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HomeMy WebLinkAboutBuilding Permit #492 - Millpond 1/4/2007Permit NO: Date Issued: IMPORTANT:A LOCATION t PROPERTY MAP NO. t'(� PARCEL: TYPE AND USE OF BUILDING ant m(u��st complete all items on this page3,):(:gc(—kco k-c-bq�, Print ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT OE 1ti TOWN OF NORTH ANDOVER ,NORTIJ O APPLICATION FOR PLAN EXAMINATION Non- Residential ❑ New Building ❑ Addition ❑ Alte `on x�9SSACHU5F4� } ❑ Industrial epair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial Date Received ❑ Other IMPORTANT:A LOCATION t PROPERTY MAP NO. t'(� PARCEL: TYPE AND USE OF BUILDING ant m(u��st complete all items on this page3,):(:gc(—kco k-c-bq�, Print ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alte `on ❑ One family ❑ Two or more family No. of units: ❑ Industrial epair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED ka V-�, 6-C krx t -c �z ges Identification Please Type or Print Clearly) `� q OWNER: Name -.11 11�2i`���1�� `%l`(� UO,­�ho.e:4- �(1 Address: t� �x << CONTRACTOR Name: ���`�%°^� Phone: !'76-a779'yaco Address: �a /vim °J S ­i�ec& ('00— 1 1R/L� ci) c) Supervisor's Construction License: CS D �� � Exp. Date: t 14 Z" je Home. Improvement License: N Exp. Date: ARCHITECT/ENGINEERName: Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT. $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST 40ASED ON $125-.,Q0 PER S.F. Total Project Cost :$( Oc u FEE:$ Check No.: Receipt No.: L Page I of 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 ❑ 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 DEPARTMENT:BPFORM05 Page 4 of 4 TYPE OF SEWARGE DISPOSAL Art ❑ Swimming Pools 11anning/Massage/Body Public Sewer ❑ ❑ Tobacco Sales Food Packaging/Sales ❑ Well ❑ Permanent Dumpster on Site ❑ Private (septic tank, etc. Electric Meter location to proj ect NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of At rj 77-��� Signature of Contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS COMMENTS Zoning Board of Appeals: Variance, Petition N Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer DATE REJECTED ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED DATE REJECTED ,1,IEALTH11 Comments Comments Dri DATE APPROVED DATE APPROVED El C DATE APPROVED Temp Dumpster on sit es o_ Fire Department signature/dateT ' l -C 0+ T-0 b . Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided ION Number of Stories: Total land area, sq. ft.: NOTES and DATA — (For department use) Total square feet of floor area, based on Exterior dimensions. VIA bA Z- UN Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC. Jan.2006 DIM ENS Location No. � � Date 1 +D MORTIy TOWN OF NORTH ANDOVER A i • p L Certificate of Occupancy $ CMusttA Building/Frame Permit Fee $ — Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # '9914 Building Inspector Location��/nuT- , No. ��� Date NORTH TOWN OF NORTH ANDOi VER f A � t s + ; , Certificate of Occupancy $ 1'�s ••°'tt�' s�cMus Building/Frame Permit Fee $ n� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 19714 `= Building Inspector CA m X m x m m CA O Z CCD O O.� CL o p a� CS CD CD ELI to to CD CA CD a O CA d O C7 C O CO) d CD O CD COD CD COD O CCD O CCD O z OMI O C b O Oo b O0 Oj n w scp C Ly n Ll. \ OMI O C The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information_ Please Print Legibly Name (Business/Organization/Individual): JLd (2 � Vk-L Address: C 604k City/State/Zip: Vv',- © k ((0C_-:> Phone.#: I 10 - d- 16 —'t0U0 Are an employer? Check the appropriate bog: 1. I am a employer with 4. ❑ I am a general contractor and I 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. employees and have workers' [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required):. 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumb' g repairs or additions 12.oof repairs 13. D -Other -2� A ?-2 t�eT *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. `� Insurance Company Name: l ,-�._a,�4 l ez- S ' 0 3- 6,35 �{�J�p Policy # or Self -ins. Lic. #: 1,, ,, I _ T � 67 Expiration Date: � - � C � �%� Job Site Address:- -I ( �v\ ` 1 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 vi?hTo-r-_B e advised that a copy of this statement may be forwarded to the Office of I do hereby use only. Do not City or Town: area, of perjury that the information provided above is true and correct or town official, 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 #: RightFax Norcross 1/4/2007 10:13 iJAUh =51ULIJ rax Survux' PRODUCER LY14AN INS AGCY INC A41 a rig (Mwbo%." THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES Nar AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIEd BEI.OW. 299 BALLARDVALE ST COMPANIES AFFORDING COVERAGE WILMINGTON MA 31887 C01012AW 72P4R A THE ntwaLsgs IND=-rTY QQ=NY INSURED COMIAW JGCA, INC. 6 C/O GREAT NORTH PROP MGMT INC COM2AW 100 DANIEL WEBSTER HWY, C NASHUA NH 03060 COMPANY THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR CON0ffION CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED EXCLUSIONS AND OONDfflONS; OF SUCH POLICIES, LWITS SHOWN MAY HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OF ANY CCNTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, BEEN REDUCED BY PAID CLAIMS. CO LT TYPE OF INSURANCE POLICY POUEF110111E POU DATE " PW.DD%YY) POLICY EXPIRATION IIW DATeOMADD%YY) LIMITS GENERAL LIABILITY GENERAL AG3REGA:TE S PROD=TS-COMP/OP AGG. $ COMMERCIAL w-veRAL LiAeury COMMERCIAL PERSONAL I ADY. INJU:Iy 6 C MA)ErOCCLR. � EACH CCCURREWE O;KRLAWS S 9 CONTRACTORS PRDT ARE DAMAGE (Any ons I,*) P MED. EXPENSE:Any *n6 patsom s AUTOMOBILE LIABKJTY ANY AU TC COMEIN=)Sl*-.LE LIMIT BODILY INJJRY (Par Fer6m) ALLOWKEDAUTOS SCHEDULED AUTOS BODILY INJJRY (Per Ac-.IdenQ HIRED AUTOS NON -OWNED AJTOS PROPEPTY DAMAGE S H IGARAGE LIABILITY ANY AUTO !! p AUTO ONLY - EA ACCIDENT OTHERTHAN AUTO ONLY. EACH ACCIDENT AGGREGATE EXCESS UlABIuTY EACH OCCUqREhCE AGGREGATE UAL-AFORM OTHER TFAN JVIBRELLA FORM Al11FORKER'll COMPENSATION AM EMPLOYERS LIABILITY (UB -0354360-4-07) 01-01-07 01-01-38 STAIUTCPY U EACHAOCIDENT $ 71• E PROPMETOR/ INCL PARTNERWEXECUTIVE OFFICE -13 ARE. EXCL_ DISEASE-POLCYLIM17 S nn,arn DISEASE -EACH EMPLOvEE $ 5 THER ION OF OPERATIO NStLOCA 'nONWEtieLES! RFs-rRiCnONS(SPECAL IITEMS ?RKEFLS CO C� GE HIS LACES A.' I lY PRIOR CERT--':-ICATE ISSUED TO TEE RTIFICATF■ HOLDER AFF-CTIJG ) MP YERA '-RAFT W!�#Rlpm� dl-& SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE. EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL MILLPOND HOMEOWNERS :0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE ASSOCIATION LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR 123 MILLPOND LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. N ANDOVER MA 01843 AUTHORIZED REPRESENTATIVE k MARK L AUDETTF.,, 18 HIGH ROAD NEWBURY, MA 01951 7ulations and Standards ;vlsoi L16.ense 85725 6/1956 Commissioner