HomeMy WebLinkAboutBuilding Permit #82 - 62 SAILE WAY 8/7/2009-± TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: A{ Date Received: A Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
PROPERTY O
NIAP NO.: PARCEL:
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Print
ZONING DISTRICT:
FiiCTnRi(' i lgTRiCT VFC fl
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
?:-New Building
❑ One family
Addition
❑ Two or more family
❑ Industrial
C Alteration
No. of units:
Repair, replacement
❑ Assessory Bldg
n Commercial
❑ Demolition
F] Moving (relocation)
❑ Other
❑ Others:
Foundation only
DESCRIPTION OF WORK TO BE PREFORMED 2C2 &4e 7r All
-ta
e y V6 . _9rw5 l J/7i.S , , m"n 7S //
N.
Identification
OWNER: Name:
Address:
CONTRACTOR Name;///G/,<iC-=
Address:
Type or Print Clearly)
Supervisor's Construction License: 04oC7,�?i (3 Exp. Date: U
Home Improvement License:
Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE: 6ULDING PERMIT: 510.O0PER 51000.00 OF THE TOT,4L E.STLIVIATED COSTBASED ON S115.00 PER S.F.
Total Project Cost=FEE:$
Check No.: C�c1; Receipt No.: 1
Page Iofa
TYPE OF SEWARGE DISPOSAL
Tanning/Massage/Body Art
Swirmning Pools
Public Sewer
Tobacco Sales -
Food Packaging/Sales
Well _
—_
Permanent Dumpster on Site
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Pet -sons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Xgent/OwLSignature of
Contractod02 �.
Plans Submitted 1:1 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
COLINIENTS
Zoning Board of Appeals: Variance etition No:
Zoning Decisionircceipt submitted yes
DATE REJECTED
❑ ❑
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE APPROVED
DATE REJECTED DATE APPROVED
DATE REJECTED
i
Planning Board Decision: Comments
DATE APPROVED
Cnmervatinn Derisinn• Comments
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required Provided Required
Provides Require
Provided
& Sewer connection signature & date
Temp Dumpster on site yes—no— Fire Department signature/date
Building Permit Approved and Issued by:
Page? of
DIMENSION
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
1• V'AMR-IM TiIOMGQIWWI
Pa.ge 3 o
Doc: INSPEC HONA1. SkRVICF.S Df_PAR'I MENTA311FORN105
Nater
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
La 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 DF.PAR'rmENT:BPI-'0RNI05
Page,l 44
Location 6..2 S� Gw 4 4
No. A�— Date ' ' 0.
HORTN TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
�'�• ^^� ^''t�' Builr inn/Frame Permit Fee $ �
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
19 31 r-.'`----�-
Building Inspector
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The Co mmonwealth of Massachusetts
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Department of Industrial Accidents
Office
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of Investigations
600 Was Street
Boston, MA 02111
Workers' Compensation Insurance Affidavit: Bu de s/Contractors/Electricians/Plumbe
L11—canttInformation rs
Name (Business/Organizarion/Individual):
Address:
City/State/Zip: ,,(> / Iq P S 2 Hyl
C,
Phone #:
Are you an employer? Check the appropriate box:
1 •
Warn a.employer with y�� 4. El am a general contractor and I
2. ❑employees (full and/or part-time).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No.workers' comp, insurance 5. El We are a corporation and its
required.]
z n T _TM _ t ___ officers have exercised their
- . .
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
COMM insurance reu' d
Type of project (required):
6. El New construction
7. El Remodeling
8. El Demolition
9. n Building addition
10. ❑ Electrical repairs or additions
12.0 Roof repairs
q ue ] 13.® Other _
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I.am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: N y
Gni
Policy # or Self -ins. Lic. #:
/ Expiration Date: /J Q
Job Site.Address-
Attach acopy of the workers' compensation policy dec aration page (showing he 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 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 cetify� under the pains ad penalties of perjury that the information provided above is true and correct
M l., .� /
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town:
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 #:
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BOARD OFBUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: C3 060219
Birthdate: 04/37/1954
--
EX;
ires: 04/27/2007 Tr. no: 9737.0
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BOARD OFBUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: C3 060219
Birthdate: 04/37/1954
--
EX;
ires: 04/27/2007 Tr. no: 9737.0
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