HomeMy WebLinkAboutBuilding Permit #818 - 56 MAGNOLIA DRIVE 6/20/2006E pORTFI
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
9SSACHUSf.
Permit NO: f / Date Received: L� "o
Date Issued:
IMPORTANT: Applicant must complete all items on this paiae
LOCATION S 6 A1,4 *A16 /-laq— Sr , /1/, '�11/P0 vOe
�`' Print
PROPERTY OWNER (/ 0 h�v M :::' !q 14 <� ,�-
Print
MAP NO.: Y� PARCEL: �G ZONING DISTRICT:
TYPF AND I1SF OF BUILDING
HISTORIC, DISTRICT YFS F1
TYPE OF IMPROVEMENT
PROPOSED USE
L a
one: 47
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
One family
❑ Two or more family
No. of units:
❑ Industrial
Repair, replacement
Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
'00 #
Identification
OWNER: Name:
Address: 5,;9
_qlAl5'fi,4�-z
Please Type or Print Clearly)
R G e,? k, I"XF
0
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CONTRACTOR Name:
Al
L a
one: 47
Address: 'YO
�ti �/ i L" i4 PE,
/d
;,/ ,//,., ivp I.,
Supervisor's Construction License: ��� ! y% Exp. Date: S/d
Home Improvement License: ��� �� Exp. Date:_
ARCHITECT/ENGINEER Name: Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDINGPWYN
0 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.Total Project Cost:$ s ---- x10.00=FEE:$
Check No.: /(,o Receipt No.: � l
Page Iof4
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 UEPARTMENTMFORM1105
Page 4 of 4
TYPE OF SEWARGE DISPOSAL
Massage/Body Art ❑
Swimming Pools ElF1Tannin«
Public Sewer
Well
Tobacco Sales ❑
Food Packaging/Sales El❑
❑
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
L4
Signature of Agent/Owner6V
�i , gnature of Contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
-
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
I Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
DATE REJECTED
J
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
11
DATE REJECTED
Comments
Comments
IN
LE
DATE APPROVED
DATE APPROVED
DATE APPROVED
Water & Sewer connection signature & date
Temp Dumpster on site yes_�no Fire Department signature/date
Building Permit Approved and Issued by:
Pa -e 2 of
Building Setback (ft.)
Front Yard Side Yard
Rear Yard
Required
Provided Required
Provides
Required
Provided
011VI r INMUiv
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
NOTES and DATA — For department use)
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMEN'rJ3PFoRmm
Created PAC. Jan.2000
Location M � 5 A) v Z,, A
No. k Datey ��
TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
6+4
Building/Frame Permit Fee $
s�cMusE
Foundation Permit Fee $
Other Permit Fee $ _
TOTAL $
Check #
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Norman L Blad Construction
40 Fernview Ave. #10, N. Andover
Tel: (978)687-6263
Lic# 016141 - MA Reg# 131950
#_ of .7
Proposal Submitted To: Job Name Job #
�- cGc� rc-
Address � a � Job Location
i
Date / D Date of Plans
�y
Phone #9 Fax # Architect
�herebyubmit specifications and estimates for: ......... _....... ...__............. ... ... ...... _.._........ ._...__._......... ._............. 10._.. ....... _... _..._........... ... ........_........ _.._..__.._.._... _.._........ _......... ___.__.._._..,__.._._,.......... ..... ........ ......____....... _... .....
.
41
..._._.... ___.___._._._._..._.........__.... ... __.__._...__...... _.......... _........... _... ._...__........ __._._...__.._.__.__._....._:.........__..._..._....._.__. . _ _f':..._.,.....___.._.._.__..
We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of:
$ % QOp�""
Dollars
with payments to be made as follows: r
Any alteration or dev`ation from above specifications involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over andj
above the estimate. All agreements contingent upon strikes, accidents, or delays submitted
beyond our control. Note — this proposal may be withdrawn by us if not accepted within days.
2cceptance of Pro ora[
The above prices, specifications and conditions are satisfactory and are
Signature
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance `l Signature
NC3819 MADE IN USA
t BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 016141 1
Birthdate: 03/15/1947 E
Expires: 03/15/2008 Tr. no: 20180
Restricted: 00
NORMAN L BLAD
I 40 FERNVIEW AVE #10 G- j
N ANDOVER, MA 01845 f
Commissioner
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 131950
Expiration: 10/13/2006
Type: Individual
NORMAN L. BLAD
NORMAN BLAD
40 FERNVIEW AVE #10
N. ANDOVER, MA 01845 Administrator
The Commonwealth of Jlassachusetts
Department of Industrial. lecidents
Office of Investigations
600 Washington Street
Boston, JL4 02111
/J
www.mnss.gow'dia
Workers' Compensation Insurance ,affidavit: Builders/Contractors/E:lectricianslPlumbers
,applicant Information �JPlease Print Legibly
Nam lllusincss.l)r anitalit,n Individual): 141 01?114 A.{%
Address: f40 � RdplV 7/J e tV �91IR
City, State,, Zip/4/
Are you an employer? Check the appropriate box:
1. ❑ 1 am a employer with
4. ❑ 1 am a general contractor and 1
i full and,'or part-time).*
have hired the sub -contractors
Vniployces
r am a sole proprietor or partner-
listed on the attached :sheet. '
ship and have no employees
'These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeow ner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
'Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
3. ❑ Demolition
9. ❑ Building addition
10.❑ F,lectrical repairs or additions
I I.❑ Plumbing repairs or additions
12foof repairs
13.0 Other
'.any applicant that checks box ;r 1 must also fill uut the ;cclion below showing their workers compensation policy intumrrtion.
y Ilun,eowners who,uhmit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating:•uch.
('nntraclors that check this box mnsl altaclud an additional :.heel ,howing the name of the mth-contractors and their workers' comp. policy inturmalion.
I um an employer t/tut is providing workers' compensation insurance fur my emplgpeec. Below is the policy and job site
information.
Insurance Company Name:. -------
Policy ' or Self -ins. Lic. ?:
lob Site Address:
Expiration Date:__
C ity.'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 bIGL c. 153 can lead to the imposition of criminal penalties of a
tine up to $1.500.00 andrbr one-year imprisonment, as well as civil penalties in the form of STOP ti� ORK ORDER ;Ind 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
ln,c�tigations of the DLA for insurance coverage verification.
I do hereby certify U441er the pains and penalties ul'perju /I the ipArmation provided above A irtte anti correct.
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LAD` NORMN f u 'r�;� {r den. I N'ERNETINSURANCE AGENCY i INC
sj insured4^"4U F'ERNVIEW'AVE '#10. � x <;, ` 'Phone (978} 685=7690
�r N ANDOVER. .018 4 5- Agent # 20155
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PORM bF,;,BU8tk88S.
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PolicyPeriod."bNE YEAR fi '02'/64/06"k
from to • 02/04/07
This declarations "age together �ivith .ther policq jacket,` the `policq form and."tahy' endorsements, completes this policy.
Coverage begms a P 12:0 t . AaVL ? Standard :,Time at the eovei'ed premises, , .
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INSURANCE WE PROVIDE DURING THE APPLICABLE -ANNUAL, PERIOD, PLEASE .REFER TO PARAGRAPH DA OF, THE BUSINESS
LIABILITY dOVERAGE FORM
LiAB, & f1�EDrEXP fOCCtiRRENCE/GEN AGG/PROD COi1AP OPS AGG) 3B(0 $800/ ''' 3600. .• Included,
MEDICAL' EXPENSES s 4# r `l�r�b : •'�« r t
t . DAMAGE TO PREMISES hENTEDr TO 6U _ $6 ,Included '..
. ',s ,. ° X360 "IncludedN.
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