HomeMy WebLinkAboutBuilding Permit #341 - 687 SALEM STREET 11/1/2007 0ORTlr
BUILDING PERMIT Of�tk 6G rb�ti
TOWN OF NORTH ANDOVER
02 4 "'`- .•_�.
APPLICATION FOR PLAN EXAMINATION
Permit NO: l Date Received -7
�SSACMl15E�
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration - >✓ No. of units: Commercial
Repair, replacement t/ Assessory Bldg Others:
Demolition Other
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DESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
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OWNER: Name: `; ,�,m�-s .�/,4�i-� Phone: 97,?
Address: Alb A&6AQ2Z2 As7s:
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ e,�, CO FEE: $
Check No.: wx�/ Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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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
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
a Certified 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)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
{ ❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
I ❑ 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
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
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 set this recorded at the Registry of Deeds. One copy andp roof of recording
must be submitted with the building application
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
I
Revised 2.2007
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Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools
Well Tobacco Sales Food Packaging/Sales
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
COMMENTS
4
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
I
Water $ Sewer Connection/Signature& Date Drivewav Permit
Located at 384 Osgood Street
�RE'`OEP ►RT` IET} _dfernp fDu
Fmpsters�l� site des no
Located at:12 Mainstreet77
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No .
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
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❑ Notified for pickup - Date
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t
Doc.Building Permit Revised 2007
Location
}
No. Date S 07
M°RTM TOWN OF NORTH ANDOVER
o�,,..o
16.
Y y
• � ; . Certificate of Occupancy $
JAcHus`� Building/Frame Permit Fee $
Foundation Permit Fee $
7
Other Permit Fee $
TOTAL $ 7
Check # '7'Gt ffl
,2075
Wiling Inspector
Re u tions and.St�u+ii+dti +
Bgard of Build ing t;
HOME IMPROVEMENT4CONTRAC7Ufi
Registeatign 127972 T 1?(8�5
Ezpirat in" 2J-sq 09,
T� Inc�i
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'i 'NiICNAEL 1N GOSSE�.IN',';` �f F fi
` MICHAEL GOSSEL,N
38 FORREST ST. `'
NHO,5
NORTH
To" of
No. o
CONo , dover, Mass.,
O - LAKE
COCHICHEWICK
7�S RATED P'V Cl
BOARD OF HEALTH
PER IT T Food/Kitchen
Septic System
i /����s BUILDING INSPECTOR
THISCERTIFIES THAT................................. ............................................................................................................................... Foundation
has permission to erect............ .......... buildings on ....A S�/ ...� ......................... . Rough
1 . ..........
to be occupied as ���G p '`l r�:j' / r Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR.
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR.
UNLESS CONSTRUCTION STARTS Rough
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises = Do Not Remove Final
No Lathing or Dry Wall To BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
Also, note Permits are required under Fire Prevention laws:Chapter 148 Section
I 0A.
The debris will be disposed of in:
(Location of Facility)
Signature of Vermit Applicant
Fire Department Sign off:
P g
Dumpster Permit
Date
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burl inrg'an,- sssachusetts - -- —_--
(800)876-2765 NCCI NO 26158
POLICY NO. AWC 7013481012006
PRIOR NO. AWC 7013481012005
ITEM
1. The Insured Michael Gosselin dba M W G Construction
Mailing Address: 38 Forrest Street Plaistow NH 03865
(No. Street Town or City County State Zip Code
® Individual ❑ Partnership ❑ Corporation ❑ Other FEIN 01-9506249
Other workplaces not shown above:
2. The policy period is from08/12/2006 to 08/12/2007 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A-
The limits of our liability under Part Two are: Bodily Injury by Accident$ 5 0 0,0 00 each accident
Bodily Injury by Disease $ 5 0 0,0 0 0 policy limit
Bodily Injury by Disease $ 500,000 eachemployee
C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
Total Annual of Annual
No. Remuneration Remuneration Premium
i
INTRA 300911
SEE EXTENSION OF INFOR14ATION PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 550.00
As indicated,interim adjustments of premium shall be made: Deposit Premium $ 550.00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg-
$308.00 x 4.1920% $0.00
This policy,including all endorsements,is hereby countersigned by &0, 07/25/2006
Authorized Signature Date
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Byfield Insurance Agency Inc
MA 15645 2 1705 1 P O Box 400
WC 00 00 01 A(11-88) Byfield,MA 01922
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
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✓fie �o�inin�a�zusocc%C� a�✓�,aaaac�tuaet�a �1
S Board of Building Regulations and Stud.
HOME IMPROVEMENT66NTRACI0th,
Registrapo_ 127972 ;
I Ezpiratirt $ p09 Tr# t?Uu' "' 1
t .,Y
t
Tye IndivfdAl
MICHAEL•W.GWo,OSSELIN�.
w MICHAEL GOSSELIN
38 FORREST ST ik
5
PLAtSTOVtI