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HomeMy WebLinkAboutBuilding Permit #840 - 4 MILLPOND 6/23/2006Page 4 of 4 Permit NO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received cla-2-3" 6 L 0 t A a �RAT�D pPP��,�S IMPORTANT: Applicant must complete all items on this page LOCATION v t f ` j ( P" - A PROPERTY OWNER �` t ( Pri O lJU I `� '► SCJ` (�C MAP NO.: PARCEL: TVVri AN71 7TCF "F RTTii "INf_' Print ZONING DISTRICT: ATCTnRTC DTSTRICT VVS fl TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: C?Iepair, replacement ❑ Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving (relocation) ❑ Other ❑ Others: - ❑ Foundation only DESCRIPTION OF WORK TO 13E PItEFORMI✓ll '-,2-e p(Lc e_ A- C, t�)-j OWNER: Name Address: CONTRACTOR Name: Address: Identification Please Type or Print Clearly) <( �DC,4 *C) PIZ- Supervisor's Construction License: 6� S- - - Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER V`-� Name: Phone: Address: Reg. No. I I t� / aco( FEE SCHEDULE: BULDING PER I : $�®PPEER $1000.00 OF THE TOTAL ESTIMATED COST BASED 0125.00 PER S.F. Total Project Cost :$ `�, V x10.00=FEE:$ Check No.:4ZO Receipt No.: Z G�S 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 ❑ 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 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 1 of 4 TYPE OF SEWARGE DISPOSAL Tanning/Massage/Body Art E]g Swimming Pools ❑ Public Sewer ❑ Well F1Tobacco Sales ❑ Food Packaging/Sales El (septic tank, etc. El Permanent Permanent Dumpster on Site ElPrivate Meter location to proj ect rersons contracting warn unregisterea contractors do not have access to the guaranty fund Signature of Agent/Owner Plans Submitted ❑ Plans Waived ❑ Signature of contractor Certified Plot Plan ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS 1 CONSERVATION COMMENTS HEALTH COMMENTS Stamped Plans ❑ DATE REJECTED DATE APPROVED ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED El DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ coning board ot-Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer connection/Signature & Date Driveway Permit Temp Dumpster on site yes—no— Fire Department signature/date Building Setback (ft.) Front Yard Side Yard Rear Yard ed 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 I Location No. Date& 2 TOWN OF NORTH ANDOVER Certificate of Occupancy $ CHU I Building/Frame Permit Fee $ 'A— Foundation Permit Fee $ Other Permit Fee TOTAL Check # �4465 Z-�� - Building Inspector AA t CERTIFICATE OF LIABILITY INSURANCE OPIDAY DATE (6/oonv/ -CORD. JGCAI 1 06/15/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HUB International New England HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 299 Ballardvale St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NSRD Wilmington MA 01887 Phone: 978-657-5100 Fax: 978-658-9185 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Travelers Insurance Co. INSURER B: JGCA, Inc INSURER C: INSURER D: 182 Newbury St. Danvers, MA 01923 INSURER E: CAVFRAGFS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DDT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL POLICY EFFECTIVE POLICY EXPIRATION 124 Main Street LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MMIDD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurence) $ CLAIMS MADE ❑ OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY S ' GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ .. PRO - POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT IS ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per amident) GARAGE LI ABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANYAUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ - WORKERS COMPENSATION AND X WC STATU- OTH- TORYLIMITS ER A EMPLOYERS' LIABILITY 6KCiB0354B60-4-06 01/01/06 01/01/07 E.L. EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 500,000 OFFICER/MEMBER EXCLUDED? If res, des«ioe under SPECIAL PROVISIONS oelow E.;_DISEASE -POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Millpond Condominiums Millpond Rd. North Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION TOWNORl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of No. Andover DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Building Inspector NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Town Hall 124 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR No. Andover MA 01845 REPRESENTATIVES. AUTHOR ES NT ,TIVfit . 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