HomeMy WebLinkAboutBuilding Permit #817 - 793 WINTER STREET 6/20/2006Of ttORTN 1
° p TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
�SSACHUSEt
Permit NO: Date Received:A49hf/L
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION —7
Print
PROPERTY OWNER `^ ', E it S? Vs.—
ZZ Print
MAP NO.: 10 k4*&PARCEL: 1 U ZONING DISTRICT:
mvnu ItXTn iTC1r flu DUTY ilI P
t-iiCTnRir n[gTRICT VFS F1
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteratio
sorolne family
❑ Two or more family
No. of units:
❑ Industrial
u Repair, replacement
❑ Demoliti
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK 1U 13h FK 1,UK1V1h1)
o1ac-p- Qx.%5+-,y\.c.,
Identification Please Type or Print Clearly)
OWNER: Name: ('��-�eV)SPhone:
Address:
gctvr�
CONTRACTOR Name: Ch�d�v� Phone: r
Q
Address: 'J4`� f2cnwod� S�-� �oc-Ces�e� ��S- 5(,� -'�?V(
Supervisor's Construction License: Exp. Date:
L"Z Sq� 9-S ate
Home Improvement License: � Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ (0,00c) x10.00=FEE:$
Check No.: L 3 �a L(
Page W4
4
Receipt No.:
TYPE OF SEWARGE DISPOSAL
Tanning/Massa,-,e/Body Art ❑
wmmng
Swimming Pools ❑
Public Sewer F1Tanning/Massag
Well
Tobacco Sales ❑
Food Packaging/Sales El❑
❑
Permanent Dumpster on Site ❑
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of Contractor
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:
DATE REJECTED
❑ ❑
❑ Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
DATE REJECTED
11
Comments
Conservation Decision: Comments
Water & Sewer connection signature & date
Temp Dumpster on site yesno_ Fire Department signature/date
Building Permit Approved and Issued by:
Pace 2 of 4
I
DATE APPROVED
DATE APPROVED
DATE APPROVED
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required
Provided
U11VI 11431VPl
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
NO FES and DATA — (For department use)
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:QPFORM05
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
❑ 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 DEPARTNIENTMFORN105
Page 4 of 4
Location
No. Date
I '?c�
r ,
TOWN OF NORTH ANDOVER
.,•-- • �a
Certificate of Occupancy $
,SsACMUSEA
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
7n
Check #
Building Inspector
t
y3
A
►propriate permit to be obtained.
1
ruS kOA 5
1&9 N
Department of Industria! Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: ,!,gg
Phone #: 4 i & — S�o� — 57 G_
Are you an employer? Check the appropriate box:
1. ® I am a employer with _ n
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 t
ship and have no employees
Ilese 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ® Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
I l . ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Any applicant that checks box # 1 must also fill 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 suck
tContractors that check this box must attached 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 employees. Below is the policy and job site,
information.
Insurance Company
Policy # or Self -ins. Lic. #: �p (O Q 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 a STOP WORK ORDER and a fine
if 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.
l do hereby certify undertains and penalties of perjury that the information provided above is true and correct
'hone #: I? -7s-- 5'&9-- 5_7 (1 61
Oficial use only. Do not write in this area, to be completed by city or town offteid
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of health Z. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #•
JUN -20-2006 10:16AM FROL1 M HOLE SERVICES
5097569009 T-460 P_002/002 F-120
Sold, Furnished and Installed by:
1117tneb Name: NE Date: THD At -Home Services, Inc.
d/b(a The Home Depot At -Home Services
345A Greenwood Street, Worcester, MA 01607
Broth Number.. It job N: a 4 b Cqi Toll Free (800) 657.5182: Fax: 508.736.2859
Federal 10 r 75.2696460 ME tic 9 C 02439 lel Com. Lies "I
CT Lie A 565522: MA Home lotptovemem coatiactor keg. n 126893
Installation Address: `7 X13 i Kr Ayr qtr % A b1 Q 1J 5'
City State Zip
n
rarourt(s); Luo d d to of Drr� a Lre. N & E . Mo/Yr: We fhoaee Home Plana;
W � _•ll t ( ) 6r 1 7 MI
( ) ( )
Rome Addmu:
(If different from Installation Address)
City
State Zip
E-mail Address (to receive updates and promotions from The Home Depot):
Ptroicct I�formatioa: IlWe/You ("Purchaser"), the owners of the property located at the above installation address, offer to
contract with Homc Depot U.S.A., lac. TIC hi DepQQt") to furnish, deliver and arrange for the installation of all materials as
described on the attached Spec Sheet q: W ZN F12% S , incorporated herein by reference and made a pan hereof,
Dome Depot reserves the right to cancel this Contract if, upon re-htspection of the job, Home Depot determines that it
cannot perform its obligailoas due to a structural problem with the home, pricing error+ or because work required to
complete the job wits not included in the Spec Sheet or Contract.
CONTRACT AMOUNT FS"V"
V"
•LESS DEPOSIT S %101
BALANCE DUE
ON COMPLETION $ Sy 04
norm 2'%of Contract Amount due upon execution
contract.
Indicate Payment Method For
.AKCE DUE ON COMPLETt
{oil AMA Cox W-"�.
X505.00 f a7 P
DEPOSIT PAYMENT OPTIONS
(Sulvw to Lad varifieation and/or credit Approval.)
I. Check. Cathie^ Cheek or UL Portal Service Money toner
(Made poyhhle to The Horne Depot).
2. Credit Card' and/or other payrnam opetOhe - CtrUr One Belw
Visa W.MErC.nrr1 Dwever AmtncanExpubs
The Homo Imptovunwra Lave The None Depot Credit Card
%-' .Vew ,comm I' ErlNene' Account C ML & iiDCC ONLY)
v ArallablvCWil!5 J106t{lsee 1(IL frDCCONL1j
AenA:���jiiJ'W�9� vll Ecp. Date: _
Nerreas a appears an card
-By tnyrour eigonturo Mow, V'We agree to allow Home 1)'W to rA%U%v the dbovc
rerm"Ittl—il44,1.he deposit indicate&
i a 5rgoet uta
'F b0 X 3 saz-6'101 `� 0I S ML or RUCC Author"tion Codc
07-41,16 t�� De.eposit Final Pa
A0'� 0`? �# 005b9L � W 9-1
Ptrchaser agrees that, immediately upon Satisfactory completion of the work. Purchaser will execute a Completion Certificate
and pay any balance due. Purchaser also agrees to bosomtly and severally obligated and liable hereunder.
Eet This agreement and its attachmeam including any Snaneing agreement, cotnain the complete agreement
erwean a warties and can cut be amended or modified unless in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do sot sign this contract before you read it. You are entitled to a completely fillyd-is copy or the contract of the time you stlpL Keep
h to protect your rights. Do not sip Completion Certificate before this proJect b complete. I.ow Pruhlblts home re air
conttsrcta" tram requesdog or accepting a Comp%tlon Certificate xi6med by the owner prior to rte actual completion of the work to
be performed under the contract.
YOU m acted this transaction at ate��yy rime prior m mido' t ar rhe third buslaess day epee fire date or this contract. See NmIca of
Cancellaion for an esplaaalion of tiro right. There, will a service charge equal to 25% of the contracr amount If the job is
cancelled by Purchaser AFTER the third business clay.
BY MY -OUR SIGN:%TURE BELOW, IAVE AGRPL•' TO BE BOUND BY THS "l,rntros OP THis CONTItACT. [AVE ACKNOW LEM.:r
RECEIP f Oh A COPY OF THIS CONTRACT AND Two COMPLF,'flil) COPIES OF THE NOTICE OF CANCELI.A? ION,
BY MYIOUR SIGNATURE BELOW, I/WF UNDERSTAND T'H,%T THC A(AREvtENT 15 S031fCT TO REt'1-W OF MY;OL it
CREDIT HISTORY AND I/WE AUTIJOIC71i HOME DEPOT TO VERIFY AND REVIEW MY+Olrlt CHEDIT RLCORD WITH rNN
INDEPLNDENT CRED Rf:PORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY INCURRED FROM
rNADRE VFRTEUr ONUS& NS OORS. DO NOT SIGN THIS CONTRACT IF THe E ARE ANY BLANK SnACES.
SUBMITTED SY; Date:
ACCEPTED BY." Date:—
OtrKOwner
_ Dare:
Homrowhr
%*TICK: ADDITIOVALTETNM CONDITIONS AND %V,01W71125 Alit STATED ON THE RF.VLRSF Y t:,T VF f t.1t ('0'. 1 H IWT
w6eo-0.- J,rJ1. Yeaoa. onto—, NA-S.etcamdtac
0.5^ r. cr.
AT-HOME
,t
Installed
Siding and Windows
��
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Regist aafion:.,_ 26893
Expirafion• 8/3/2006
$uplilement Card
THE Home Dep6t6f:... ff —
ATJNROEUN CHHOU - i
3200 COBB GALLERY
ALTANTA, GA 30339 Administrator
Proudly sold, furnished and installed by RMA Home Services, Inc., a Home Depot authorized contractor.
345 Greenwood St. Unit 2 • Worcester, MA 01607.508-756-6686 • Fax 508-756-2859 • Toll Free 800-657-5182
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