HomeMy WebLinkAboutBuilding Permit #752 - 66 LACY STREET 6/5/2006IIC
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EX.WINATION
1 �SSACHUS� APPROVED
.,' 'J,S'� � Date Received:
• permit NO:
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 66' A �
Print
PROPERTY OWNER
M,w NO.:
Print
PARCEL: U ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition = Two or more family =Industrial
Alteration No. of units:
Repair, replacement _ Assessory Bldg Commercial
Demolition
Moving (relocation) = Other Others:
= Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
7r• DfcK 6t/yAgl
Identification Please Type or Print Clearly)
OWNER: Name: �,c� �� `/ Phone:
address:_ env
CONTR1XCTOR Name: /(—
address:
Super%isor's Construction License. Oylr65?
y.
Exp. Date:_A��
Home Improvement License:�%/��g Exp. Date: —�
1RC'HI I'ECT. E�'G[NEER Namc: Phone:
Wdress:
Reg. No.
FEE SC'HEDL LE: SULDtNG PERMIT. S10.i) PER S190.00 OF THE TOT. IL ESTIJI.-t TED COST B.-ISEROA S125.00 PER S.F.
Total Project Cost :$_-____ � f __x10.00=FEE:$ _' _
Check No.: S10'/1) Reccipt No.:
TYPE OF SEWARGE DISPOSAL
Public Seller
Well _
Private i.. tic t nk t t�
TanningAlas�ge Body .Xrt SAimming Pools z
Tobacco`Sales Food Packaging S'd 1 s,
"Permanent Dumpster on Site _
�p .► a c. Electric deter location to
project
tiOTE: Persons contracting '1h unregistered contractors do not htwe (recess to Nie i,► art nt • irnt!
Signature of Agent Owner. t Signature of Contract
Plans Submitted ' ans Wai��ed Certified Plot Plan Stamped Plans y
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
0LANNING & DEVELOPMENT
COMMENTS
DATE REJECTED
A
�D_
[]Water Shed Special Permit
F� Site Plan Special Permit
J Other
DATE APPROVED
DATE REJECTED DATE APPROVED
/CONSERVATION`" vy
COMMENTS
HEALTH
CO,%vl-' LENTS
DATE REJEC'T'ED
DATE :APPROVED
r r
4
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tonin, Decisionireceipt submitted ,es
planning Board [decision: _..-- -----.-----Corn
Cu-iscr�;tticn Ducieiun: ---------('untments
�tcr � S.:�-i Lr COnncCCl(Tn �'�n1tUl'l' �: mate
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i cmp Dempster cn siccyec_ no_— Fire Department si:naturc date ✓ t!�firi�.� _--- �`�/2B� L
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Building Permit Appresud and Issued by:
Building Setback (tI.)
Front Ward Side Yard
Rear Yard
Required
Provided Required
Provides
Required
Provided
3U
3G
DIMENSION
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
-
f ,..".,A
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
a 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 Hydrau
Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
• Building Permit Application
• Certified Proposed Plot Plan
a Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
Mass check Energy Compliance Report
In all cases ira variance or special permit was required the Town Clerks office must stamp the decision from the Board of
.%ppeals 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
`nc: I`.til'!.("1'[U\,tL, ti►iR%'PIES OFT 1Rl ME, 1':i)1'F0R`105
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Location
No. 5� Date 'o
NORTH TOWN OF NORTH ANDOVER
Oi�•n I',h0
• L
Certificate of Occupancy $
Eta Building/Frame Permit Fee $ b
S CMUS 1
Foundation Permit Fee $
c
Other Permit Fee $
TOTAL $ o x) �
Check # " U
a '" U Building Inspector""
The Commonwealth of Massachusetts
Department of Fire Services
Office of the State. Fire Marshal
P. O. Box 1025 State Road, Stow, MA 01775 :r
PERMIT Date:
North Andover`rl
( City of Town) x erg.. V (If Applicable) 1lig Save 1`7anrber
In accordance with the provisions of M.G.L 14 8 Chapters as provided in section--q2-7--CMR 34 Start Date
This Permit is granted to:
Full name ofperson, Firm or Corporation
Pennissionto locate dumpster for construction/renovation/demolition of building.
Co=nents: dumpster must be 25' from structure if unable to place with required
Rcstri0L10ns:clearance dumpster mus be covered with plywood or tarp end of work day
at
( Give location by street and no., or describe in such ann to provied adequate identification of location )
Fee Paid$ 50.00 Fire Chief
This Permit will expire 7 r/ o C ( Signature of offical anting permit) Ofiical granting permit ( Title )
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The Commonwealth of Alassaehuselts
Department of Industrial, l ccidents
Office of Investigations
600 Washington Street
Boston, ,114 02111
www.mass.gov/din
Workers' Compensation Insurance .affidavit: Builders/Contractors/Electricians/Plumbers
ADDlicant Information Please Print Legibly
Name/j ,/fd4j� s
;address: r-0 _
City;StaterZip:/lifd,UG &,,0'. 400V Phone :#• ¢'5-6 6- ?ell
,kre you an employer? Check the appropriate box: .
1. ❑ I atm a employer with
4. ❑ 1 am a general contractor and
/employees (.full and/or part-time).*
have hired the sub -contractors
2. (�'" 1 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, § 1(4), and we have no
insurance required.]'
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
3. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I l.❑ Plumbing repairs or additions
12.❑ Roof repairs
131-1 Other _
'Any applicant that checks box 4I must also fill out the section below showing their workers' compensation policy information.
+ Homeowners 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 attached an additional :,lice( showing the name of the sub -contractors and their workers' comp. policy information.
I um am employer that is providing workers' compensation insurance for my emplayeec. Below is the policy and job site
information.
Insurance Company Name:_____
Policy t or Self -ins. Lic..tl:
Job Site
Expiration Date:
City: 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 `blGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP �XORK ORDER and a tine
Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
(nvestigatiorysa�the DLA for insurance coverage verification.
I du !
tii��t •ttt
Phone -
the pains and penalties of perjury that the information provided above is true and correct.
!)/frcird use only, l)n ,:��t write in this rrrr.��i, to bc� /:n;nplrted h)- �•;Il� rtr iow» ,,l�c•inl.
City or Town:
.Permit/License #
—//-U
Issuing ,Authority (circle one):
I. Hoard of Health 2. Building Department 3. City/To"at Cleric 4. E!eetrical Inspector 3. Flumbing Inspector
6. Other
C,)ntact Person: Phone #:
Pages
Page No. of
rn�ro�tti {
DGM R. KR017
Ant itct�l�dtun �,€aRoa}c#
944
PROPOSAL SUBMITTED TOPHONE DATE:
MEET r JOB NAME
,tTY, STATE and Z(P CODE; JOB LOCATION
MCHITECT I DATE OF PL N S J08 PHONE
We hereby submit specifications and estimates for:
4", *+ f aG < _ ' Grp✓ < ,� �
xv
We PrOPOSP hereby to furtzjsh material and labor-`cornplete in accordance:+uith above specifications, for the sum of:
dDllars- j$ ).
Payment to be made as follows.
All material is guaranteed to .be as specified. All' work to be Completed fina workmanlike
manner according to standard practices; Any alteration or deviation from above specifications . AuthorizedStgnature
involving. extra costs will be executed only, upon written orders, and will become an extra
charge over and 'above the. estimate:. All agreemertts contingent :upon .strikes, :'accidents.,
or delays beyond our. control., Owner to carry fire, tomado And: other necessary fnsurance. Note: This proposal may be
Our workers are fully covered by Workman's Compensation insurance: withdrawn by us "tf not accepted withindays.
Arte IfMn r :01 ` ra 'QsiaF' The above prices, specifiCations
and conditions are satisfactory and are. hereby accepted. You are authorized Signature
to do the work as specified: Payment will be made as'outlined above,
Date of Acceptance: _ . _. ... .Signature w