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HomeMy WebLinkAboutBuilding Permit #168 - 951 FOREST STREET 8/11/2008 / BUILDING PERMIT o�,t,.�o pORTH,°gtio TOWN OF NORTH ANDOVER F� a;y'_ o� APPLICATION FOR PLAN EXAMINATION ` 49 Permit NO: Date Received 01 SSACH�1`-+���y Date Issued: • IMPORTANT:Applicant must complete all items on this page LOCATION_ 11 1 rC ✓ 15 leef 74 Tint PROPERTY OWNER , - 'L//n f' /1 e3/ Print MAP NOAS e4 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes 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 r ESC IPTION OF WORK TO BE P FORMED: Identification Please Type or Print Clearly) / OWNER: Name: t/1-17 -5�/ -ems e X Phone: Address: � z CONTRACTOR Name: /oVOP)Oq 9�t IAF ' `" Phone: 17� 5 3�z Address: 2-3oecyl;1,0-1l 47 �f�/f .r �/' ins I /01 Supervisor's Construction License: /� �j/y Exp. Date: Home Improvement License: /3 5-8� Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS/ED ON$125.00 PER S.F. 14 Total Project Cost: $ 3� a� d FEE: $ -71 0,0 Check No.: � � Receipt No.: t O S�- NOTE: Persons contracting with unregistered contractors do not have access to the ran Signature of Agent/Owner Signature of contracto Location No. Dater�l�©��rr NORTH TOWN OF NORTH ANDOVER ran- F 9 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ —� Other Permit Fee $ TOTAL $ Check # ' 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/Sale-s 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 t �n 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: ' Located 384 Osgood Street FIRE DEPARTMENT, =Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/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 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 The Commonwealth of Massachusetts Department of Industrial Accidents k a ;, Office of Investigations i ,;L ,t 600 Washington Street Boston MA 02111 t'l` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/ anization/Individual): Address: �j City/State/Zip: /� �Phone #:AL � AE/you an employer?Check the appropriate box: Type of project(required): a employer with (- 4. ❑ I am a general contractor and 1 .6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9, ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised-their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL ILEI.❑ 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.❑ Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t homeowners who submit.this a�;idavit 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 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. A h- 11 Insurance Company Name: C7 ( _�P, /V r Policy#or Self-ins. Lie.#: (/�C �3 `J -3 5�4 q D I 57— Expiration Date: Job Site Address: / . U U�'�s� 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 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 for insurance coverage verification. I do hereby c i and enalties of perjury that the information provided above is true and correct. Sianat �� e) Date: P #: Official<'use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: c Town of -C1®RTIy s _ Andover No. "' �. ;;. ..R.. 0 o dower, Mass., '//• a� COCMICKEMCK V ADRATED PPN �y `r E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... 00i ?.......U.40!0. ............l................................................... Foundation has permission to erect........................................ buildings on ..fr/.... ............. .... ...-............................ Rough to be occupied as........vlei. 1..... .0-4v ., SZ- ..:lr...........�....... �'........... .. Chimney provided that the person accepting this permit shall in every respect c form to the term of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONS O T TSRough ............... ....... ...................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. GTS -� �� . Board of Building Regulatio natla Construction Supervisor License LficS° ds CS 90414 11?f_12010 fi Tr# 13029 .st�c�troq Q t:L T LARRY J LEBLAN PO BOX 5389 BRADFORD, MA 01835' " Commissioner T Board of Building Regulations and Standards s HOME IMPROVEMENT CONTRACTOR g Registratip� ,135829 t Expj ''�r4/2010 Trsx 266809 Tye- lrtdiv dual LARRY LEBLANC ', u LARRY LEBL,* 33 MEDITATION LANA ATKINSON,MA 03811 Administrator ; r • • Page No. of Pages �.C. .__.. 'SSE' PROPOs4L SUBMITTED TO, PHONE BATE STREET`+ /r- - JOB NAME CITY,STAB ad ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: Imo' �'�' �� �� �- �-� -' � ''rl� �/C'� rr_�`• l �'%--v, ? ` - - %, / •.f rr �`L� ffl/1 I ����� ,, r J,�• ur'P1_ ` /= l.il� II -I! /, r We Propose hereby'furnish material and,labor—complete in accordance with above specifications, for the sum of: r`l J f� ; ���F ',.,. ll� /+;/• r//. j_+ dollars($ Payment to be made as.#bllows: All material is guaranteed to be as specified All work to be completed in a workManliYe ' manner according to standard practices. Any alteration or deviation from above speckicatfonsAuthorized 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. Our Note.This proposo'm8y be workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days. Acceptance of Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature - work as specified.Payment will be made as outlined above. - Date of Acceptance: Signature