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HomeMy WebLinkAboutBuilding Permit #288 - 79 KARA DRIVE 10/11/2006 OF NORTH 7N a," a'6• O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 9SSACNUSEt Permit NO: Date Received: l/ Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION /17 yelU 't PROPERTY OWNER G Print MAP NO.:b 4' A PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building el6ne 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 © D e, Identification Please Type or Print Clearly) OWNER: Name: / '//GJ/� i ,L /,SS Phone: r� L� Signature Address: D A/C) CONTRACTOR Name: I'V 37- "6She Cy SU1,S Phone: Address: Supervisor's Construction License: D 1� Exp. Date: Home Improvement License: /6�3 3S Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERM T:$10.00 PER$1000.00 OF THE TOTAL ESTIM TED COST BASED ON$12 PER S.F. Total Project Cost :$ ,ol� FEE:$ I U� �, j � Check No.: I 10 Receipt No.: Page 1 of 4 TYPE OF SEWARGE DISPOSAL Public Sewer F1Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well F1Tobacco Sales ❑ Food Packaging/Sales 11 Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of Contractor�a �I� 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 CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ R 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_ Fire Department signature/date G�it�ca.n �� ..,`D//—d 6 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 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 o 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 iA1 No. Date ,.oer►, TOWN OF NORTH ANDOVER Certificate of Occupancy $ ;7s'••O'Eta' Building/Frame Permit Fee $ J�CMus Foundation Permit Fee $ Other Permit Fee $ 'r TOTAL $ Check # /0 S 19530 V Building Inspector NORTH ® of tAndover No. C;�� o dover, Mass. A #//,a _424 OLA COC HIC EWICK ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System � BUILDING INSPECTOR THIS CERTIFIES THAT.................................. ...... ..�........... .r �O O��Y Page# of pages CS # 022680 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 55 Pleasant Street 1-866-AJWALSH North Andover, MA 01845 Proposal Submitted,To: Job Name / Job# Address / Job Location Date Date of Plans Alm- Phone �.1.��,��/,�-tom_/ c�• # r/zlf g --- Fax# Architect r.We hereby submit specifications and estimates for:....... w- _- ice FF hereby to furnish Material and labor—complete in accordance with the abovespecifications for t�um of: `� ���� r ��� .--- Dollars ts to be made as follows: Any alteration or deviation from above will specifications involving extra costs will be Respectfully executed only upon written order,and will become an extra charge over and submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn bylfis if not accepted within days. Rcceptance of proposal The above prices,specifications and conditions are satisfactory and are �ignatuire n n hereby accepted.You are authorized to do the work as specified. V _ Payments will be made as outlined above. Date of Acceptance Signature , J f BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR � � Number: CS 022680 �- Birthdate:46/09/1939 ' Expires 06/09/2008 Tr.no: 28249 Restriew: 00 ARTHUR J WALSH JR 55 PLEASANT ST N N ANDOVER, MA 01845 Commissioner Board oi"Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 103358 Expiration: 7/7/2008 Type: Private Corporation WAL SH 8 SONS.INC ,',onut Walsh,Jr 5 ?Ieasar!St �•c.� � N Andover, MA 01845 Deputy Administrator a ` \ The Commonwealth of,Massachusetts c Department of Industrial Accidents Office of Investigations �'f = 600 Washington Street Boston, SMA 02111 �f www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Dame(l3usincss/(hganir.ationllndivi�tutll: ��� ��`✓�✓� v, So Address: ��� f��ii9SRN/ �1 City/State/Zip: Z - Phone #: 92t `- ������`3 7 Are you an employer?Check the appropriate 1309--1• Type of project(required): I.❑ I am a employer with 4. 1 am a general contractor and l 6. E] New construction employees(full and/or part-time).* have hired the sub-contractors 2.F1 1 am a sole proprietor or partner- listed on the attached sheet. : 7. E] Remodeling ship and have no employees These sub-contractors have 8. E] Demolition working for me in any capacity. workers' comp. insurance. q. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp. insurance required.] *,\ny applicant that checks box N 1 must also till 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 such. Contractors that check this box must attached an additional sheet slowing 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 inf urination. Insurance Company Name: /W Policy �or Self-ins. Lic. 4: ���y� lie� J�,2 o Expiration Date:_ Job Site Address: ` /f A/e� City/State/Zip: /A�� /y04Vee— 17 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 N,IGL c. 152 can lead to the imposition of criminal penalties of a Fine ftp to$1,500.00 and/or one-year imprisonment,as well its 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 insurance coverage verification. /do hereby cert* * under pains and penalties of perjury that the information provided above is true and correct. Si mature: /����iL�� Date: Official use only. Do not write in this area,to be completed by rite or town official. 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#: