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
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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