HomeMy WebLinkAboutBuilding Permit #731 - 349 BEAR HILL ROAD 6/11/2008Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued: l r ' ` V 1
IMPORTANT: Applicant must complete all items on this page
LOCA
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PROPERTY OWNER X 114 A,/
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MAP NO: PARCEL:/I-L-ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
PNggE,ir, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK I U Lit rKthVKmtu: i-
��/1° r r/a,✓� / (� ��.f j � � cry 'E'_ � '�-(�'eA .a�
Identification Please Type or Print Clearly) K9,2OWNER: Name: / ���� e>5 <— '' Phone:�T
Address: r�`� A
CONTRACTOR Name.�''C`� Phone: q ->9--3
i
Address: ✓ ! . it1 a' , Z,4
Supervisor's Construction License: Exp. Date:
Home Improvement License: / -s�� a Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
i dad -� � ,
Total Project Cost: $ ��d'1 /� FEE: $ � 0d
Check No.: a 31 r a ly Receipt No.: 0�
NOTE: Persons contracting with unregistered contractors do not have access to the g aran un
Signature of Agent/Owner Signature of contract <�
Location?
No. Date
NORTH TOWN OF NORTH ANDOVER
Certificate of Occupancy $
\a:—�„S Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #
2►«n
R
Building Inspector
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
COMMENTS
-: r
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:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
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'-; www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.pplicant Information Please Print LeLyibl,
Name (Business/Organization/Individual):
-Pi
Address: oC /1/ � "J j� 6-A �' C
City/State/Zip: L, A 1z/ /W G Phone
Are you an employer? Check the appropriate box:
. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. $
These sub -contractors have
workers' comp. insurance.
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. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 1.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # I 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.
/ am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:/.qiJ�✓� �.
Policy # or Self -ins. Lic. #: `�,fl + t C � �' j' % � Expiration Date: ,%�` oZ J -'• �
Job Site Address: 14, Aln_10 7/ e J City/State/Zip: o
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.
do hereby certify under the pains an
Phone #: / F �j 3 L��, _�) '
the information provided above is true and correct.
Date:
Official use only. Do not write in this area, to be completed by city or town gffacial.
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 #:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'-; www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.pplicant Information Please Print LeLyibl,
Name (Business/Organization/Individual):
-Pi
Address: oC /1/ � "J j� 6-A �' C
City/State/Zip: L, A 1z/ /W G Phone
Are you an employer? Check the appropriate box:
. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. $
These sub -contractors have
workers' comp. insurance.
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. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 1.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # I 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.
/ am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:/.qiJ�✓� �.
Policy # or Self -ins. Lic. #: `�,fl + t C � �' j' % � Expiration Date: ,%�` oZ J -'• �
Job Site Address: 14, Aln_10 7/ e J City/State/Zip: o
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.
do hereby certify under the pains an
Phone #: / F �j 3 L��, _�) '
the information provided above is true and correct.
Date:
Official use only. Do not write in this area, to be completed by city or town gffacial.
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 #:
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
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 (LLC) 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 pen-nit/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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
AC -080- CERTIFICATE O
Samuel J. Durso Insurance Agcy
Charles S. Randone
198 Massachusetts Avenue
North Andover MA 01845
Phone: 978-682-5175 Fax: 978-794-0313
INSURED
3ML Construction Co Inc.
2 Nightinggale Court
Lawrence P!A 01841
.LIABILITY( INSURANCE OP IDD DATE(MM/DDm'YY)
3MLC0-1 0412 9
4 29 (
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAtC #
INSURERA Nautilus Insurance Co. 17370
INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF iNSURANCV LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERfq OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE M(jAWE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATO tAWA SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NS TYPE OF INSURANCE POUCY NUMBER - I Y EFF U Y IRATI N
• GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILITY TBI
CLAIMS MADE a OCCUR
GEFLAGGR TELIMITAPPLIESPER:
POLICY PRO-
JECT f LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULEDAUTOS
HIRED AUTO)
NON-OYW4ED,A!, -p'3
GARAGE LIABILITY
I ANY AUTO
EXCESS/UMBRELLA LIABILITY
IOCCUR 11 CLAIMS MADE
' DEDUCTIBLE
RETENTION SRETENTION S
WORKERS COMPENSATION AND
EMPLOYERS`LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
Carpentry:
�.. 4vl%oK 1 C nULUCK
ACORD 25 (2001108)
.+ .. WA I o mm1UUIYY) LIMITS
------------------
EACH OCCURRENCE $ 1000000
04/29/08 04/29/09 PREMISES(Eaoccurence) $
MED EXP (Any one person) $
PERSONAL&ADV INJURY $1000000
GENERAL AGGREGATE $2000000
PRODUCTS-COMP/OPAGG 62000000
COMBINED SINGLE LIMIT
(Ea accident) S
BODILY INJURY $
(Per person)
BODILY INJURY S
(Per accident)
PROPERTY DAMAGE
(Per accident) S
AUTO ONLY -EA ACCIDENT S
OTHER THAN EA ACC $
AUTO ONLY: qGG $
EACH OCCURRENCE $
AGGREGATE. S
S
S
S
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE S
E.L. DISEASE - POLICY LIMIT $
BY ENDORSEMENT/
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO',
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABtUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
ki
` ' r
If _ Board of Buildin nd Stagy - —i
a
HOME IMPROVEMENT CONTRACTOR
Registration:.
134830
Expiration: 1/29/2010
Tr# 267467
Type: Individual L
J. LAROCHELLE
LAROCHELLE
NGALE CT.
CE, MA 01841~��"'`
Administrator '
f
C-1
Page of
I!�Vd4 oU
SHHO
CONSTRUCTION, INC.
MIKE FAX
(978) 975-9874 (978) 258-1131
PROPOSAL SUBMITTED TO
PHONE DATE 6/
9/b/oiln
S RET
e
t�
z11PODE v
JOB NAME
CITY, STATE and
' � j �o--<—
JOB LOCATION
ARCHITECT DATE OF PLANS
JOB PHONE
We hereby submit estimates for:
1
G gal,
I eA,S
�.
UQ PNV= hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars 1$ adv
Payment to be mode as follows:
�
I,ltAe-4/1(11-1
All matorlal la guarontOCd to be as spcctflad. All work to be completed In a
workmanlike monner according to standard practices. Any altoration or Authorized
deviation from ebovo opccifications Involving extra coats will bo executed Signature
only upon written ordoro, and will bxomo an extra charge over and above the
catlmato. All agreomonts contingent'upon strikes, accidents or delays beyond
our control. Ownor to carry flro, tornado and other necessary insurance. NOTE: This proposal may be
Our workers aro fully covorcd by Workmon'o Compensation Insurance. withdrawn by us If not accepted within days.
�� ®� — The above
prices,
specifiCa Ions and conditions are satisfactory and are hereby
accepted. You are authorized to do Vv work pa spocl icd. Payment Signet
will be made as outlined above.
�)
Date ��
of Acceptance: Slgnatu
-
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AMWE
CHARLES%;J touGHLIN' IN5
`3a DIN7,EY .Sr
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Box
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COMPANY
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'F.AiZz'ORB_
COMPANY -
3ML CONSTRUCTION CO INC
2 NIGHIIN_GALS :CI '
i�iL(�TRENCE MA O1B41
COMPANY .
COMPANY
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THIS""!S TO_CEATiFY THATTHE:POLICIES:.OF INSURANCE"i(STEQ.BELOIIU
1IAVE'BI;EN S (JED TO THE INSURED NAMED Tigj;r
fNDIGATfD, NOT{iV(iF(51`/;ifD(iVG' ANY REIIt?)Ag wr:.TERM•OR CONDMON-:OF ANY'CONTRACT'. OR OTHER DOCUN{E!1[L,llit- .- .
CEti77F(CATE MAYBE ISSUED OR MAY PERTAIN, T}lE:(NSitAANCE-AFFOADED'$Y-714
sesm
P011CIE$ DESCRIED HEREIN-Mg[j �p }
>DCGLUS[ON$ A(NO CONDITIONS OF SUCH POLICIES C!M(TS SHOWN
MAY NAllE.BEEN
�
REDUCED 8YPA1D CLAIMS.
LTR fYPEOFINSURANCE
' POLICY NUMBER
_
P0uCY.EFF0TlPE FULICYEVIRATION
DA7E(ltSMiDDIYY) DATE(MMHD1YY) - _ UlffTS
GEVERALIJABIbTY
COMMERCIAL GENERAL LIABILITY
GENERAL
X33 < CLAIMSMADE OCGUR-
PRODUCTS-MMPIPP ASG, _ a .. .
_
OWNER'S-& CONTRACTOR'S PRDT. -
PERSONAL& AOY INJURY-'"
EACki OCCIiRnews
AfiE DAtu(AGE {Any on P_ fue) .;
AU'f0!l oELELIABILi} Y
MEII:.EX?EiVSE(/tny onepetsunJ .
ANYAUTO
COMBINED SINGLE
AU_0➢1tNEDAUTOS :.
$-
- :SCHEDULED AUTOS
BODILY INJURY
HIREDAUI 5
(Per Parson)
NOMPYiNED AUTOSBODILY-INJURY
-(Per Acndent) . - g
'
GARAGE U11BIliTY -_
PROPERTY. DAMAGE
.. �-. .
ANYAUTO
Atf is ONLY- EA-ACC10i81T( "
THAN AUTO ONLY;.
FAdR ACCiDEVT." S
ESCESS'fJAHIUTY
AGGREGATE `.
UMBREU.A.FORM
EABH"OCCURRENCE g
. OTHefi'WAN UMHRECW-foAM'
r: 5
AGGREGATI:
•
- WORKE(i'SCQETFENSATfOIV�AiVD " -
.
A SMPLOYE&S UAdlLitY. UB-2063La8-1-08 •
i
sTATUTORYL�trrs = = _-
THEPROPRISTOR/INCL
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01-24-a8 01-24-0g iiAZC(DEM g
PAffTNEAStt�iECUTlYE
_
OFFicEAS_AR�. x.• EXCL
D�BE-POIlCYLiNiT $ O(i. nt1r
OTHER 3
DMEASE-EACH EMPLOYEE.
DESCRIPTION OFOPERATION5ILOCATIONSIYEh(ICLFSIRESTRICii NSiSFECfAMal
IRIS. REPLACES T TY. PRIOR-. CERT:WlC�3.TJi -ISSUED ?O-
THE :CER221+ gCAi� Et3LDgi; , Biwr�CiINC yTORi�sRS COMP CQVE�.
._ -
" __ .AZeTvSi+'q: L`J.`I.ONijvibq'i Sv.'�`w.....`:•_ .n'Z'mj•.(�—
:�n� -�.-- .-
SHOULO ANY OF THE ABOVE B CIES BE t:AI'TCELlEO 13fcFCRE Tim
EXPERARON DATE Tt)£REQF,..TiiE ISSI&NG C�APAIiY YtA.L PAIDEAVQF# To mft
• "'
PtOTtCETO'iiiECEK'tACATEi-ALD�tN1LS!@iRtii�-
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L'EFTi BUT. FAILURETQ. h1AIL' SUCH NQiTCE $HALL I>l�OSE � :OBiiG tA"#� QR
LIABLRAliI
YOFY HI NDUPQNTtiECOMPANY_TiSAGEITSRA
AUTHl MZEO REPRESENT'ATNE:
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
M
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
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:
FIRE DEPARTMENT - Temp Dumpster on site yes.
Located at 124 Main Street
Fire Department signature/date
COMMENTS
t_ocatea &54 usgooa Street
no nl/
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
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued
LOCATION
�] V(
IMPORTANT:
.3 y cl
Applicant must complf
all items on this
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Residential
Print
PROPERTY OWNER /'� /✓ ��' 7 ° C'
Print
MAP NO: PARCEL: Z��—ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Fair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESGKIF 1 IUN Ur VVUMM IV DC rmr-r--Vr-,In
OWNER: Name:
Address: ? ,
Please Type or Print Clearly)
CONTRACTOR Name:/-/,
Address: �2
Supervisor's Construction License:
Home Improvement License:
30
ne:
,4,4
Exp. Date:
EXD. Date: 0
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cont. s; FEE: $ 1 �b
Check No.: a 31 / a �� j Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the g aran un
_ _ -46
Signature of Agent/Owner Signature of contract