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Home My WebLink AboutMiscellaneous - 18 KINGSTON STREET 4/30/2018sr� -- TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT WA RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING E? BUILDING PERMIT NUMBER- DATE ISSUED: SIGNATURE: Budding Commissioner/I r o Buildings Date SE ON 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and V Map Number Parcel Number: Parcel Number 1.3 Zoning Information: zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts 11 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply UGI -C.40. 54) 1.3. Flood Zone Infoimstion: 1.8 Sewerage Disposal System: Public 0 private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORUMD AGENT Historic District: Yes No 2.1 Owner of Record P/1 ` ,3eve v/� r�w�y / f/ 1u,9 Name (Print) Address for Service STO S7-. Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Y Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: e6- 1 fH T (0 U4 1 q If - Licensed Construction Supervisor: /� ,, � � IP W �� ` Y � ( � •.`� � W� I ► ` Address Signature (/ Telephone Not Applicable ❑ License Number /JO iration Date 3.2 Registered Home Improvement Contractor ll ; 1. ) e V Co Gv 5-1-- Not Applicable ❑ C 3d;- r" IA-Ae Le-, 6 f 4'"e M e r k, Registration Number Address CSL 4 7�r f Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 2506) 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 it. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ,_ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descriptio oposed Work: C I e (ACP kfew—j Gcc/S SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) tobe Completed by permit applicant bl?iCIA'USE ONLY /Fee x, 1. Building 2-95-0, GJ (a) Building Permit Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number 2 / SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Own LAuthonzed Agent o subject property Hereby authorize �/ �` C ( `�✓ wl (� 2 to act on My behal 'n all 'ma rs Oative to work authorized by this building permit application. / Signature ofl6wner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS iST2ND 3RD SPAN DIN ENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE IWO Y r ri Board of Building Regulations and Standards -a�-, HOME IMPROVEMENT CONTRACTOR Registration: 125049 Expiration: 10/1/2007 Type: DBA K.J. Cormier Construction Keith Cormier E. 35 Maplewood Ave �, . ,u✓ r Methuen, MA 01844 Administrator 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street .... g Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Marne tt3usincss/()rganiration/Individual): %C 1�1 J r al I e V - Address: w&J % UP City/State/Zip: 0 (S -q'( Phone #: 7 Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and employees (full and/or part-time).* 2.�` 1 am a sole proprietor or partner - U/ ship and have no employees working for me in any capacity. [No workers' comp. insurance 5. ❑ required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. # These sub -contractors have workers' comp. insurance. We are a corporation and its officers have exercised their right of exemption per MGL 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 10.0 Electrical repairs or additions 1 1.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other "Any applicant that checks box it I must also till out the section below showing their workers' compensation policy information. a Homeowners who submit this affidavit 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 intimmation. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy unci job site information. Insurance Company Name: Policy ,4 or Self -ins. Lic. It: Expiration Date: Job Site Address: 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 line 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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of'perjury that the information provided above is trice and correct. Siwnature: �r tl i Date: / / l z rC'/0 S Phone_�t: g 7 r,- & SZ Q Yr, l" (!ficial use only. Do not write in this area, to be completed by city or town ollicial. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other _ Contact Person: Phone #: r L n O z t•+ r•] u x t� w O o w° T a co O w o G w° a�' , U w EO-. a R+ a�' m w F a w W a p°G u ci ro w O p,, C7 w w a w rA ° z cn o cn 0 _ c N �p O V m G O 0 LZ O � CD Ea CF 0- v .r n N �O = O r.+ o o Of mi �m C y v E mm � p�m3 N cm G m N C � C N W _O N •a 0 m m> cm x N aGt om .mm C3 y O O Z C O cm CL c Q o ymG .o = m :C.-3 N ~ w y COL. - t W O 4r..�t c •- •cad= p C Z W .E � o .cm C� m p� C _ G O N O h- t 0..... dr m II710i L� z O u C/) 0 y CD CL O .c c O CD CL CO) O O O CL y c 0 C.3 O C cc H L O ts CD C. CA c O CM c O C � co M�y� �W 3� O 0 Q L d O d c"a c eo �p� c J .O O O Z ts CDCL CO2 c ' Location Le 0/Y 5� No. . ` / Date �� a MORT#j TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ ��s "••°' E<�' s�CHus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3U --�'— Check # o1// 7 188U4 ` Building Inspector