HomeMy WebLinkAboutMiscellaneous - 1782 SALEM STREET 4/30/2018u
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No. 4� 2 Date
TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # i-7,3 %
18 '1 5 ,1
Building In215-Etor
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6 TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
111k see"� V* .
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Colnmissioner/lpgwor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
»ser sa�,t,, � of ��ao>,�r-. M11-
1.2 Assessors Map and Parcel Number:
a,,, bI!���
Map Number Parcel Number
1.3 Zoning Information:
Zoning Dii;ic-1 ProposedUse
1.4 Property Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS 00
Front Yard Side Yard Rear Yard
Required Provide Regaired. Provided ReqLiired Provided
1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
1.7 Water Supply M.G.L.C.40. 34) Zoae Oalside ❑ Manicipal ❑ On Site Disposal System ❑
Public ❑ Private ❑
:> i. U i i i; t •` t! ' C;t: `,'=: !'! O
SECTION 2 - PROPERTY OWNERS /AUTHORIZED AGENT
2.1 Owner of Record
L/Ay-d i elm 'Sq c c-0 -J-7 8j2 S Q 1 e -PA 6-F , ttl. &d4lo t/o-✓
Name (Print
��Address for Service
&AIJ
ignature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Tele on
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
AvN&ev3 5giccc C�cf 11pa
Not Applicable ❑
1.31y
Company Name
Sgrgv1 1�v �d'd I w�►� o(_, 36
Registration Number
l`7
A5�/T�8'1- D -I I- 13 3 R,
Expirdtion Date
Signature Telephone
00
M
M
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SECTION 4 - WORKERS COMPENSATION (XG.L C 152 § 25c(6) •
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work check ad a cable
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Descri ion of Proposed Work: ...�
,
Sfrt o 4iaa-� a 11!2, S
f��pl�� 2c� a►�d �,,1��-�� sh�1�. Ahd r.�i-� �®ter
►4Pt� !�/ 30 Yr -,t r S �v i nct/ - ci ka 1,09 Vey+
I SECTION 6 - FATIMATFn rnNQ7V1Tf•T7nN rne•re
Item Estimated Cost (Dollar) to be
Completed bpermit applicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical /
(b) Estimated Total Cost of
Construction
r
3 Plumbin
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
CL`r1ri/V►i'7 1%%W?ZV1M A7TTiIATirf TTAv
Check Number
-•^aavaav ur. <, vll.f LL' 1L'L h'111:1\ `: I
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ./ i�}tn�] �'Cit1 �Q C CO , as Owner/ uthorized Agent f subject property
Hereby authorize to act on
My behalf, i i ail mattrAs relative to work authorized by this building permit application.
Signature of Owner �
Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are Lrue and accurate, to the best of my knowledge
and belief
Print Name
of Owner/.
NO. OF STORIES
BASEMENT OR SLAB
SIZE OF FLOOR TII413ERS 1'
SPAN
DM,1ENSIONS OF SILLS
DIMENSIONS OF POSTS
DEV ENSIGNS OF GIRDERS
HEIGHT OF FOUNDATION
SIZE OF FOOTING
MATERIAL OF CH MNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Date
SIZE
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of InvesHgaftns
Boston, Mass. 02111
Workers' Cw perlsadw Insurance A
Name Please Print
Name• 6Lc ISP UJ gCCn
Q at-c`� _ Phone # '"l �i - a� ► - �3 g
I am a haneowrter perforating all work myself.
I am a sok proprietor and have no one worldng in any capacity
aI am an employer providng workers' compensation for my employees worldng on this job.
COMO v name'
Address
CMG Phare It
fin)A f it Ln Poticv S ,N4 -Iq
C�DBrN n�rte: �
Addmu
coz
Phare:
Po1w a
FA" to MM oro WqR n requked under Sectlan 25A or MOL 152 cin Iead to rhe krpattion of abdi pinaN d,a fh* up to:1,5W.W
andsaneyss.s'imprficrmient.n.wd.n.cfiM.pa mbnJnAwl= dA STDPVIIDRKOROERindAfkrd.f;:1oDAMAAMa901W.Ma. I
understand that a copy of this titemint may be farwrded to the Offbe of Inveadge ns or Mie DIA far coveripe verMbow.
1 do hereby curdy under ft pakib wWtppnaltfea d psdfury dW tM kft,, n provldad above li bus an0 ccinect
Print name -"VLeAd Sq ec O Phow it
of 1cm up only do not wrfte In this res to be completed by city or town Adel'
City or Town ParmMIL inp
❑ Bufi ft Dept
❑Check If immedlsts nmPonse IS requked ❑ Lxeroft Board
❑ Selectmen's Ofte
Contad person: Ftw* tfr ❑ HeaNh Department
0 Other
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provisionis that the debris�esult ng from this workn of shall Permit
Number shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
The debris will be disposed of in:
T
1---v e-rf--e+I m
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Town of North Andover
Building Department
The following is a list of the required forms to be filled out for the appropriate
permit to be obtained.
FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS
1) BUILDING PERMIT APPLICATION
2) DEBRI REMOVAL FORM
3) WORKERS COMP AFFIDAVIT
4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICENSES
5) COPY OF CONTRACT
6) FLOOR PLAN OF PROPOSED INTERIOR WORK
FOR ADDITIONS / DECKS
1) BUILDING PERMIT APPLICATION
2) FORM U
3) MORTGAGE PLOT PLAN (MINIMUM)
4) DEBRI REMOVAL FORM
5) WORKERS COMP AFFIDAVIT
6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES
7) COPY OF CONTRACT
8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED
WORK WITH SPRINKLER PLAN AND HYDRAULIC
CALCULATIONS (if applicable)
9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable)
FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY)
1) BUILDING PERMIT APPLICATION_
2) FORM U
3) GROWTH MANAGEMENT BYLAW
4) CERTIFIED PROPOSED PLOT PLAN
5) PHOTO COPY.OF H.I.C. AND C.S.L. LICENSES
6) WORKERS COMP AFFIDAVIT
7) TWO SETS OF BUILDING PLANS (one to be returned) TO
INCLUDE SPRINKLER PLAN AND HYDRAULIC
CALCULATIONS (if applicable)
8) COPY OF CONTRACT (if applicable)
9) MASCHECK 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 application.
-- -
NUMBER DRIVER'S LICENSE
S_E
026623546 '
DATEOFOIRTH"^-
CLASS HEST HEIGHT � ,.
110-01-1974 D sos SIX ..EXPIRES M it
10-01-2006
SACCO x
ANDREW W f i
4 SARAN AVE
BEDFORD, MA i iaol u�`J i I
01730 j
Page #
Sara •� ��e . �J
eCTCXd W1 i`� 01"13C
OF 1) -IS 39,
Proposalubmi ed To: .. Job Name Job #
Gv WI�r
Address /71).
11a Job Location
Date Date of Plans
Fax # Architect
1 �
61
We hereby submit specifications and estimates for .............I. _. ___..._ ^ .. y .. __ __ __ ........_
_._ _ _
._... _ _ ____ ..____.............................. .........
...
GG nn 49.9 v `-C-) ._ ..... __.
d
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1f CCau..
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` C I 011I.- __--- _ I _1 . __ `� G S
_. .. _...................... _ .. .....
.. .- _ .........
VC -1 4
vlrti
c- Joc�r Poe
We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of:
g
L with payments to be made as follows: 113 ,Dr o r ds
V Don Cr— "A,
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over and submitted
above the estimate. All agreements contingent upon strikes, accidents, or delays
beyond our control. Note — this proposal may be withdrawn by us if not accepted within
0cceptance of Propool
The above prices, specifications and conditions are satisfactory and are Signature A
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outl)no O�.
Date of Acceptance 9
//�'S� Si nature
C&', NC3819 MADE IN USA
Dollars
days.