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HomeMy WebLinkAboutBuilding Permit #668 - 92 FRENCH FARM ROAD 4/20/2006Of NORTN try e M1�' • O F T M ,o 41 M # }�,SS4CHUSE44g Permit NO Date Issued WV TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received: 4)26J6t, F_ IMPORTANT: Applicant must complete all items on this page J LOCATI PROPERTY OWN MAP NO.: PARCEL: TVDL A MI UQU n1W nIT17 nlVd"- nt ZONING DISTRICT: NICTnR1C 13ISTRICT VF.S F1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential C New Building �] Addition i] Alteration One family ❑ Two or more family No. of units: D Industrial R'Repair, replacement Demolition E. Assessory Bldg E Commercial 1-1 Moving (relocation) C Other ❑ Others: ❑ Foundation only DESCRIPTION OF WOKK IU tst; VKtVUiuvit✓ll OWNER: Name: Address: CONTRACTOR Name: ,Tej S,Jt,,)4 - Identification Please Type or Print Clearly) p v rj e, C.4-IlAAA-^. Phone(` / 12) M.2 " Address: l 3 w i o b(/ -#__/I I a Vt"-/" Supervisor's Construction License: Ott 1124 Exp. Date: 3 s x Home Improvement License: / 1� 5�l Exp. Dater Z adv ARCH ITECUENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULDING PE MIT: $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost S / ,C '> xI0.00=FEE:$ & 0�— Check No.: �% Receipt No.: ` `l Page Iol'4 Location /2V No. Date c/4-1 h Check # la� Building Inspector TOWN OF NORTH ANDOVERA ertificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # la� Building Inspector TYPE OF SEWARGE DISPOSAL Public Sewer Well Private (se t' t k t Tanning/Massage/Body Art Tobacco Sales J Permanent Dumpster on Site Swimming Pools C� Food Packaging/Sales C V is an , e c. J Electric Meter location to project NOTE: Persons contracting h unre x'ster co tractors (Io not have access to the guaranty fun r Signature of Agent/Owner Signature of Contractor -� Plans Submitted ❑ Plans Waived ❑ Certificd Plot Plan ❑ Stam ed Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS 1 CONSERVATION COMMENTS DATE REJECTED ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ DATE 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 t Building Permit Approved and Issued by: Page 2 of 4 Building Setback (ft. Front Yard wired Provided DIMENSION Number of Stories: Total land area, sq. ft.: XjrA,rro .__ , Side Yard wiredProvides Rear Yard aired T Provided Total square feet of floor area, based on Exterior dimensions. 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 DEPARTNIENf:BPPORN105 Page 4 of CERTIFICATE OF INSURANCE ISSUEDATE(MM/DD/YY) 104/13/2006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND PRODUCER CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Degnan Insurance Agency Inc DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 85 Salem Street COMPANIES AFFORDING COVERAGE Lawrence, MA 01843 INSURED Robert A Bohondoney COMPANY A.I.M. Mutual Insurance Co A dba Robert A Bohondoney Construction Co LETTER 12 Hall Street Methuen, MA 01844 COVERAGES ^THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR PERTAIN. THE INSURANCE AFFORDED BY -THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. -MAY EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ffLCT0, TYPE OF INSURANCE POLICY NUDIBER POLICY EFFECTIVE DATE(MM/DD/YY) POLICY EXPDDITlO DATE(MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE S AGG. S COMMERCIAL GENERAL LIABILITY ItPRODUCTS-COMP/OP PERSONAL & ADV. INJURY S LAIMS MADEOCCUR EACH OCCURRENCE S OWNER'S & CONTRACTOR'S PROT. FIRE DAMAGE (Any one lire) $ MED. EXPENSE (Any one person) S AUTOMOBILE LIABILITY COMBINEDSINGLE S LIMIT ANY AUTO BODILY INJURY S ALL OWNED AUTOS SCIIEDULED AUTOS (Pur person) .BODILY INJURY $ HIRED AUTOS (Per xxidoil) , NON -OWNED AUTOS PROPERTY DAMAGE E GARAGE LIABILITY EXCESS LIABILITY EACH OCCURRENCE S AGGREGATE S MBRELLA FORM TITER THAN UMBRELLA FORM WCSTATU- OTII- X TORY LIMITS ER WORKER'S COMPENSATION AND 6I__F.ACUI�S:( (l7ENT S EMPLOYERS' LIABILITY — - 70000G20I2005 08/090005 (1R/09/2006 S500 000 A'1'IIE PROPRIETOR/ EL DISEASE—POLICY LIMIT INCL PARTNERS/EXECUTIVE Hx OFFICERS ARE: EXCL EL DISEASE—EA EMPLOYEE 100 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEIIICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO KEVIN SMITH CONSTRUCTION MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR P.O. BOX 1002 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. N. ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE G?'P 12 March 2006 Ms. Laurie Callahan 92 French Farm Road North Andover, MA, 01845 Dear Laurie: My estimate to remove the existing masonite siding from your house and install new cedar clapboards is $ 16,000.00. This estimate includes: Building Permit Removal and disposal of existing siding Installation of new 1/2" x 6" cedar clapboards Clean-up If you have any questions, please call at any time. Sincerely yours, ')"V -, Kevinwnith P.O. Box 1002 - North Andover, MA 01845 - Phone (978) 687-7064 The Commonwealth of Massachusetts Department of Industrial. Iecidents Office of Investigations 600 Washington Street VAN t . Boston, A14 02111 www.mass.gov/dia Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers ,�ppllicant Information I Please Print Le ibl Hanle(1)usinessrlh•geniia( it) Ili lndivitlual): Address: 13 )ed *w - C ity; State,, Zip: T/(ti, j I,) /, j(4 Phone ,%re you an employer? Check the appropriate box: • 4..M I and l I . ❑ I am a employer with am a general contractor employees (full and,'or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 3. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I .❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other 'Any applicant that checks box 41 must also till out the section below showing their workers' compensation policy intimation. + homeowners tvho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating :aach. Contractors that check this box must attached an additional :,beet showing the name of the sub -contractors and their workers' comp. policy information. I um an employer dart is providing workers' compensation insurance fur my emplt�yees. Below is the policy and job site information. Insurance Company Name:___-__ Policy ' or Self -ins. Lic. 4: Expiration Date:_ Job Site Address:._�7 � � G� r� ��^ � CityState,'Zip:_012,�41% 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 %IGL 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 DLA for insurance coverage verification. I do hereby certy� underf4te painsl nt�Ilenrr/ties of'perjuty that the informution provided 1'hohe � -7 fY t(fl �►r t�twn ,,lireial. City or Town: Permit/License ,� is true and correct. /P _- Issuing ,Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk T. Electrical Inspector 5. f lumbing Inspector 6, Other CoiiNct Prr•,on: `_._--- _. Phone #:..