The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #029 - 81 LISA LANE 7/24/2006 TOWN OF NORTH ANDOVER X10 R TF1 APPLICATION FOR PLAN EXAMINATION 0 p i Permit NO: Date Received 2 -O #+► i e �`, * a* .... Date Issued: -7AC" IMPORTANT: Applicant must complete all items on this page LOCATION ei 4(d;,r, 1,aKe-, /') Print PROPERTY OWNER/WI lag,,- lea✓ Print YIAP N0.: PARCF.1.: ZONING DIS•fRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 0 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ikOrie family Addition Two or more family = Industrial E Alteration No. of units: epair, replacement Assessory Bldg Commercial = Demolition Moving(relocation) Other Others: i- Foundation only DESCRIPTION OF WORK TO BE PREFORMED Stj[-t Identification Please Type or Print Clearly) �7 OWNER: Name jj,-4- -s �4-G([ 0� fie► -e Phone:9 7��'� - �7 Address: 4,S4,- 4 t,-e__._. "r CONTRACTOR Name: r�e"c( �� ue�(� S � a0�7 hone: Address: ?ttj-k,-,6 Ixt— S'1 �°✓ Supervisor's Construction License: zro � Exp. Date: (Iun1e Inlpt-w cnlcrtt License: j�Z9 JC' Exp. Date: ARCI IITECT, ENGINEER Na111c: Phone: ,` ddress: Rcg. No. FEE SCHEDULE:BULDIA PE ,V1T:.Q10.00 PER$1200.00 OF THE TOTAL ESTIMATED COST BASED OA'5125.(10 PER S.F. Total Project Cost :S r' x12.00--FEE:$ l Check No.: W-V� Receipt No.:_ � Page lot-4 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 g g i ` ❑ 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 Withh Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) o 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 j 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 Poe:1N:A'E("I'I0,V.\I,SF.R\I('F:'i UF:f'.\R'I'\IIiV'(:nPGOR\1115 I-1,v l ii I i r i I TYPE OF SEWERAGE DISPOSAL Tanning-Massage,Body Art J Swimming Pools Public Sewer _ Well _ Tobacco Sales Food Packaging/Sales 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. ihnd Signature of Agent'Owner Signature of contractor Plans Submitted ❑ Plans Waived ! Certified Plot Plan r^ �! 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 F- Other COMNIENTS DATE REJECTED DATE APPROVED CONSERVATION CONINIENTS DATE REJECTED DATE APPROVED a HEALTH ] c — CONINIENTS Zoning Board of Appeals: Variance. Petition No: 1_.onin,l Decision:receipt submitted }cs Plannimty Board Decision: Comments Conservation Decision:_ Conmicnts �\;atcr& Sewer connection.Signature& Date Driveway Permit Temp Dempster onsite yes—no— Fire Department signatum date Building Setback Front Yard Side Yard Rear Yard Required— ProN:ided Required —Provides Re aired Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NO'rr-s and DA r,k—(For department use) ra,-,C."of i IC Location UwA No. Date 40(o TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ �Ss�cNust Foundation Permit Fee Other Permit Fee TOTAL Check #311 e6 7 Building Inspector i The Commonwealth of Massachuselts Department of Industrial,Iecidents Office of Investigations L ti i' 600 Washington Street VW, Boston, ,V14 02111 ww►U.mass.gov/din Workers' Compensation Insurance .affidavit: Builders/Contractors/Electricians/Plumbers ADDlicant Information Please Print Le%ibly Name ll3usin�ssiUrgunitatitmllntlividual): ./,j�Qti., .C� C/ �er�a C' ©U��' 2 Address. 33 feel m City:State,%Zip:AR-A Ah t 6 /8'Y'9 Phone:4• F you an employer?Check the appropriate box: Type of project(required): 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and'or part-time).* have hired the sub-contractorsI am a sole proprietor or partner- listed on the attached sheet.' ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. y, ❑ 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 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.kOther Yi-1- r 161 comp. insurance required.] '.any applicant that checks box 14 1 must also fill out the section below showing their workers'compensation policy information. y Ilomeowners 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:,heel showing the mune of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my empl gees. Below is the policy and job site information. Insurance Company Vame: _-- - --------_._--- --- --- Policy 't or Self-ins. Lic. `�: --.—__ _ Expiration Date: J006 U --- —— 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. 153 can lead to the imposition of criminal penalties of a tine 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 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 certify antler the pains andpenalties of'perjury then the information provided above is true and correct tiinature: ��r(�/t��t�(� t oa Date: Phone /)ljic•ial use only. I)o jtut write in this ltrett, to be canrpleted by cit),rtr town q%ficial. City or Town: Permit/License 4 Issuing,Authority(circle one): I. Board of Health 2. Building Department 3.City/T,ivvn Clerk 4. Electrical Inspector 3. ulurnbing Inspector 6.Other CraMact Pcrson: -._- _ _ Phone NORFOLK AND DEDHAM MUTUAL FIRE INSURANCE COMPANY SMALL CONTRACTORS POLICY Policy # 80311023 RENEWAL CERTIFICATE earned OUELLETTE, GERARD E Agent SAMEL INSURANCE AGENCY, INC Insured 31 PIEDMONT ST Phone (978) 474-0810 METHUEN MA 01844 Agent # 20790 FORM OF BUSINESS: ndivtidual Policy Period: ONE YEAR from 09/13/05 to 09/13/06 This declarations page together with the policy jacket, the policy form and any endorsements, completes this policy. Coverage begins at 12:01 A.M. Standard Time at the covered premises. PLIY PI<iEMILIMS /#::MQ CREDITS Basic Annual Endorsements State Taxes Total Annual Add'I/Return PrPrnhirn $635 $635 ;:.;;:.; :.;:.; Bid g /Location 1 Address if Different Mortgagee Information Business Description SIDING INSTALLATION POLICY DEDUCTIBLE $250 BUSINESS PERSONAL PROPERTY Limit $10,000 Included T O T A L P R E M I U M P E R B U I L D I N G $635.00 EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH D.4 OF THE BUSINESS LIABILITY COVERAGE FORM. LIAB & MED EXP (OCCURRENCE/GEN AGG/PROD COMP OPS AGG) $300/ $600/ $600 Included MEDICAL EXPENSES DAMAGE TO PREMISES RENTED TO YOU $5 Included $50 Included SEE ATTACHED PAGE L Premium Pre NOTA Th# ROIL#CY PR01/ISIf31VS REQt#IRI" THAT A $ aet� Gr?LiNTEF#SIGNEQ BY. AUTf#(RIZ£D RE#'RESE#1#TAT#VE M111[IMUM #�r#EIyIILIC.. . ... r #V©F3MALLY aPPLIfrS IF Yeti CA11i I*L ISI tOF1 T Q XPIRI�7IQN pA7I, W� SNALI. FiE fAlht A I' 4E�15t $3Q0>REGARI3LESS OF TERM; BOP-2 (REv.04/05) Type of Payment: DIRECT BILL 4 PAY LcTTE GERARD E. E .. Y SIDING - ROOFING 31 PIEDMONT ST. METHUEN MASS. 01844 I/we, the owners) of.the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials,labor and workmanship,to install,construct and place.the improvements according to the following specifications, terms and conditions, on premises below described: Owner's Name ..h . ': .. -!. .1._ Y2.' ................................................ ./....................................... ............. J / ..,.�.//....�,4,. State ..t............ Job Address ....b..l...........�L.��l......F-�:�.............:............................................City/,r'�S! SPECIFICATIONS Y,(.!/t �." ...................tSc. J�1..... ............` h c..0 /.�. ......... . - .... � ..... : ..w ...��.. . ............................................................................_................. .. .......... ............................ 4. ..... ! ! ... .( :41...` !.4.!!K-S...: .... e:..... :.....(J✓� :....."�. .:...GCurti� ... - u...... ...... e ? e. .:.. ..... rt..e ..... . ........................................................... . .. Gu .� .- ...... -............................................................ c-ae:...:u :::: : .......................... :::::: : .:.......:::...::::..::::::::...:::.::.......::::::.................. ...................................................................................................................................................... . ............................................................................................................................................................. .. ..................................................................................................................................................................... ................................................................................................................� ': .................................................................... iDi:►te ials an labor to Lost L.T.s � ..••••.•••••••••••-•• Playable nd ba;*� d-t.... •• i Contractor will do all of said work in a good workmanlike manner. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accord- ance with his (their) above obligation and a completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains,unpaid immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s),all reasonable costs,attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and,or any-lien in connection therewith. It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s). PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused. There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract dependent upon or subject to any conditions not herein stated. Any sub- sequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Receipt of a copy of this contract is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not here- in contained shall be binding upon the parties and that all of the agreements and understandings of said parties are con- tained herein. 1. Owner or Owners are not responsible for Property Damage or Liability while job is in operati a?Q p(p O er Po f& / IN WITNESS WHEREOF, the parties have hereunto signed their names this ....:.../..G..... day of .2l ...........V....... Accepted: Signed ... ...................................... QSigned ......... ...... ...............1 C