HomeMy WebLinkAboutMiscellaneous - 21 HIGH WOOD WAY 4/30/2018N
O N
Location
RR No. 12
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
17871
'56ilding InspeAr
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/InEeEtor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Niumbei Parcel Nu&ber
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area (sf) Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.G. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ (^k-; `tine Outside Flood Zone ❑
Municipal' ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWPTERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
/n►
d2 �f �iccr�oo� Gfi/9-S/
Na Print) Address fbilService
/0 Gcf�
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
c s 03 99 r 0 6r,
Lt-ensed Construction Supervisor:
2 �y
of q7 aCy
License Number
'
k/100 711 -xnai�e ya. #&do UL5x
, _
Wn 9 7f !�
Signature Telephone
3-/6-0�
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
8&q4 i9.
Company Name
U
/"-d
Registration Number
Address
q- 9 -C'2ao6
A
Expiration Date
Si nature Telephone
69
X
ic
z
Q
SECTION 4 - WORKERS COMPENSATION (M.G.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 .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check au a licable
New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) 0 Addition 0
Accessory Bldg. ❑ Demolition ❑ 1 Other 0 Specify
1-#.
Brief Description of Proposed Work:
LOLL U PP O(, 7'AbY 0 0 d �
1.4pe& -nae_ded i
I SECTION 6 - FSTIMATFD CONSTRITCTION COCTC I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
_ ` OF)F tC Ati USE DNLY Y u ;
1.
Building
/p
(a) Building Permit Fee
Multiplier
2
Electrical
(b) Estimated Total Cost of
Construction
3
Plumbing
Building Permit fee (a) X (b)
O
4 Mechanical(HVAC)/
5 Fire Protection
6
Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, A*AC(Ct /R- A b ch -woo %- , as Owner/Authorized Agent of subject property
Hereby authorize Pff u L_ I" 1'E2 d (r to act on
WyAi2JL in all matters �ative,to work uthbrized by this building permit application.
1a—G - d
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, _PAUL h. P l nwt — 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
of
Z, 2 - 7—
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST2 ND3
SPAN
DD,4ENSIONS OF SILLS
DIN ENSIONS OF POSTS
DINE- NSIONS OF GIRDERS
-I [EIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
cr,
nn
Location: 1006101-0ike, J
City A A d o u 1br PA. Phone # 7 / R O '00?
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job
Companv name:
Address
City: Phone#
Insurance. Cm Policy #
Company name:
Address
City. Phone #-
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal
penalties of,a fine up to $1,500.00
and/or one years' imprisonment_as_weeU_as_civil,penaltiesiniheinan.-d-a.STDPWORK ORDER-and_a.fine_cf.($1-OD-00 -aidayagainst.ml
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
02 — %—
f �1 v
Print name _fi U / �/ �J �Y`d P_hone.#
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Ucensi
El Building. Dept
OCheck if immediate response is required .0 Licensing Board
p Selectman's Office
Contact person: Phone # n Health Department
❑ Other
It
Z'
.J
North Andover Building Departme
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work 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:
b
ro rest Srt
(Location of Facility)
w; ~
Signature of P it Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
0
PAUL A. PIEROG
gx?�Rg0R � ZdD�,L'� & MSW
,,JWM
1000 TURNPIKE ST.
Home Imp. Cont. Reg. No. 103577
Mass. Const. Pc. No. 039928
Owners Name
Home Address
Job Address
NORTH ANDOVER MA 01845
978 685-1007
U
SPECIFICATION SHEET
SAVINGS
QUALITY
CRAFTSMANSHIP
Home Phone: q90 - 6 --Z/(Y4 k_
Work Phone:
ri�?�
Ci � _ f'� State Zip 4 l
City State Zip
SIDING
1. Siding Type � �- Width I3.C_ Color i' _
2. Areas to be done. Main House rormers
�Breezeway V-- Garage Additions W
Porches a Bulkhead �
s Other
3. Prepare exterior walls for siding 4. Remove existing siding ❑ Yes EVNo
5. Insulation 3" 0 /
6. Aluminum trim cover EJ -'Yes ❑ No Color Trim to be done: Soffitts I Fascia
Rakes Ve Ceilings 11/ j/
7. Casings`.
8. Gutters and spouts ❑ Yes C�' o
9. Shutters M' Yes ❑ No
10. Storm Windows and Doors
11. See notes for replacement windows, doors, awnings, carpentry, etc.
ROOFING
Material Type
Areas to be done
Remove existing shingles ❑ Yes ❑ No 15 lb felt
Color
Metal Edging
Chimney and vents, etc. O °1
Notes
e PieS
�U ZL
J $ " Deposit
'3JMaterial and labor cost $ t .� U � v payable as follows: $ L �j . ° " 1st installment
g 2nd installmen t
l p i+� N e dd . �lS , b 'f U f�S� PR `( $ 3 �. �y Balance on com
letion
consummated be a party thereto at lace other
Contractor will do all said work in a good workmanship manner. You may cancel this agreement if it has been cons p ty p ,
'which branch thereof, notify the seller in writing at his main office ice or branch be ordinary mail
than an
posted, by
address of the seller, may be his main office or provided you
telegram of be delivery, not later than midnight of the third business day following the signing of this agreement.
IN WITNESS THEREOF, the parties have hereunto signed their names this day of _ 20
Oel
Signe
er
Accepted: UL iS EXTERIOR REMODELING & INSULATION
�
Per: ,�f,Q Signed
Owner
I re esentative
Strikes, labor disputes, inclement weather, or material supplier delays resulting in work stoppage are beyond the control of the company. The comparry�gua�
workmanship fora period of 1 year from the date on installation. Guarantee of workmanship assumes performance of product installation under normal wec}r
antees all
and tear
conditions and does notguarantee against storm damage, acts ofgod or nature, neglect ofproper maintenance or malicious damage or vandalism. Material g
antees are
the sole responsibility -of the manufacturers.
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Location L-511/ 4?0�
v
No. Date
Check #
�w
17449
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ -�—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
c! Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: D DATE ISSUED:
-2—
_SIGNATURE:
SIGNATURE: Ak Cq-�—
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address: ,
1.2 Assessors Map and Parcel Number:
9U
Mai Number Parcel Number
Y/
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
R -red Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2- PROPERTY OWNERSHIPIAUTHORIZEDAGENT
I 11C)LUIiahci• ies tvo
2.1 Owner of Record
Ag7x c
N (Print) Address for Ser&c
M
Signature Telephone
2j Owner of Record:
C-
ame Print Address for Service:
Signature Telephone
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
Y
rt+`.
Not Applicable ❑
i
Company Name
t*
Registration Number
Address
Expiration Date
Signature Telephone
64,
�_ I
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 S 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 ........❑ No ....... ❑
SECTION 5 Description of Proposed Work check altapplicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
1. Building
Estimated Cost to be
(Dollar)
Dollar
Completed b mut a licant
000 ( 00
-�� ° n
�(FF'ICIAL
d
..��r,
(a) Building Permit Fee
Multiplier
rtTSEONLY �X �
1 '
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
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNE AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
< <a r
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters 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 true and accurate, to the best of my knowledge
and belief
r
Print Name
Signature of Own er/A ent Date
�.
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIIVMERS 1 2 ND 3 RD
SPAN
DIMENSIONS OF SII LS
DIMENSIONS OF POSTS
DIMENSIONS 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
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: a0 -F Est. Cost..> 000, oc)
Address of Work �� M
Owner Name
Date of Permit Application
I hereby certify that:
C ICS
Iq y
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner -occupied
Owner pulling own permit
Other (specify)
For office Use Only
Pemit No.
Date
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND LINER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date
Owner Name
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9
284 Hampstead RD
Derry NH, 03038
603-432-26.12