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Home My WebLink AboutBuilding Permit #617 - 64 WAVERLY ROAD 4/5/2006Of NORTH dt ��O �°• O O - A 9SS.ICHU`�E� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: &/? Date Received: Date Issued: J rlo,6 IMPORTANT: Applicant must complete all items on this page LOCATION Print a PROPERTY OWNER l �/ Pri kj -- ��C7. V MAP NO.: PARCEL: d l g`d � tZ%�NG DISTRICT: TYPF AND ITSF, OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Aoition C►i*AGeration ❑ One family ❑ Two or more family No. of units: '�y'"" ❑ Industrial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Pv� AD ST34t kliz_S Af o U•e Wyi- I ( S 0R-0� S 'J, ,e ( -I) (<r •e.2 �e i1�e�-�Q QCs -� cy`-' Type or �rint Clearly) U ,, I rleoo 7 410 V-Mi+� OWNER: Name: �6,� k*/'t �Jd �i �� Phone: Signature _ `Address: 6 `� �� ei�et±j ( of, ��"�-3 N�r�� Ac^�r�y A` , n77 5 CONTRACTOR Name:�S e--irI Phone: G a 3 ' `7 3 - 0-t( (03 4 I —s 37 7 - Address: °�y� 6 te"o �o Supervisor's Construction License: c27E6 Exp. Date: 02 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER J, St I U A �AIC_ Name: Phone: 1 Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAS D ON $125.00 PER S.F. Total Project Cost :$ �G�0- C d x10.00=FEE:$ C0 4910 Check No.: �� Receipt No.: ( 66 Page I of 4 TYPE OF SEWARGE DISPOSAL Tanning/Massage/Body Art ❑ wmmn i SiPools ❑ g Public Sewer ❑ Well F]Tobacco Sales LlFood Packaging/Sales ❑ Private ❑ Permanent Dumpster on Site ❑ (septic tank, etc. Electric Meter location to project NOTE: Persons contracting witl unregistered contractors do not have access to the guaranty fund Signature of Agent/Own Signature of Contractor /,)A. 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: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: DATE REJECTED ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED DATE REJECTED 11 Comments Comments Water & Sewer connection signature & date Temp Dumpster on site yes no Fire Department signature/date IN] DATE APPROVED DATE APPROVED DATE APPROVED Building Permit Approved and Issued by: Page 2 of 4 ti Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: Total land area, sq. ft.: NV IUJ ana UAIA— Doc: INSPECTIONAL Created JMC. Jan.2006 Total square feet of floor area, based on Exterior dimensions. 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 DEPARTMENT:BPFORM05 Page 4 of 4 Location 4, v- 4,6 11jad,01 No. Da;te - A. TOWN OF NORTH ANDOVER Certificate of Occupancy $ 06 S Building/Frame Permit Fee $ CH Foundation Permit Fee $ Other Permit Fee TOTAL Check # 19082 Building Inspector T 0) CD CA x _ CD 1.6 CEN N� to Ln -P qbzl tD ' v 8 mm .0mmm mgmmww 3mm °c°' -0O' m m- m _� 4 .. 0m.m 0j m K z OD0 <xwx CA Doo'W ma'm=moo� �. x»mxmo R& �� gw=�,-0 >� 00 RODM_m °0 0 O A CA) O � m -n wm = c m =r r. 3Jl 3 Apd eToQ_<m -lCDCK 0.0 m�`, 0 aO m CL °o0am�'n�m�3 O a.A to' 3 3 m ap53 cW DmDD3 I- - m ND m� m ;a m z C1 m z O 3 a 2 y_&a0� v+w OCD mm 0 oc 0 _&O -< �'i n o� m m m > m Z I O � Z 0 m 1 o c O co °° a V O O C O "DO o m m -I -•1 j C °Oxm 00 b D v -" o 0 yy, wa �� OG1am 7 aro CL 0 D�� m r0 n 8" po z C7 a a > 0 ��n m 3 �n.D 0o�+ m V.URO z 3003 3D -4 W rom<Uva� r o @3m � adv ., NR � CD �mmmsn c w a. 0D am®m o ` .. 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FE A m N O C) 1 -1 w0 a 'am CM C O •� ca Q m■_ Aa O O 'F co m CL 3.0 Q L � O � C Q os c ev v C Z ai 0 CL C.3 y c C C CO) is 0 N U) ce W LLI 19 LLIW N OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANOVER P_n ON PROJECT PROJECT LOCATlCiid, 6_4 - W+ NAME OF ftILMi?ma.--_.V.1 SZ.��s1�-� My�.T�•Far�� cs�__� �,_�. NATURE Of PROJECT:��°ktLT�i WITH APTICLE t IB OF THE MASSACHUSETTS STATE BUILDING COODE, - - -.—�� hREGIS ;TION NO, 3 g BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITE01 HEREBY CERT'FY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PIANS, COMPUTATIONS AND SPECIMAT1ONS CONCERNING: ENTIRE PROJECT 0 ARCHITECTURAL Q ST'RUCTUPAL D/ McCHANICAL FIRE PRM-ECTEGN U ELECTRICAL OT'H'ER (SPECIFY) FQR THE ADOVE NAMED PROJECT AND THAT, TO THE BEST OF IVY f611IOWLEOL. SUCH PLANS, COMPUTATIONS AND SPECIFICAT10148 MEEI:T THE APPLIC RLE PROVISION OF THE MASS c v$& ,. TE; ,3TATE BUILDIIQ CODE, ALL. AC CErrAKE ENGINEERING PRATIOES, AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSE© t)SE ANO OCCUPANCY. I FURTHFR Cs'f. 2TIFY THAT I SHALL PERFORM THE 14EGESSARY PROFESSIONAL SERVICES AND 8 EPRE_$EryT ON THE CONSTRUOTION SITE ON A REGULAR AND PERIODIC BASIS To t)�TlwRI�tNE THAT 1 4 WORK 15 PROQEEEDIIrG IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL SI_ RESP0,,14SI&E FOR THI; FOLLOWING AS SPECIFIED EN SECTION 116.0 ksview, for conformame to the deeign conoeo, shop driwings, sumPes and O tier su mi"Sls wWch 2M Submitted thy the co tractor in acrzitanoe with ft requiremerb of tttt; wns"Otlon dXurneft 2. RGY16w and approval d the qusllty control prt�A, =Lres for ail c0'd&Nquirad Wr;trol#ed materials. 3. % grr...sa" at intervals at�R�Ptlete 4o tI>e stage of ccur:�t. vvEth�ihe pr r s¢ and que1lty of the `mak and to determ ne Iir� to IC�ccrlis, generally familiar I _rPc+Pr O in a rarrrter co%$tent �rittl the can�trtt tl�xl dac;i� Oral, if the wank is beinI; PURSUANT To SECTION 1113.2 ,2 1 SHAE-. SUBMIT WE7EKLY , A PRAGRESs REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NOL IRTH .ANDD- VErt i3UILDING INSPECTOR. UPON COMPLETION OF THE WORK,.i SHALL SURMI'TA FINAL REPORT AS TO THE SATISFACTORY CCIIMPLETION ANIS READINESS OF'THE PROJECT FOR OCCUR S' C RIi E®ANL" SWOI N T® BEFORE ME 7HIS� DAY 01= a E' NOTARY PUBLI ��---�--�-- O DONNA Ni. CARIDEO MY COMMISSION EXPIFMS ® NOTARY PUBLIC STATE OF NEW HAkVSHIRB My ComrnWon expires July. Ift.M c d WdEZ :80 300E LT 9E@LL R%LE : 'ON Xbd SNO 1- 03dE:N r .['a : ia:0 a Er�'d T� SDS SSE 43L6 I Iz�a! piy� epiia�O vqv L;.:g 900E Z I, 4j :njgad `,ep;:d The Commonwealth of Massachuseft§ Department of Fire Services Off -ice of the State Fire Marshal P. 0. Box 1025 State Road, Stow, MA 01775 PERMIT North Andover Permit No Date: (City of Town) (If Applicable) Dig Safe Number In accordance with the provisions of M.G.Ll 4 8 Chapter _]_O_ as provided in section—ULL-fM 34 Start Date This Permit is granto to: J- 5Lk Full name of person, Firm"/ or C oration otp / locate dumpster for construlction Permission to reno.vation/demolition of building Comments: dumpster must be 25' -from structure if unable to I Place with recuired Restnchons: clearance dumpster must be covered with vlvwood or tarn end of wnrk day at Give location by street andno., or describe in such manner as to provied adequate identification of location FeePaids 50.00 Fire Chief This Pennit will expire 2 (SignatroTbffia—grantingperinit) Offical granting permit (Tide) MMME40- TWI.q P;=PrAIT RAI 1-1,-T Ri= rom-qPiri ini i-qi V Pn.c,-Tpn I ipr)M TWI= PPPIVII.qg=.C,- y� The Commonwealth of Massachuselts Department of Industrial Accidents Office of Investigations 600 Washington Street F Boston, AM 02111 t WWIV.n1aSS.gUVIdla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information' Please Print Legibly Nalne lBusiness/(h•gani/ation/Individual►: Jam_ ,address: / t ' —SPhone, 6 P`City/StateiZip: -Vji Are ou an employer? Check the appropriate box: ' I . am a employer with �I 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I 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. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §I(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 4. ❑ Demolition 9. ❑ Building addition 10.❑ F.lectrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ':\ny applicant that checks box 9 1 must also 1111 out the section below showing their workers' compensation policy information. L I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating ,uch. Contractors that check this box must attachcd 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 emplgvees. Below is the policy and job site information. _ Insurance Company Mame:-- Policy 'f or Self -ins. Lic. 4: Vut/ (l(Y aa6✓r -o Expiration Date:____ __ Job Site Address: � / —C//C1 `'�� y CityiState/Zip:�� _,, J � 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 tiIGL c. 152 can lead to the imposition of criminal penalties of a tine 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 DIA for in4rance coverage verification. I du hereby certify au h a . and penalties of perjury that the information provided above is trite and correct. - nnte. Phone• ": 5(7 1?3 7 Oljic•ial ase only. Do not write in this area, to be completed by cit), or town olicial. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk -l. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: