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HomeMy WebLinkAboutBuilding Permit #9-12 - 92 FRENCH FARM ROAD 4/5/2011Permit NO: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 'One family El Addition Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ©"Well 0 Floodplain ❑ Wetlands 0 Watershed -District ❑ Water/Sewer . DESC TION OF W/ORK TO, 13� PREFORM /D L.l �OviC+-lila I,�I i1UX �� dine Ide tification Pl9ase Type or Print Clearly) OWNER: Name: e e 5 aih oY) Phone: , Address: q }(C() CONTRACTOR Name: i evin O m(reo Phone M Supervisor's Construction License: 75 57 a _ Exp. Dater 1z,1/Z Home Improvement License: 16 o/y4 Date` b ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ ?, - 3 � 3 1,2` FEE: $ 0_�_ Check No.: 9 oat ('0 J -yam 5 (//,;?P— Receipt No.: 9Y3��= NOTE: Persons contracting with unregistered contractors do not have access to the guara ty fund Signature of Agent/Owner lSignature of contractor Location Ael ede�A No. Date Tpf TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ must, Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 01c) aril��20 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 ❑ r� Food Packaging/Salts ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT t. DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEA!.TH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os o d Street FIRE DEPARTMENT -Temp Dumpster on site yes ..no Located,at 124 Main Street Fire Depatt_meritsignature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date 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 ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified 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) ❑ 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) ❑ 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 ❑ Engineering Affidavits for Engineered products MOTE: 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 Doe: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 CA m X X CO) v m H C � 10 O C7 Z y 00 �. r C _=� CL W y 0 CD CDCL O Q �dCD CDo CD ca w 23 CD CL. O y C 0 15 Wo 1 z4o:,, FA VJ n O cn rn C O O O m O R _ m. O C CL .5. U2 CD 0 CL 0 CO) CO) m ... c?moo ? o m m coo y � O o m C7 l m �� L --I CD m �Omy O CO) O �m W = gym-,: _ a �. o : COD .oy, _ o =r :� V OC W y ToCL m: tai N ' 01 CO) CL gym. C � m y y N "y - O CA C. C3`a' I'" v 0 sr a : .� G cD o CA CD F.CD a3 N : d _m: mm: a'g : C-3om: CD . 0• rro w Z ro W CIl � � 7d ��' �' b C� ro R p pi � r C�j� Cf) al A.. ."I , 0rD I 0 0 rj H 0 O C lD The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 lVashington Street L Boston, MA 02111 www,ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Natne (Businessl,Organization;individual): ��Uln kcrtNro—_---- ------------ _ /address:---� 511r1e3 F- • - — - City/State/lip: K&)c, �M , NV 031 Phone ti: —7 Are you an employer' Check the appropriate boa: 1. ❑ 1 am a employer xvith . 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner listed on the attached sheet. ship and have no employees working for me in any capacity. (No workers' comp. insurance req u i red. J 3. ❑ 1 am a homeowner doing all work myself. INo workers' comp. insurance required.)' 'these sub -contractors have employees and have workers' comp. insurance.,' 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGI. c. 152. § 1(4), and we have no employees. [No workers' coma. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ I lectrical repairs or additions 1 l .❑ MUmbing repairs or additions 12.❑ Roof repairs 1 Other `Am applicant that check, ho.w --'I must al,o till out the section belott showing their %Norkers' compensation police intormation. " IlomeONtier, who submit Qti, aliida%it indicating the% are doing all %%ort: and then hire outside contractors must submit a ncx% aftidat it indicating such. Contractor that check thi, how must attached an additional ,beef shorn ing the name of the sub -contractor, anti state vthether or not those entities hate cmplo%ec,. Ifthe sub -contractors haNc employees. thc} must provide their workers' comp. polio number. lam an emplrq,er that is providing; workers' compensation insurance for my enrplgyees. Below is the policy and job site information. T Insurance Company Name:^ c� IAS %e — Policy ;; or Self' -ills. I,ic. 4:6KUS— 4251 I'F—t Expiration Date:_ 5 '� .lob Site Address:. - - ---_( �:►�(— (� �c�tt4- -—.._.__ CitvlState%%iP: _—fQ( Yri [�trX�(� /0.4 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 MGI. c. 152 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 forth of a STOP WORK ORDL-R and a tine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be fornvarded to the Office of Investigations ot'the DiA for insurance covera�ue verification. I do herebt, certify under thepis and pf nalties of perjurr that the information provided above is true and correct. Phone fr;_ Official use only. Do not write in this area, to be completed by citr or town official. Citi or Town: Permit/License # issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Tov+,n Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Oct 19 10 02:16P Michasl.Doualm Alm 6033821974 p.1 -CERTIFICATE OF UABUrY INSURANCE 1ais��o ' TH13 CERTIIhG►YE IS MWO A8 A INATnM OF TION idlchael $, +D� A�encl+ 08tY AND CONFERS NO RIGHTS lIMM T6E �OMWATE 160 PIAWW Rd. 1t 125 U73 ft HCIDM TI®S CER KATE DOES WT AJOW, MCM110 OR Plahftw, NH. 03W AL R IN I OVEI QE AFFoFam w m E3 "now. 1 8 AFFORDING COVERAGE mme s Eex i�eain deny -carriers , a$A ICC Consaudion tAnC.Road *&Map KhigatM NM 03m f�VERA6E9. . It PM=OFgNSUFlt1N(;EiWEDMdPNHAVEOWSWOIOTILEBMREDNaiMABMEFOFtnMP0=PMWINWATMNOiTW[T STAT lG N 7 PEiii 7iWETOMB Rf1NGEOOMRION OF ANY COWRIkey Olt 07M 7 POW W EEar ifiTo MOM t�TBII+IB. FXV NS D COWTWM8 OF 8"OR �tt FF[]�� A[�R�7F [.BlRTS �10hM WlY iiAVE Bpi R�7tICEC g1f F'AIO:R.l1i11@. _ �i9tALtJAY�.rrY IK WtGiQALGENWALUAMUrT cIJ iomAmn ow ANfJWTB' M 759 M •A X scEemxwmm �,p�j�Y1NEIbALlip3 MeiUri ltAorl2tr AURAURf P=W WWMAM E7FAlC. &E REYBi110N ummm EdovUM s w9sw4L riuurr s 9c0,fl00 .. Oi�r 2o�a p��17�01� OS►25It4 1 o9a5f'I1 CL c to auk► L'�► L coim IM 04 any and at SWEA rin aream nmas 9N U MI kwed as mqmft Cpnpsrdes fnc Attn. IS irmxanca pudomm &K 1111 Nord'+ W&nb= HC 25 S orate++►,n��LccAnro�+!��"'--"--____ _... �,o ruEsaF �uwe � caacar. W eat •��ra�ntpll oA7e , a� ARE. amomm I* wm 84 vm rtmc Rm NdElci7o7reaa �eOt FiAfl!°itsT u3r MUM 1000BaOWL Wm rm arLmvjW at umww er MY am UFO tm wwm& ns Asegm OR I)ACOF5 00RpM110H 9988 2010-12-10 12:52 #2657 INSTALL SALES 478 310 8052 >> Installed Sales P 1/1 volc }hist? D`�,�,tnrcn+ ��t . vtdardA C+�•^•S~wed 'u• WOWS Soo Ile �. t "awh HMO 1Z 08A 6'd "CL-Zog" uovon*wo ON sAV,-RA nG PL xw% i r DATE LOWE'S HOME CENTERS, INC.'S MA HIC NO.: 148688 RANKy�, LOC f 'REG , FEIN 56-0748356 .- -;� CAM CHARGETtft Is mom P V document, Bie TarR19'd[d C95 ° '$ srs` ressar-09—•>�r X15..- atndi8orryFRadedhgwsfl�ta atlreraddairWa ypt@0aF}yAerdsherKos�al}en6dEo."figem ai�GsaY;rrrNa� PLEASE READ ALI.TERMSiD`C9NQ}T;O3iS�OhI,jH e/,OF?1I.S' f LfMN?.PAC.i.�Si •w'. . cdmpie6ed'pages ofBYs �. _ � a.?�.e,''. s 6NlNCrt.' �i C �.i .-ath; , INST IONS ADDRESS �� �Ty (� [[ ' , \ Y•YIVU1 f i \� Awl III I RATE .Ilei l -•••r•� •-o •�.a.� rvyn�. my srgnmg mis contract, customer acknowledges having received a copy of this pamphlet before work began informing Custo r of the potential risk nf tr,e i—a i --A _ _..— a......,.__.._ --------- -- -_ _..••••••�.. ... vuawmm s awenm unit. - PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees the right to take photographs of all work pe a to this Contract, and irrevocably grants to Lowe's all right, title and interest in and to the photographs for use in all markets and media, worldwide; in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such Photographs for any lawful purpose, including, but not limited to, marketing, advertising, publicity, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left]. Work is o co ence upon r a onable availability of Contractor and/or any special o error ustomer m d Good(s) which is anticipated to be �_ r ffille.in date]. Estimated completion date Is fill in date]. Said este ed Su star al completion date is not of the essence. A statement of any contingencies that w uld me erially change said estimated substantial completion date is as follows: (if applicable, inserta statment of such Contingencies). IF THE CONTRACT TOTAL IS $1,000.00 OR LESS Customer must pay in full. CO KETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00: [ Customer to Pay in Full; OR [ ] Customer to use the following payment schedule: (1) Deposit $ to be paid upon siging contract. Deposit should be 1/3 the total contract price; and (2) Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, 1/We authorize Lowe's to do one of the following (check appropriate box below): [ ] Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [ ] Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and (3) Final payment of $100.00 to be paid upon completion of the installation and both parties' satisfaction. NOTICE REG I R T G N CLAIMS COVEREaDIM&L. LOWE'S AN OWNER HEREBY TUALLYAGREE I VANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT, THAT LOWE'S SUBMIT SUCH DI TE TO A PRI VA A BITRATI SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- IVE OF E OF CONSUMER F IRS AND BUI$N 5 GU I SAND TI{E OW NE S LLB REQUIRED TO SUBMIT TO SUCH ARBITRATIWN ID . fB1 M.G t . Date: o�ont Inc�� By' Date: Owner Signature THE SIGNATURES OF THE PARTIESABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW, YOU A ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SIP ORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONT CT. YOU A ENTITL TOA P OF THIS CONTRA AT THE TIME OF SIGNATURE. WIT ES OU (S) D SEAL(S) l OW I DAY OF Lo e . Home e, SP CI ist or Above r Customer acknowledges receipt of a true coov of this cnnf—t —hi,k ,..�� •_._r.. • r•_� ._ _1 __ . Co-owner or Witness --••w• ••••� uu,rau�arvn az any rime pnor to midnight of the third business day after the date of this transaction. See the attached notice of cancellationay form for an explanation of this right #90981 (Rev. 12/10) FILE COPY 02004 by Lowe's.® Lowe's and the gable design are registered trademarks of LF Coroorabon.