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HomeMy WebLinkAboutMiscellaneous - 77 BEAR HILL ROAD 4/30/2018 (3)SECTION 4 - WORKERS COMPENSATION (MG.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 unit. Signed affidavit Attached Yes ....:..0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: C10 //NSJr4K:--4- N'ec�- -two .9*0r/ da- Q("4' Jp,.l ,CPA/ �6av[r ✓N�+Qi:a.�- Lre1C2oA0b(- a -14-L -4o6r. bfttrw-M • SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item . Estimated Cost (Dollar) to be Completed by permit applicant 1. Building (a) Building Permit Fee -1/go Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5�p 5 Fire Protection 6 Total 1+2+3+4+5 D 900 -- Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII.DING PERMIT 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 I, (SbA,-A O&US o 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 NO. OF STORIES BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS " DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION ,-,o c7o c.rn/ SIZE OF FOOTING '2011, MATERIAL OF CHIMNEY ; IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE THICKNESS /a-"' X ;? r� 0r1*6i% IY#L TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING a ` s T�uS Se til l O[' off, BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 10 ©/oF�—AS' 1.3 Zoning Information: 1.2 Assessors Map Map Number Dag/ ,$/o k Parcel Number Z13. 91/pc /SO Zoning District ProposedUse f Lot Area ? s Frontage (ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Reqtdred Provided Required Provided o of Z8a. aV0' � 1.7 Water Suy�ly M.G.L.C.40. S4) 1.3. Flood Zone Infomutioa: a/ 1.8 SOP W Disposal System: Public Private ❑ TO°e Outside Flood Zone Municipal ®/ on Site Disposal System SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Nam Print) Address for Service Sig amre Telephone 2.2 Owner of Record: Name Print Address for Service: ?, Ywou,e I kY (6 DIEC(C I Cox.. S4 tee+ of Sfvv r FORM U -LOT RELEASE FORM ►�cQ�o��d,� ,N I I = q_,a1or INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT 94 Aq zaxo PHONE 9Zd- 6:`9--cPI :3 LOCATION: Assessor's Map Number PARCEL SUBDIVISION BP&r I:L If ,4,L. LOT (S) � STREET -7 '7 %3&a(' *// Oo/4d ST. NUMBER__7,7 RECOMMENDATIONS OF9OWN AGENTS: USE ONLY****** DATE APPROVED 11 �� DATE REJECTED 1� o ( 1 COMMENTS k /,P_1'I�� a_hJ11 _,,? i 1'{. In mire rn�r-e,�— G� in5-f L)e eel ,ham , fi� �i� ay °�-e.4,A . FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED9 / 1 D / I DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm D. Robert Nicetta Building Commissioner (978) 688-9545 ...-.(978) 688-9542 Fax building Department 27 Charles Street North Andover, MA. 01845 s�crruse� HOMEOWNER LICENSE EXEMPTION Please print ll DATE JOB LOCATION�.T �J / Number Street Address M /lot "HOMEOWNER Name PRESENT MAILING ADDRESS /D Afo City Town I o 9 V _ 4+Pf A11q3 Home Phone r { N1 State 7@!- Z89-353 Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as supervisor (State Building Code Section 108.3.5.1)• DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a. one or two family dwelling, attached or detached structures ac- cessory. to such use and/or farm structures. A person who constructs more than one home in a Mo -year period shall not be'considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, bylaws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFI f Town of North Andover 0�t;L20 Building Department o o - c 27 Charles Street North Andover, Massachusetts 01845 z '� (978) 688-9545 Fax. (978) 688-9542 gcHus���y DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, anda condition of Building permit. # the debris resulting from the work shall .be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, sl 56a. The debris will be disposed of in /at: Facility location ignature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02 919 Workers' Compensation Insurance Affidavit 1. Name Please Print Name: RBAh&a1d d4gaza Location: -7 7 XZI-IL A%3cL . If- N_7. I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City- Phone #: Insurance.Co.. - ,Policy Carnpanv name: Address . City' Phone #: Of andfor one years' iMpdsonmentas-Wa-as-Civil.frenatties.jnstielo=W—aBIOFINPRKDPDFF .grid:mine_of-$IDD-24)�siayagainstme. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for Coverage ver' cation. l do hereby certify under the pains and penalties ofpedury that the information provided above is true and correct. Signature Date Print name ..Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing El Building Dept OCheck if immediate response is required .0 Licensing Board p Selectman's Office Contact person: Phone # E] Health Department 0 Other .' '. W99 17-R AL�x CARUso 7-7-99 ENERGY CONSERVATION APPLICATION FORM FOR LOW-1ZJ;;g RESM)ENTI'AL NE'w CONSTRUCTION Applicant Name: Applicant Address: Site Address: CiVrown: Use Group: Applicant Phone: Date of Application: Applicant Signature: Compliance Path (check one): Prescriptive Packageimited (L to 1- or 2 -family frame buildings heated with fossil fuels... only) Package (A through Xk): ; (For items dHeating Degree Days $ase 6S (HDDM) from Table`•JS.2.1a: throu, gh i., fill in all values that apply from Table J5.2.1 b;) a. Gross;Wall Area Z 4 ' L sq.R f. Wil -v b. Glazing'PO. Area R slue R_ f 3 T sq.ft. g. Flo':i R -value c: Glazing % (100 x b + a) � � % �.P ` d. Glazing'U-value U. �— h. $a ment wall R- i. Slalc Perimeter R_ Ceiling R -value R_• () j. Hcat:ing AFUE $ �j Component Pcrformance:'' Manual Trade -0!r' (Limited to tivrod or metal Figure J6.2.2) Zone 12 framed buildings only) Climate Zone (from "• Attach Trad ❑ �j Zone 13 ❑Zone 14 e�0„ff�Worksheet•from Apper:dix-J-[and- HYrfCTrade=Ofj Worksheet,-ifnppl icable]••••-•- ❑Ili Sclieck Sofrivarc Attach Compliance Report and Inspection Checklist'printouts. ❑ Systems Analysis OR ❑ Renewable Energy Sou -ccs Asch Mass Registered Architect or Enl ineer Analysis r� Official's Name: I .0.—fcia—l's Si n_ature•Application Approved E:] � -- Application Denied Date of Approv cl: Reason(s) for Denial: Date of Denial: (provide more details, if needed, on opPo;ite side noun o!!22;O.x ?80 CMR Appendix J C Builder Name Manual Trade -Off Worksheet Builder Address Date Fer mit V Site Address Submitted By Zone []�2 A13 X14 Checked Sy Phone Date Ceilin s Sk li hts and Floors Over Outsid e Air M ' Description Insulation x Nee Required Ceiling R•Value U -Value Area U -Value (Table J6.2.2a) Z Q Q 33 ! 2 UA (Table J6.2.2) x Area = UA Floor Over Outside (Table 1 .2.28) 9 b 1 174, .63 d 3 8,17 Total Area aro 8 ft Walls Windows and Doors Description Insulation x Lej Walls R -Value U -Value Area Required (Table.J6.2.2b,c,d) ' 3 a UA U -Value cxArea Windows . - • d 8 Z Z� 3 19,9 = UA .8� 1.38 (NFRC or Table J1.5.3a) 3 3 � O ft'� � 8 Doors -____� 2 � 1 1 (NFRC or Table J1 .5.3b) 2 8 Sliding Glass Doors 2S �+ 7.4 (NFRC or Table J1.5.3a) ft, ft2 ' Total Area 38 Floors and Foundations Insulation Insulation Description Depth x Area or • Floor Over Unconditioned R -Value U -Value Perimeter a UA Required Space • (table U -Value x Area Basement Wall J6.2.2e) ft, UA (Table Unheated Slab J6.2'20 (Table J6.2.2 ) ft Heated Slab In. (Table J6.2.2) ft Total Proposed UA must be less than or equal to Total Required UA TOfal Statement of Compliance; The proposed building desi nPrOPOSed UA `"�—+ Total speU�cations, and other calculations submitted with thr Required UA 9 , represented In these documents Is consistent with the building plans, Permit application. Build r/De gner aAQ, ---a'' _C i+dGl Company Name 7-7—q7 DRAFT (f, -;r training purposes) Date .. . . ...... JBYERLEY JBYERLEY Microsoft Word - FINANCE COMMITTEE REPOR' 04-10-01 08:40 .......... .................................. ............. ................... ............... ......... LA