HomeMy WebLinkAboutBuilding Permit #664 - 87 BARKER STREET 6/3/2009BUILDING PERMIT 86-6 "tio
TOWN OF NORTH ANDOVER F�44- "' °A
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
.^ 3 �b � SSACHUSE
Date Issued:
IMPORTANT: Applicant must complete all items on this pate
LOCATION t 5A,1 -� � All J
PROPERTY OWNER T4tr %1,,i_ -1 -SA /A!!1
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village ves no
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
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
.DESCRIPTION OF WORK TO BE PREFORMED:
Al X 11k10d N1.-( 4W - 1i
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
1 /ltd
CONTRACTOR Name:Phone'
Address:013
Supervisor's Construction License: C5 1 !1Y kj Exp. Date: /cg zle
Home Improvement License: zt,'?rri Exp.. Date:
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: $�FEE: $ L/
Check No.:_hReceipt No.: a
NOTE: Persons contracting with unregistered contractors do not have accesst t e guaranty fund
SS nature of Agent/OwnerQ Q �►'j,Signature of contract
Location -57-
6 ��-Oj
No Date
40RT" TOWN OF NORTH ANDOVER
Certificate of Occupancy $
S Building/Frame Permit Fee $
2 CMUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22bt� 1
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
x
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
a
Located 384 Osgood Street
yes no
Dimension
Number of Stories
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
No
No
Doc.Building Permit Revised 2008
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
L3 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
MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Li Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
_ ❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o 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)
o Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
L3 Copy of Contract
Li Mass check Energy Compliance Report
o 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 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:BPFORM07
Revised 2.2008
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
City/state/Zip:
Failureure to
Attacha copy of the workers' ensation Policy declaration page (showing the policy number and expiration date}.
secure compcoverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
fine up to $1,500.00 an one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER ted a fine
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 certify rode a airs and peri o
f r! that the infor»tatfon provided above is [rue and correct
Si ture: .
-► Date: �
'hone #:
O, fficW use only. Do not write in Phis asea, to he completed b or town. official
—
y �J'
City or Towm.
Issuing Authority (circle one):
L Board of Health 2. Building Department
6.Otbe'r
�j Contact Person:
Permit/License #
3. City/Towu Cierk 4. Electrical Inspector S. Plumbing Inspector
Phone #:
The Commonwealth of Massachusefts
f
Department of Industrial Accidents
Office of investigations
600 ff r
ashington Street
Boston, MA 02111
t www nuus,gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Co ntractors/Eieatricians/Piambers
A Iicant nformation
I
Please Print Leaibl
Name (Business/orpoira6arL4ndividual):
Address:
/ 7
City/State/Zip:_
Phone #:
employer? Check.the appropriate box:
employer with
FED//1
4, Type of prOject (required):
❑ i am a general contractor and T
employees (fun andlorparf-time).*
have hired the sorb -contractors 6. ❑ New construction
ole proprietor or partner-
ship and have no employees
listed ort. the attached sheet, i 7. ❑ Remodeling
These
working for mei' airy capacity,
suh-contractors have
workers' comp. insurance, g' Q �moiition
[No workers' comp, insurance
5. ❑ We are a corporation and its 9. [] Building addition
3. ❑required.)
1 am a homeowner doing all work
officers have exercised their 10.❑ Electrical repairs oradditions
right of exemption per MGL 11.❑ Plumbing repairs
myself. [No•workers' comp.
insurance required.] t
m9 ]
or additions
c. 15Z § 1(4), and we have no 12.❑ Roof repairs
.employees. (No workers'
comp. insurance required.] I3.❑.Other
that checkz #
Any applicant s boI must also fill out the section below ahow.ing tbeir woricerc' isation
pensation policy informa
1 i fomeownera who submit this affidavit indicating they ate doing
thall wont end then hire outside contractors
;Contractors at check this box mustrtmch.� an adciitiaasl sheatshow' must submit a new affidavit indicating such.
the rams of the sub-cortteacturs and their workers' r.-.•
cer.q
! ant an employer thug cs pr?Vj&ng worfiers' co errsatron r p^ i- formation
informadom mP eursurawefor my employees; Below fs the policy aredyob site .
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
City/state/Zip:
Failureure to
Attacha copy of the workers' ensation Policy declaration page (showing the policy number and expiration date}.
secure compcoverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
fine up to $1,500.00 an one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER ted a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
! do hereby certify rode a airs and peri o
f r! that the infor»tatfon provided above is [rue and correct
Si ture: .
-► Date: �
'hone #:
O, fficW use only. Do not write in Phis asea, to he completed b or town. official
—
y �J'
City or Towm.
Issuing Authority (circle one):
L Board of Health 2. Building Department
6.Otbe'r
�j Contact Person:
Permit/License #
3. City/Towu Cierk 4. Electrical Inspector S. Plumbing Inspector
Phone #:
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Proposal Page No. of Pages
EMERSON REMODELING
22B Bridge St.
Chelmsford, MA 01824 -
(978) 256-4177
PROP AL SUBMITTED TO C PHONE DATE
S EET JOB NAME
IS77 f ".."iA .�
CITY, STATE and ZIP C9DE JOB LOCATION
ARCHIT C� DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
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.�. . . .........._...................................................................
'exot Ao?m,-�
We propm hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars ($
Payment to be madVs follo s:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
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. N6te: This proposal may be
Our workers are fully covered by Workman's Compensation Insurance. withdraly us if not accepted within days.
Arreptance of Proposal— The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature