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Home My WebLink AboutBuilding Permit #679 - 56 MONTEIRO WAY 4/24/2009Of NORTH 1H ,SSACHU`�ES Permit NO: ('25 Date Issued: VI 141 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received: -171-,-1-76 — 0'6 I IMPORTANT: ADDlicant must complete all items on this page I LOCATION L!5_6 42 Oa /&AT 0� 0 W / 40A /71)<ob0e"?\ Print PROPERTY OWNER `''7 0+444�1_ Print MAP NO.: i L PARCEL: ZONING DISTRICT:-� 0(06,0 ' /cr16 TYPE ANTI ITSF. OF RITILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration X 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 a(ff(2-0 13,46� S; OWNER: Name: Address: %-r"a4 fl»d 12fl S1k Identification Please Type or Print Clearly) fti� �ti� 7t - CONTRACTOR Name: ,� Ocl /ft5 Dll ke J Phone: 97X ,3g7 7Z90 Address: �J U✓n /171 1 �� I W(T h 4e l Supervisor's Construction License: Exp. Date: Home Improvement License: / 38 72 ,5 Exp. Date: 5113 /0 7 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT. $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S. F. Total Project Cost :$ x10.00=FEE:$/ Check No.: Receipt No.: C l Page I of 4 TYPE OF SEWARGE DISPOSAL Art ❑ wmmn i SiPools 11F1Tanning/Massage/Body g Public Sewer Well Tobacco Sales L1 Food Packaging/Sales L1❑ ❑ Permanent Dumpster on Site F1Private (septic tank, etc. Electric Meter location to project NOTE: Persons contracting with unregi tered contractors do not have access to the guaranty fu_ d Signature of Agent/Owner Signature of Contractor '` t't'' Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ n ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer connection signature & date DATE REJECTED 11 DATE REJECTED Comments Comments Temp Dumpster on site yes_noX Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 DATE APPROVED DATE APPROVED DATE APPROVED Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. NOTES and DATA — (For department use) AAA Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENT RPFORM05 Created 1MC. Jan.2006 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 DEPARTNI ENT: BPFORM05 Page 4 of 4 Location No. Date t ` TOWN OF NORTH ANDOVER �� • 0 9 Oertificate of Occupancy $ s;CNUSE< Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # !9►2 )} Building Inspector WD 4 J W z v � o u A i m c x W o W Qa H O y C O W A V CiCc W p w° p, Cf)w° � q � �a U in w � a�' m w W W m a°' cc iv w OG w w W C rA ° cin C p cn J W z I rs v 'Qr •: c S CD . o i m c j o O y C O V CiCc a� Cc . cc 'N E a ts n �Eyc CD c:5 +v$ tsCD oc fti E � H W m � • � m H cm 0 3 c m O ED O re awe C m d) O Z = O OD C Z cO O O � �6vi N O m Z V p coo c v, c o = :neo N W 0 �rLt cri y CL. 32 5 = eya a`H� O 06 cc zip I rs v 'Qr Tooqlfo W �6 q78- W - ?2-10 201691 AME k + l7o ke ` SHIP TO - -- X60 4 DDRESS S � fty 4X -o U) ADDRESS ITY, SV: ZIP ` /, Q CITY, STATE, ZIP ORDER NUMBER'\�� DEPARTMENT SALESPERSON WHEN SHIP TERMS HOW SHIP DATE QUANTITY ;, DESCRIPTION PRICE AMOUNT 7;2,5 _. 4 — 1400 (p}c@ Sada w ?rg-rl&s C14tgg k4-4- Ung CIO Af Tok- -pf— SSS O5� Pdl WYER: I,adan* KEEP THIS SLIP FOR REFERENCE 100 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ti Board of Building Regulations and Standards Re istrafion:+ 738775 =� One Ashburton Place Rm 1301 Expiration- 5/a 3/2007 Boston, Ma. 02108 =Type: Intlividual DOUGLAS DALKE.: ; DOUGLAS DALK 22 SUMMIT STREET 4 rd -1 G r�u✓ N. ANDOVER, MA 01845 Administrator ."+?ut valid without signature The Commonwealth of Massachusetts Department of Industrial, lccidents Office of Investigations 600 Washin-ton Street Boston, MA 02111 y� ♦ imm inass.govId►a Workers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Iltusiness th!!anii;uiun;lndi�idual): �CSI)�IPIS � I�� Address: City,State,Zip: PA dol)-� Phone :+#: a72; 39-7 kre you an employer? Check the appropriate box: . ❑ I am a employer with 4. ❑ I am a general contractor and employees (full and ior part-time).* I am a sole proprietor or partner- ship and have no employees working for the in any capacity. [No workers' comp. insurance required.] ❑ I 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 N1GL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I I .❑ Plumbing repairs or additions 12.❑ Roof repairs 13 . nd Other _15 dj , `,\ny applicant that checks box iiI must also Dill out the section below howing their workers cumlxnsatien policy mtixn,:)tioh. y ng they are doing all work and then hire outside contractors must suhmit a new affidavit indicating such. Homeowners who Snhmll II11S affidavit indicati Gmtractors that check this box trust attached an additional sheet ::bowing the name of the sub -contractors and (heir workers' comp. policy information. I am em employer that is providing workers' conipensalion insurance for my einplovees. Below is the policy and job .site in%ormation. Insurance Company Name:— ------.-----_—.._-. —.-__---- - ----- ----- Policy "- or Self -ins. Lic. -1:_ _ Expiration Date: Job Site Address: 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 ,%IGL c. 153 can lead to the imposition of criminal penalties of a tine 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 tine Of up to 5250.00 a clay 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 lrerebv r the poi ind penalties oJ'petjury drat the in ' rmation provided �7_ is tru , and correct. „ --- pace: 6,nature: Oficial use ort/v, oo not wrile in this lirea, to i)e completed by cit), or lowu o/ficial. City or Town: Issuing Authoritv (circle one): 1. Board of health 3. Building Department 6. Other Contact Person: Pi:rrnit/license # 3. City/Twvn Clerk 4. Electrical Inspector 5. Plumping Inspector Phone #: