HomeMy WebLinkAboutBuilding Permit #700 - 536 FOREST STREET 5/23/2006fib TOWN OF NORTHANDOVER
APPLICATION FOR PLAN EXAMINATION
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�" Date Received: 23
Permit NO:7/
Date Issued: ,
IMPORTANT: A licant must complete all items on this age
LOCATION 3 R 2 s k- St -
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PROPERTY O\VNIER Sv�'e au tt.rj e
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MAP NO.: 1 0 (9. 9 PARCEL: �� ZONING DISTRICT: !
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE_OF IMPROVEMENT PROPOSED USEResidential
Residential
;FOne family
New Building
Addition -j Two or more family n Industrial
✓Alteration No. of units:
Repair, replacement Assessory Bldg Commercial
Demolition
Moving (relocation) J Other Others:
Foundation only*-
DESCRIPTION OF WORK. TO BE PREFORMED 12e�-�'�
Identification Please Type or Print Clearly)
OWNER: Name: 60 S` -j L a A- Q `''`' tL 4%7 e a Q Phone:
Address: S 3 F0 ft
CONTRACTOR Name:- -
j e S -w - Phone: 9 -?fib- G 6i - v� 3
Address: e- 'r ,j S
'Date:—
SuperoisWs Construction License: CS 05�I'1 I$ _Exp.
Home Improvement License: Exp. Date:
ARCHITECT. ENGINEER Lame: Phene:
address:
Reg. No.
FEE SCHEDULE: BULDLNG PERMIT: 510.00 PER $1000.00 OF THE TOT. IL ESTIMATED COST BASED ON ,5115.00 PER S.F.
Total Project Cost :$_ t o o C, x 10.00= -FEE:$_
Check No.: �`� Receipt No.
11;q w 10A
TYPE OF SEWARGE DISPOSAL
Public Sewer
Well
Private (septic tank, etc.
Tanning"Massage, Body Art SA imming Pools
Tobacco Sales = Food Packaging'Sales
Permanent Dumpster on Site _
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty. fund
Signature of Agent,'Owner
Plans Submitted `7�j
Plans Waived 17
Signature of Contractor
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Certified Plot Plan ❑ Stamped Plans
" THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
❑ Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
CONSERVATION ❑ ❑
COMMENTS
IIEALTH -- - ___---
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision receipt submitted yes
Planning Board Decision: ---- ---- Cumnwn
Conseruticn Decision: _ _ _�___Commei
DATE APPROVED
DATE REJECTED DATE APPROVED
Watcr & Sewer connection signature & date
Fcmp Dempster on site yes__no Fire Department signature. date
Building Permit ApproNed and ISSUed by:
Page? c1'4
Building Setback_( .)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required
Provided
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Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
>K
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
j Building Permit Application
❑ Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
:3 Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
C. And C.S.L. Licenses
Photo Copy of H.L
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraul
Calculations (If Applicable) i
❑ 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
j Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
a 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
;)oc: INSPEC.I,10NAl. SERVICES DEP 1RI ME`'IAPFOV105
P:re4cf-I
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The Commonwealth of Alassachusetts
'
Department of Industrial: lecidents
�.'►�
Office of Investigations
600 Washington Street
Boston, A14 02111
www.tnass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name t l3usinessrt )rgauiiatit,nllndiv idut►I l: �—e 5} A S j : e- --,o
Address: 5 Ape it 6'. S�-tz�zs-
City.StaterZip:Nj
Phone #: 9 7S— (0 8 a- — v -,a- �
,%re you an employer? Check the appropriate box:
I. ❑ I am a employer with q. ❑ 1 am a general contractor and
employees (full and/or part-time).*
2. tg I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp, insurance
required.]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] '
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp, insurance.
❑ 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 required.]
Type of project (required):
6. ❑ New construction
7. Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.[] Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
'Any ;applicant that checks box AI must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this aflidav it indicating Ihey are doing all work and then hire outside contractors must submit anew affidavit indicating :arch.
Contractors that check this box must attached an additional :sheet showing the name of the sub -contractors and their workers' comp. policy information.
1 am an employer that is prnvirling workers' compensation incuranc•e for my emplr�pees. Below is the policy and job site
information.
Insurance Company Name:
Policy or Self -ins. Lic. 4:
Job Site A
Expiration Date:_
City Statc/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 tine
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 DLA for insurance coverage verification.
1 do hereby cert/ 4under the pains and penalties of perjury that the information provided above is true and correct.
tii;n ►Lire: ! Cwo Z",5— nate: 5-1a-3 / d &
!)/fi'cird rc�e duly. IDu r:ut rv,•ite in tltis rrrc�a, to hr cn,np/ctcd h�• �iO• nr rntw� ,,jftc•ial.
City or To -A n:
Pci-mit/License #
Issuing ,authority (circle one):
1. Board of Health 2. Building Department 3. City/To"n Clerk -d. Electrical !,nspector 3. F lumbing Inspector
6. Ether
Contact Persam:
Phone #:
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T TA
Building and Remodeling
5 Appleton Street
North Andover, Ma 01845
(978) 682 2023
Proposal
May 21, 2006
Proposal Submitted To:
Susan & Gary Letoumeau
536 Forest Street
North Andover, MA 01845
Job: Install new kitchen cabinets
Home Phone: (978) 687-0442
Cell Phone: (978) 807-7323
Job Description:
Obtain building permit
Complete removal of all demolition and construction materials
generated by Testa Building and Remodeling and its subcontractors.
CONSTRUCTION:
PLUMBING:
Remove old counter tops and cabinets. Install new cabinets and moldings.
Install new sink and dishwasher. Install a line for the ice maker
A finance charge of 1 1[2% per month (18% per year) will apply to all accounts over 30 days past due. In the event collection activity
is required the customer shall be responsible for all costs associated with collection, including reasonable attorney's fees.
I propose hereby to furnish material and labor complete in accordance with above
specifications, And according to architectural drawings with changes as noted
for the sum of.
$ 5, 500.00 five thousand five hundred dollars
One-half to start one-half upon completion.
Authorized signature
I reserve the right to cancel this contract if not accepted in_30_ days
Signature
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Signature