HomeMy WebLinkAboutBuilding Permit #887 - 35 EVERGREEN DRIVE 6/13/2012Permit NO: �
Date Issued: < f I
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
NORTH
b
(� O
DESCRIPTION OF WORK TO BE PREFORMED; i
Type or Print Clearly)
OWNER: Name:
a
ne: i�rjA- 7-26® baa/
ARCHITECT/ENGINEER 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.
Total Project Cost: $ �o?�� FEE: $�-
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location,
No Date
Check#Dj
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $1
Foundation Permit Fee
Other Permit Fee
TOTAL $
25400 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
0
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
Located at 384 Osgood Street
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
❑ 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 2.2007
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4 The Commonwealth ofMassochitsetts
r
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
Applicant Information f Please Print Legibly
Name (Business/Organization/Individual): Te I e_R S p v'\ ?0 R+Y _ceV,4ek
_
Address:
City/State/Zip: l Jo bu 2Y) . {/� �} o / go J Phone #: 7 97 - 7o7 9- 4/o o c)
Are you an employer? Check the appropriate box:
Type of project,(required):
I am a employer with aZ U o
4. ❑ I am a general contractor and I
employees (full and/or part-time).'
have hired the sub -contractors
6. ❑ New constriction
'. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
employees and have workers'
9. Building addition
[No workers' comp. insurance
required.]
comp. insurance.=
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
9. ❑ I am a homeowner doing all work,
officers have exercised their
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.❑ Roof repairs
insurance required.]
c. 152, §1(4), and we have no
/
13. ®,Other'% J'>') ), / � k7 T
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I 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 isproviding workers' compensation insurance for my employees. Below is the policy and job site
Information. /"
Insurance Company Name: TRa U -e /- ZS 1 aS'V 6k j PTV
Policy If or Self -ins. Lic. #: I-k)C q3 (o 3 Expiration Date:
Job Site Address: _357 eG e -n It_ectj �/ xw-c 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 tip 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 cert�fy under nthe pains and penallies of peijuly that the information provided above is trite and correct.
Phone #: 7 F/ — 7a7 q y0 c, -o
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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: 11
} �l�r..achu.cit, Ucl►urtruent of Public
F oal—d of, Builrfin' Re�_,uiat1,011S rnrf `-,tantl:ri r)•
Construction Supervisor License_
License: CS 60219
MARK , TRAI NA
33 HANFORD RD
STONEHAM, MA 02180
-'� _, Expiration: 4/27/2013
( +niimi�.i mrr Tr#: 13389
Ac<D```D? CERTIFICATE OF LIABILITY INSUR=ANCE I `'T."
THIS CERTI"KATE IS ISSUED AS A t,1.-!,TTEF, OF I`,FOri.IAT+ON ON: Y A D CO,` EFS i3O F. vHTS UPON THE CE TI=1C T HO 0= _—
CEnTI•--iCt,TE DOES NOT riEi,'.,TI`v'clY OR h=G4TIVELY AG: I`:G, EXTEt:O Q., i•.LTEs: THE COVERAGE T c
THIS CERTIFICATE O:` i`,SUR;C GOES NOT CONSTITUTE CO.',T=. CT E = i 'oVE I =~I tiFFC .v _ 6'. THE F`.- -c
R~?R- T11, -E OR Fr-ODU.,Er., AND THE CERiI=iC'f,Tc HO GEF.. - T: • !' Sv
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Claim #
Advantage Claim Services Adjuster Assigned: Glenn Guarente
522 Chickering Road #B
North Andover, MA 01845
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
To: Building Commissioner GY Board of Health or
Inspector of Buildings Board of Selectmen
Town Hall Town Hall
North Andover, MA 01843 North Andover, MA
Re: Insured: John Armstrong
Property address: 35 Evergreen Dr.
Policy #:
Loss of
North Andover, MA 01843
2645991
2016/03/02
File or Claim No. AD 1982
Claim has been made involving loss, damage or destruction of the above
captioned property, which may either exceed $1,000.00 or caus.e.
Mass. _ Gen. _Laws,_Chapter_ 143,_ Section _6 to be applicable. If any
notice under Mass_ Gen _Laws,_Ch._139_Sec. _3B is appropriate please
direct it to the attention of the writer and include a reference to the
captioned insured, location, policy number, date of loss and claim or
file number.
Glenn Guarente
Title: Adjuster
On this date, I caused copies of this notice to be sent to the persons
named at the addresses indicated above by first class mail.
03-04-16
Signature and date.