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HomeMy WebLinkAboutBuilding Permit #246 - 40 EDGELAWN AVENUE 9/29/2006 TOWN OF NORTH ANDOVER pORTh APPLICATION FOR PLAN EXAMINATION o�t,�Eo gtio 3� e.. '• ° OL ti � Permit NO: Z-116 Date Received a �.9 A0RATEO Date Issued: -f SSACHU IMPORTANT: Applicant must complete all items on this page LOCATION LI0 CJ0 G� LLQ A A r Q � ��� a Print PROPERTY OWNER Ant F e n h-e MAP NO.: o3 V c PARCEL: `7 C) Print ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑One family ❑Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ,-,�F Repair, replacement ❑ Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving(relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED y 2-e.pC/+rem caT lel`lKQ G`-,'-5 P Identification Please Type or Print Clearly) OWNER: Name: (y\ A(\ i \A f I Phone: q7 S 6 9 1 �I q i 0 Address: Cf jS- L✓4. -0, (Jn i ,V, o,-e 2 /1-14 t CONTRACTOR Name: `C�� 1'1'l��'r^c� r l p i>UGI Phone: 6 Address: La P, ` LA�, 0k D t+,4w, A), L� < Supervisor's Construction License: OS$ S Q Exp. Date: G " U ` 03 Home Improvement License: I S 3 f Exp. Date: ^ 0 �J ARCHITECT/ENGINEER Name: 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 S DO 0 0. 0FEES 72 o �---- Check No.: 4�_7�Z Receipt No.: Z9& Page I of 4 ,F Location -No. �,�(� / . . Date 2fs O� s NORTIy TOWN OF NORTH ANDOVER s + Certificate of Occupancy $ Building/Frame Permit Fee $ s�CMus Foundation Permit Fee $ Other Permit Fee $ F TOTAL $ Check # _ r 19634 Budin Inspector TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ F1Tanning/Massage/Body Art ❑ g Public Sewer Well Tobacco Sales ❑ Food Packaging/Sales [I❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner M A(\t - nK-e L Signature of contractor -t--�- 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 ❑ ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no 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/Signature& Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Require4a 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) e 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 ❑ 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 4 of 4 .i�N t��.,r;,l���t„gin/rl. ,� , l✓a��,r.l�«�tt4 i =-\ Board of Building Regulations and Standards I CONTRACTOR s; icl HOME IMPROVEMENT Registration: 115931 s Expiration: 5/2/2008 Type: DBA RICH MUNROE BUILD.&REMODELING RICHARD MUNROE 2 LORI RD. WINDHAM,NH 03087 Deputy Administrator All toana��zanu�eal o aa3ar uaelta !j^ BOARD OF BUILDING'REGULATIONS icense: CONSTRUCTION SUPERVISOR Number: CS 058587 Birthdate: 06/10/1967 Expires: 06/10/2008 Tr;no: 25597 Restricted: 00 RICHARD A MUNROE 2 LORI RD WINDHAM, NH 03087 Commissioner a a" \ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street . ea Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Pick J g O A r`c'--e— Qu i L b i V � Address: o- Lo k City/State/Zip: W'i"�A AWS /V 1� . Phone #: 6 63 a 3 S — g g b a Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ]ij 'fiam a sole proprietor or partner- listed on the attached sheet. * 7(�emodeling 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.❑ 1 am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I must also till 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. 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. #: Expiration Date: Job Site Address: 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. /do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: ��'Z Date: Phone#: 6 Q �j S g 0 6 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#: VAORTH Town of Andover ....... ....... - 0 dover, Mass., COC HICHEWICK �� ADRAT E D P?a\ �� `S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System trip • BUILDING INSPECTOR 44 THIS CERTIFIES THAT......... .. '�.l!............ ........�...N.y .................�.:................ Foundation WO OPP has permission to erect........................................ buildings on ... D....., , .Ao.�il..Iy... ...•........... Rough to be occupied as............ ,�. ,���......... Chimney provided that the persona pting is rmdsTia in every respect—Confor o the e� rms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final d PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STARTS Rough ........... Service B G INSP Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.