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HomeMy WebLinkAboutBuilding Permit #694 - 501 BOXFORD STREET 5/23/2008Permit NO: 0UJL-UJJVv rE-MR11I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received DESCRIPTION OF WORK TO BE PREFORMED: ?emw& & or - IA5TAa 1?0o% n Please OWNER: Name: ipe or Print Clearly). 0 AqS ARCHITECT/ENGINEER Address: Phone: Reg. No FEE SCHEDULE: BULDING PERYt. $12.00 PER 1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 4�� FEE: $ / Check No.: C r Receipt No.: C I �rnm�• Poacnroc rnntrnct[n� with unregistered contractors do not have access to the guaranty fund Location�r �� ✓� No. & L Date TOWN OF NORTH ANDOVER f 9 • ; ; Certificate of Occupancy $ ;ssACNUstt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #/ �5 - 2i 8 t 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 DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED HEALTH COMMENTS DATE APPROVED 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 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 Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Cross Section/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 o 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: Building Permit Revised 2014 m m m m VA m ,,ww YI EP v CO) 'C C � CV CA Cl) 10 0 CD n Z y o C2 r C CL. = y aCO -0 O 0 0 CD CD O CL cr W CD CD O CD C — CD =0 y O = CO CD v CO) O 'CD a Z O CD O CD mc L 0 C O O 0 O O _ m 0 co CD C O h 6C CL H CA O ?==r= z o Q. 0 < m CO., y CL C"' O H m dC ?L_ % F m nod m O m H O y --1 CD 2 �C, O CD Oy. O =04 *1 c. cnl y' m ? =,a: ,: ao CL C2 CD O N � 0 CD co H d y . cd � c _ C OD n CD m O . _ m w O n C cn O W O p w : � Z' w. o o oGc �- o Wi r� C) CD m: P e m � d ��+ C) U CA o a. x o x �C: cn g C. cn O _ p w ro7n o n� Z' w. o: o oGc �- tr1 r n 7d c o r� C) El °'- P e o aq x o Z A. ��+ C) U CA cn g C. cn O w ., p w ro7n o Z' w. cn o oGc �- tr1 r n 7d o � a- r� C) El °'- P e o aq x o Z A. ��+ C) U CA o a. x o x • H 0 9 0 c I� Board of Building Regulations and Standards HOME IMPi,OVEMENT CONTRACTOR Registratiotw 403358 Expiri3tdoh 7,fto08 ' • Type:,f ri�l: Corporation A J. WALSH & SON$` Arthur Walsh,Jr. `t 55 Pleasant St N Andover, MA 01845 Deputy Administrator F � r .The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street ` Boston, MA 02111 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Y,e2ibly Name (Business/Organization/Individual): w,Soly,5 Address: _ ,r_� I LCI9SIA-N 1 St ' City/State/Zip: A16 Areyou an employer? Check the appri L ❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone.#:� riate boa: 4. 01;ai�m a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 5. We are a corporation and its officers have exercised their . right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reauired.l Type of project (required): 6. ❑ New construction 7. [] Remodeling 8. ❑ Demolition 9. [] Building. addition 10.0 Electrical repairs or additions 11.❑ Plumb' epairs or additions 12. oof repairs 13.[] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. � I Romeo xmmrs who submit this affidavit indicating they a., 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 is providing workers' compensation insurance for my employees. information. Below, is the policy and job site Insurance Company Name: �9/A /A//WraA& /6� . Policy # or Self -ins. Lic. #:' 72) 1,ZLo, � Expiration Date: Job Site Address: " 5 - -: 4 YC 0 ",77— City/Stale/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 S 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 certify under the pains -and penalties of perjury that the information provided above is true and correct /) A. ,, _ _ �, ..� one'#: Q f 6d7Z Offici d use only. Do not City or Town: area, to or town official. 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 #: CS # 022680 H I C# 103358 = Propool � A. J. Walsh & Sons 55 Pleasant Street North Andover, MA 01845 # of Proposal Submitted To: ` �. -, Job Name I Job # Address _ /t, Job Location 978-688-6737 or 1-866-AJWALSH Date I Date of Plans II Phone # Fax # Architect We hereby submit specifications and estimates for: We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of: 15v 00 $ ��W Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfullyi executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note — this proposal may be withdrawn by us if not accepted within days. acceptance off Propool The above prices, specifications and conditions are satisfactory and are SSI n' attire �L��'a hereby accepted. You are authorized to do the work as specified. g ` Payments will be made as outlined above. Date of Acceptance Signature