 14 PHONE DATE STREET -JOB NAME Bu CITY, STATE and ZIP CODE "- r, a,s - V _ j1Jl 01 f f df� JOB LOCATION �" ,> -S ARCHITECT DATE OF PLANS 14— r % _ JOB PHONE We hereby submit specifications and estimates for: / ,rye^ L„� G !� rr) CU r t� r� /' .. ...................::.96<1. r �. _..aJ. t ............... .{........ r Ur:........_._......_._....._.. ......................._................................................................. ..........--- _,.....................�............................................................................................................................................. .............................T.....V`.�.�....................._LU... ._w................._K..._e'7� �`7.._h� rc S /� f) 7 pal r j M TC) f Biu �),�i 'ry. 'r v .................................................................................. .................................................................................................................. 3 US -tf �N� k l Si ............. ......................._......._...........e_ _..., m .A....,. ., ........:.. �. .w......... ._...... ............................... _............. ............_........... ,.... ................ 9. ..... ._n... s-'........5 __........L? r._ (�. �.... _..r __.._...:._.:........... ..................... ........_._.._.,............... _............ ....................._........p_-.....:�. � .. .......-'.5........ .................................................. ........T..t......'..E......................_ ' 7.:;..:�a..._................................ 1r........................_.../.,`�..t........_5..._V4_:..... -� 1.._� !`r f i� _.. ................................................................ ----.............................................................................------------....._.._............,...r.------------..........._.....................................................---........._.._..__.._.................--....._...._................................................._......................................................... .... -................_.........................__.._...................................---------.....-......_.__.............................................._............._..............................................................__........_...I............................................................_....._.............................................................. WP proPUSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: _k 0 �'t t l . -r , ��_ ,_ � it (% h - ��� dollars ( 41 L/ Payment to be made as follows: If All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature V charge over and above the estimate. All agreements contingent upon strikes, accidents' or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days. Arreptanee of proposal— The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature L The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7th edition Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two -Family Dwelling FOR MUNICIPALITY USE Revised January 1, 2008 This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Commissioner/ Inspector of Buildings Date SECTION 1: SITE INFORMATION 1. roperty Address: :!5dE ro)k' /] S T , t10 f tomy-E A' 1.2 Assessors Map & Parcel Numbers Map Number Parcel Number L la Is this an accepted street? yes �no 13 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, § 54) Public �� Private ❑ 1.7 Flood Zone Information: Zone:_ Outside Flood Zone? Check if yes ^ 1.8 Sewage Disposal System: Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSIIITP' 2.1 wner' of Record• 4AA A--rN ayo D No Apivu"EK Name (Print) r Address for Service: Ake. Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED Nrffle (check all that apply) New Construction ❑ Existing Building ❑ Owner -Occupied Repairs(s) V1Alteration(s) ❑ Addition ❑ Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed World: YL) 1?fOR,T Ptybl— DY F—t@ Vr—P jJLT- A aV> 15X'l Err NG P067z;f, L,y4-ic7-Cc.F- 00JE- &4c &Cror SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee ❑ Total Project Cost' (Item 6) x multiplier x 2. Other Fees: $ List: 2. Electrical $ 3. Plumbing $ 4. Mechanical (HVAC) $ 5. Mechanical (Fire Su ression $ Total All Fees: $ Check No. Check Amount: Cash Amount: 0 Paid in Full 0 Outstanding Balance Due: 6. Total Project Cost: $ y SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Constriction Supervisor (CSL) t( ?s--;6— :)- t,' — C) 6' E V License Number Expiration Dane Name of CSL--ListHoloerr © LCSL Type (see below) - `�f jj Description )F�w A cess �� U Unrestricted to 35,000 Cu. Ft. -�'� �" �— R Restricted 1&2 Farm Dwelling < S x K6 30 07 RC 1 Residential Roo &,07 Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning fiance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) c f-" La� 7�i <VK4 �10)�/ N� 11 / / qC�G on Number j i 1 '_ I;kc f F.Vinition Date FIIC Company Name or MC Registrant Name �� Ad tit_ F 36 C' -7 Si Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NLGI- c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial -of the Issuance of building permit. Signed Affidavit Attached? Yes ......... No -------.._ ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,�/ O OL) as Owner of the subject property hereby �" authorize �-� 1 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accumte, to the best of my knowledge and behal Print N e / -?-09 ,_d9 Sign of Owner or Authorized Agent Date (Signedunder the pamsand penalties of NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (MC) Program), will nut have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Constriction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.115, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count , Number of fireplaces Number of bedrooms Number of bathrooms Number of hall baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 0 z 0 . ol rA rb xow w O o0a uC/) o w° .0 cn cz 0 U z O W in or. v a U x O C7 aa rL w AG w W °�°bo wo' cn w a O x ao' w z W a a w v cA z ,� cn Q o cn ui am z 0 W FA- IFMA10 0 co O w L O v Z 03 Q. O CO) � C I co cm C C_ V� p 'p O .y O O E m m L � _ 3� O O � O e_vv o a CL rm< o *-d� c eccc CD C Z CD u N3 O C C C c CA lC O C O i.+ O O 4: ea v WE= •: Cc cc D o o t EQ .. Ci o c �+ H ' O ' y m qg mCDCA a C42cm 0 3 CD m s h A �N .E S p A m N m m rz o CM' �a o c aCAt 'S N Z O s p0 dO m C Q m 12 m C •O = m Ko -0 N CO2 W _ O t .. A =ZC m y .y y Z O W C.3 CD �„ cm 's y a m o "o m o y 0 O _ 1- ce r .- n i m z 0 W FA- IFMA10 0 co O w L O v Z 03 Q. O CO) � C I co cm C C_ V� p 'p O .y O O E m m L � _ 3� O O � O e_vv o a CL rm< o *-d� c eccc CD C Z CD u N3 O C C C c CA M The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Print Form www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: J� itv/State/Zim �JO A�S D OVF-41, M -A Phone #: 'F ? Y' Z� ? 'C 3 d'd 7 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I q,, employees (full and/or part-time).* have hired the sub -contractors 2. m a sole proprietor or4r- listed on the attached sheet. / s, hiLand have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.1 required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 5. ❑ 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): 6. ❑ New construction 7. ,C9 I emode ' g 8. molition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I. F] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ 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. :Contractors 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. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Expiration Date: 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 a 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 ceM& un er the pains nQd pe�nalIdes of perjury that the information provided above is true and correct. Sienature: (' `moi-'���`1 Date:' -2 r Z�- Fg�, - K,C-) �-? 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 #: