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Home My WebLink AboutBuilding Permit #572 - 761 DALE STREET 3/13/2006 ,40RTh Of •�.°,e1q.0 TOWN OF NORTH ANDOVER � . ,_•" APPLICATION FOR PLAN EXAMINATION 9SSACMU`�Et Permit NO: Date Received: 2 / _d Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION `T 1� / Print PROPERTY OWNER Print l MAP NO.: ' t7 PARCEL: I C ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building (,'One family OAddition ❑Two or more family ❑Industrial ❑Alteration No. of units: ❑Repair, replacement ❑Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑Foundation only i DESCRIPTION OF WORK TO BE PREFORMED—S G ._N Z) % gv x, Identification Please Type or Print Clearly) OWNER Name:____ Phone: / t � Address: Mn S --gyp CONTRACTOR Name: � L— 4-N61 JE V f�J Phone: Address: Supervisor's Construction License: d G Exp. Date: I Home Improvement License: ' Exp. Date: y k ARCHITECT/ENGINEER — Name: Phone: i Address: Reg. No. I FEE SCHEDULE:BULDING PERMIT.$10.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS. D ON$12.5.00 PER S.F. i Total Project Cost :$ S{ X00 x10.00=FEE:$ # Check No.: f� � Receipt No.: 0C Page 1 of 4 V Location ,�G/ No. 5 7 Date NORTH TOWN OF NORTH ANDOVER _ O f _ � }:o Certificate of Occupancy $ 9 cNuBuilding/Frame/Frame Permit Fee $ s� st Foundation Permit Fee $ Other Permit Fee $ J._ TOTAL $ Check # 191 02 4 'Building Inspector TYPE OF SEWARGE DISPOSAL/ ,�_4,/ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer Well F1Tobacco Sales ❑ Food Packaging/Sales 11 F1 Permanent Dumpster on Site ❑ Private(septic tank,etc. NOTE: Persons contracting with unregistered contractors do not have access to the g my fund Signature of Agent/Owner �6n/'�� Signature of Contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS �..-- DATE REJECTED DATE APPROVED ,/CONSERVATI COMMENTS 066 ATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals:Variance,Petition No: 'Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection signature&date Temp Dumpster on site yes_no_ Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area,sq. ft.: NOTES and DATA—(For department use Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 I i 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 PLAN OF LAND LOCATED IN NORTH ANDOVER, MASS. g"30. SCALE.I"=40' DATE 2/23/2006 Scott L. Giles R.P.L.S. Frank. S. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. Q' O C �O e SEE ASSESSORS MAP 104C, PARCEL 109. THE ZONING DISTRICT IS R-1. O >> 'a 01 p6i pyo, °rGhPARCEL "C" EXE Fnd se PLAN #9116 N.E.R.D. �x�st 1.275 ACRES pecK Deed Book 1711 Page 329 �O X2639' �0p I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE OF B THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE 3 WITH THE ZONING 72 DETERMINATION OF ZONING CtSTEBYLAWS OF RE� NORTH ANDOVER CONFORMITY OR NON-CONFORMITY � LRS WHEN BUILT WHEN CONSTRUCTED. tAORTH Town of Andover 0 W Im _W No. E dover, Mass., � coc H It Pa\ IT 0"?ATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System .. IV* BUILDING INSPECTOR THIS CERTIFIES THAT........R.. . .r... r............. ....................................................................... Foundation has permission to erect........................................ buildings on ...1.10..I........D.0.1c......lc..r............................ Rough to be occupied as..S.C.Q.-tt.n.,ed........PAX!.Lh.................1.14..�_JA....................*******"*"*'*'**...****** Chimney provided that the person accepting this permit shall in every respect conform to the terms o 9 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 CONSTRUCTLON STARTS Rough Service BUILD G 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 Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. I p• y dlbl- __ Cog P�•t'� � i i �Yb°ca.. s I3.fix OT,��' , clo' P'i, °1'•P}•� i3 AeA, ex•"s�:a� ►1�us� •� " � {,i+ ��u� �` � •'lax6 dug t� dC. 04 i • • f I � f s I I f d 1 { 1 I i I I I I ; � I I t a: 1 ! , 1 % Il 1 O lY 1 ' 1 i 'I d J �✓ °° Mations and Standards License or regexpiration date If found return to'. d for indi,idul use only Board of Building Reg before the expiration Board of Building Regulations and Standards HOME IMRO�VEMENT CONTRACTOR One Ashburton Place Rm 1301 114strgt[P. A 1990 Boston,Ma.02108. — ._. { 1,2007 .j - !pe = i; f� MOLDING t " ROBERT LANG V $ DG R , K.J) ROBE LANGEVI � V `` t ig \` pw,✓ nature ._ 795 DALE ST �" V^ Not valid withou 0 1845 Administrator MA N ANDOVER, " - p /A4, �t�caelta � '- fie (Varnrreo°zcue _ BOARD.OF_BUILDING REGULNS ATIOI "4 License CONSTRUCTION SUPERVISOR NumberCS 002685`.:,,, ;( � Birthdate YI 0212411947 Tr.no: -15095 Expires 02/2412008 '�"~J Restricted: 00 'f , '. ROBERT M LANGEVIN µ. 795 DALE'ST. 1 , N ANDOVER, MA 0184"5 '"" dommissoner Page No. r of r Pages. ROBERT LANGEVIN BUILDING AiND REMODELING 795 Dale Street NOR,rH ANDOVER, MA 01345 PROPOSAL (508) 686.3607 PHONE DATE TO JOB NAMi/LOCATION 7 K JOB NUMBER JOB PHONE We hereby submit specifications and estimates for: �5 E tQ X, UD-F 9 tj 6Z 11jn P-4" Ajw N r /_1 74tJ/D__3 4�7 t11'Q rl _ We Propo's hereby to furnish material and labor—complete in accordance with the above specifications, for the sum of: dollars ($ Payment to be mad la as follows: V tf<T�. � i � t� �-� , All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifica. Authorized tions involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Worker's Compensation Insurance. Note:This proposal may be ,00, withdrawn by us if not accepted within -:5 days. Acceptance of Proposal —The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized Signature r o I to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: rN The Commonwealth ofMassachusetts Department of Industrial Accidents �,•, Office of Investigations I !� 600 Washington Street Boston, MA 02111 www.tnass.gov/dia t : Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly Name(BusutessH)rganizatirm/lnitividUal): Address: T S City/State/Zip: �OVEI'� Phone 63�d Are you an employer?Check the appropriate box: Type of project(required): I.❑ 1 am a employer with 4. ❑ I am a general contractor and l 6. New construction loyees(full and/or p * have hired the sub-contractors , part-tune). listed on the attached sheet. * 7• ❑ Remodeling 7& _m a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its 10 ❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I Q] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.E] Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers compensation policy information. t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �C'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers comp.policy information. I am«n employer that is providing workers'compensation insurance fir my employees. Below is the policy and job site information. Insurance Company Name: Policy 4 or Self-ins. Lic. #: Expiration Date: Job Site Address: 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 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 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 insurance coverage verification. I do hereby certi ' t'nde the pains ai enal/ies of'perjury thin the information provided above is true and correct. Si,mature: ��'� Date: Phone#: (' �� — Oljic•ial use only. Do not write in this area,to be completed by cite or town nlfleial City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: