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Home My WebLink AboutBuilding Permit #417 - 36 COTUIT STREET 11/21/2006 TOWN OF NORTH ANDOVER NORT1i APPLICATION FOR PLAN EXAMINATION °`tt``° '6,9't'o 6 6 O F- � ZI-oho Date Received ` +' Permit NO: ��SSAC HUs��y Date Issued: IMPORTANT: Applicant must complete all items on thisa e LOCATION -2 " 3 CO ;� Print PROPERTY OWNER R a� Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Non-Residential Residential ❑New Building ❑One family ❑ Addition two or more family [I Industrial ❑Alteration No. of units: ❑Assesso Bldg ❑Commercial Q-I�pair,replacement D ❑Demolition ❑ Others: ❑Moving(relocation) ❑ Other ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Aa CA W i Identification Please T' a or Print Clearly) ` 01'�ie c1 Phone: 5 -3Ga Z OWNER: Name: �Z C�I�,o. c�`yu ^ C Address: I 1� e c, Nd C> Phone: Lr U 2.31 CONTRACTOR Name: Address: �i �! Q Supervisor's Construction License: � � Exp. Date: 1� l/ Home improvement License: y� Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL FEE $ ATED ST BASED ON$125.00 PER S.F. Total Project Cost :$ r Check No.: Receipt No.: La�— Page I of 4 J TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. ElPermanent Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyand Signature of Agent/Owner p z—f �j Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 El11 COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no s Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance,Petition No: Zoning Decision receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Si nature&Date Drivewa Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use) Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 .Iwo Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ ropy of Contract ,lass check Energy Compliance Report 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:BPFORM05 Page 4 of 4 ✓ate V�ar�vina�uuea a�✓lCpdOuc�iuGel26 r BOARD OF 1BUILDING REGULATIONS i i License: CONSTRUCTION SUPERVISOR a Number: CS 077696 Birthdate: 11/28/1970 t Expires: 11/28/2007 Tr.no: 11145 Restricted: 00 MATTHEW J BURKE , 306 WEST RD RYE, NH 03870 Commissioner ti Bumg egua 'obs anc an aims ' I HOME IMPROVEMENT CONTRACTOR Registration: 142647 IV Expiration: 5/12/2006 Type: Individual i MATHEW BURKE MATTHEW BURKE 71 SUTTONHILL RD. � � NO.ANDOVER,MA 01845 Administrator i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 sY www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): re ev,\C�.w.a CO LL Address: T d -4 � City/State/Zip: ?,,, 113 c J,. (Uy 631 Phone#: 7 s Are you an employer?Check the appropriate box: Type of project(required): 1. a emp o Q 4. ® I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.�R Roof repairs insurance required.] t employees. [No workers' 13.aother comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 Name:6TICAA-S_ Policy#or Self-ins.Lie.#:10')3 3 Expiration Date: /U Job Site Address: I,-3e w 111, �J'/�. City/State/Zip: IU, rid dot ,M �� q� 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 certi unde he pains d penalties of perjury that the information provided abov is true and correct. Si nature: Date:�l Phone#: 60 3—Z;J - YoS-4— 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#: