HomeMy WebLinkAboutBuilding Permit #819 - 49 BLUEBERRY HILL LANE 6/8/2007BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Received
`✓ _ / /
Date Issued:
_
IMPORTANT: Applicant must complete all items on this page
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LOC
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building &One family
❑ Addition ❑ Two or more family ❑ Industrial
0� Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
DESCRIPTIONOFWORK TO BEPREFORI%IED:
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vL - i5-� UC O J ” - V -13-i- 01 -AWA/I
IN
Identification Please Type or Print Clearly)
OWNER: Name: 810 D" 174CA.-ey Phone:
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 Cost: $ % O v CX) FEE: $
Check No.: ` Receipt No.: 000L-0
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
....... _.__.._....._ ... ...... .. .,.m___. , _.. ...... ... ... ....
Location!d
No. Date
MORTIy
TOWN OF NORTH ANDOVER
Oft..•° ,•'fh0
i • OL
Certificate of Occupancy
$
Building/Frame Permit Fee
$
3 G
suM�s
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #i 3�
20«
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
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
A -
mooning 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
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
❑ an
❑ 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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ZitLCptaltGt? Of p1r0p0$aC —The above prices, specifications and
conditions are satisfactory and are hereby accepted. You are authorized to d6fhe Signature
work as specified. Payment will be made as outlined above.
G
DateofAcceptance: /) / Q / Sianature
RAY PARKHURST'REMODELING
c' HAVE HILL, MA
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_ No Job Too Small
NIA Lic, #CS087229 ,' Tel. 978-521-7512
'
MA Lic. #142387 Cell. 978-609-5473
PROPOSAL SUBMITTED TO / / f
/
PHONE
DATE
STREET �} j /
J i v c � c, j'1` f r
JOB NAME
0A 41. ev 4 ir, /a ryI• . 4)
CITY, STATE AND ZIP CODE
Kk, r k� dovt� t -sf "
JOB LOCATION
ARCHITECT
DATE OF PLANS `'
JOB PHONE
t�
r.
We hereby submit specifications and estimates ` for:
L...S i..MA 1177. ........ ............ T� T✓i l,` . pe ,4 �.... u w..T-. U ..................................................... s. ..! .3 ....:...........:...
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VC p rOpWk hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
p). O✓<<}/ L j Civ dollars (T
Payment to be made asfa/. ws: f
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner Authorized
according to standard practices. Any alteration or deviation from above specifications involving Signature
extra costs will be executed only upon written orders, and will become an extra charge over and ,
above the estimate. All agreements contingent upon strikes, accidents or delays beyond our
Note:
control. Owner to carry fire, tornado, and other necessary insurance. Our workers are fully cov-
ered by Workmen's Compensation Insurance. This proposal may be withdrawn by us if not accepted within days.
/ / C
ZitLCptaltGt? Of p1r0p0$aC —The above prices, specifications and
conditions are satisfactory and are hereby accepted. You are authorized to d6fhe Signature
work as specified. Payment will be made as outlined above.
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DateofAcceptance: /) / Q / Sianature
CERTIFICATE OF INSURANCE ISSUE DATE (MM/DDIYY)
11/07/2006
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
Cowan Insurance Agency Inc
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
359 Main Street
Haverhill, MA 01830
COMPANIES AFFORDING COVERAGE
I
INSURED
Ray Parkhurst
dba Parkhurst Remodeling
COMPANY A.I.M. Mutual Insurance Co
LETTER A
44 Bateman Street
Haverhill, MA 01832
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.. NOTWITHSTANDING ANY REQUIREMENT, TERM OP. CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE (
'
POLICY NUMBER POLICY
EFFECTIVE
DATE(MM/DD/YY)
POLICY EXPrRATION
DATE(MM/DD/YY)
LIMITS
IGENERAL
LIABILITY
GENERAL AGGREGATE S
PRODUCTS-COMP/OP AGG. $
ICOMMERCIAL GENERAL LIABILITY
F_ LAIMS MADE', ]1oCCUR)
'PERSONAL
& ADV. INJURY $
EACH OCCURRENCE $
��OWNER'S
& CONTRACTOR'S PROT-
FIRE DAMAGE (Any one tire) $
MED. EXPENSE (Anyone person) $
f
AUTOMOBILE
LIABILITY
ANY AUTO
(COMBINED SINGLE
LIMIT $
BODILY INJURY
(Per person) $
ALL OWNED AUTOS
SCHEDULED AUTOS
1
BODILY INJURY $
(Per accident)
IHIRED AU'r05
NON-OWNED A(iT05
I
PROPERTY DAMAGE $
'GARAGE LIABILITY
I
(EXCESS LIABILITY
I (
EACH OCCURRENCE $
AGGREGATE $
I.`:UBRELLA FORK(
--
i
)THEA TITAN UMBRELLA FORM
-*tPARTNERS/EXECUTIVE
WORKER'S COMPENSATION AND
EMPLOYERS' LIABILITY
1fe rKUI'KIt S'UItJ I{—�(INCL
I � '
OFFICERS ARE. " IFXCL
7021767012006 _ _-( 09/28/2006
I
09/28/2007
WCSTATU- OTH-
TORY LIMITS E
L $
I
EL DISEASE--POLICY LIMIT $ 500,000
EL DISEASE--EA EMPLOYEE $ 500,000
JOTIIER
I
DESCRIPTION OF OPERATIONSILOCATIONS/LJTMCLES/SPECIAL ITEMS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
i
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
_
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
HAVERHILL, MA 01832
The Commonwealth of Massachusetts
La Department of Industrial Accidents
Office Of Investigations
600 Washington Street
U1 Boston, MA 02111
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
2211cant Information
Name (Business/Organization/Individual):
r�
Address:�--
City/State/Zip:
Phone #: F,)
Are you an employers Ch k th
ec a appropriate box:
LER I am a employer with 4. ❑ I am a general contractor
2. ❑employees (full and/or part-time).*
I am a sole proprietor or
and I
have hired the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet.
These sub -contractors have
working for me in any capacity,
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We are a corporation
3. ❑required.]
I am a homeowner doing all
and its
officers have exercised their
work
myself. [No workers' comp,
right of exemptibri per MGL
c. 152, ¢ 1(4), and we have
insurance required.] t
no
employees. [No workers'
comp, insurance
Type of project (required):
6. ❑ New construction
7. ®. Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11 -El Plumbing repairs or additions
12.❑ Roof repairs
]
t 13.❑ Other
'Any applicant that checks box #I must also fill out the section below showing their workers, compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContrdctms that check this box must attached an additional sheet showing the name of the tside csub-coontractors o s must s
- ----•- ..�.��.� -111P. poncy mromtadon.
information.
am an employer that's providing workers' compensation insurance for my employee& Below is the policy and job site
Insurance Company Name: ,/./, I , (M
C C_ c").
Policy # or Self -ins. Lie. #:c�,1° �7 (o 0`yy 6
Expiration Date.F p ']
Job Site Address:_y �; /��� C a f,,, y ���
Attach a copy of the workers' compensation policy declaration page(showingt�he�oelict number and Jvcn
/?-� r
Failure to secure coverage as required under Section 25A of MGL . 152canlead to the imposition of criminal exptepenalties ation atea
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP and a fine
WORK ORDER a
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forward
Investigations of the DIA for insurance coverage verification. ed to the Office a
- '-y ccrrrJy unser rhe pains and penalties of perjury that the information provided above is true and correct
Oficial use only. Do not write in this area, to be completed by city or town offle ;
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical
6. Other Inspector 5. Plumbing Inspector
Contact Person:
Phone #: