HomeMy WebLinkAboutMiscellaneous - 80 JEFFERSON STREET 4/30/2018ki
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No. � 5 Date `o
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TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
cNus `� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
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Check # `�
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18689 Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
lu 001W 6
BUILDING PERMIT NUMBER: DATE ISSUED: 641
SIGNATURE: r
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number,
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Regaired Provide RcqWred Provided ReqWred Provided
1.7 Water Supply M.G.L.C.40. § 54) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERS /AUTHORIZED AGENT U i sti`!Ct: Ye mo
2.1 Owner of Record
AA94ss� .So, �T.
Name (Print) Address for Service:
Signa re Telephone
rtt.2 Owner of Record:
4
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
rv�l�Ysr
Licensed Construction Supervisor:
S 1n , AP `E w0_0 (1 e KI c�V
Address
`1 � Z 2 /Z
^"'
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (KG.L C 152 f 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 S Description of Proposed Work check ae applicable)
New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify ti "kt 1\
Brief Descnption of Proposed Work:
r�
I SECTION 6 - ESTIMATED CONSTRITCTION CORTc . I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1.
Building
(a) Building Permit Fee
Multiplier
2
Electrical
(b) . Estimated Total Cost of
Construction
3
Plumbing
Bu jdi%J a it fee (a) x (b)
'�36 1
4 Mechanical HVAC
S Fire Protection
6
Total 1+2+3+4+5
0 ;"`
'r,Ch9k Nutiibef="""•
SEUTIUM 7a VWINEK AV MUKIZA1IUN TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _
as Own /Authorized Agent�ubject property
Hereby authorize to act on
My behalf;iia 1 ma ers relative to work authorized by this building permit applicati / / j
% cfa / f 2 /oS� 4
Si ` nature 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
Print Name
Signature of Owner/Agent Date
NO. OF STORIES
SIZE OF FLOOR TIMBERS 1" 2"'� 3Ku
SPAN
DIMENSIONS OF SELLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS I TNF
e
The Commonwealth of Massachusetts
Department of Industrial Accidents
ORke of invesdgadons
Boston, Mass. 02111
Workers' CompenwUm Insurance Aftldn*
Nslrrle _ Please Print
Name: Covu4 (,2V-
Locancn:(��
Phone S `t 7�
I am a homeoNrtar performing all work mysslt.
El
I an a sole pmoprietor and have no one working in any capacity
0 I am an employer pnavidng workers' compensation for nIy employees working on this job.
Poticv
Commm name;(C y(r k (0 WS 17
Phone:
6le- j -,(/s .
Fdkwe to same caerape as mored under 3ecdon 25A or MGL 152 can land to the krgmklon of ah 2. peneltles d.s fine up to $1,5W.W
andlar one yeah' imprbonrnent_aa.wd.n.CM p 20=Jo fha tm dA BTnP VAORK OROER.aoda.floa d.plWJgAX i apdoat ma I
understand that a copy of this storeman may be forwarded to the Offtoe of Iraw dq@kne d the DIA for courage wwNlcWw.
I db hereby cert/jr under ft Paine and Ps MWW d perjury that flu lnlbnmgcn Provided above k bus and cat
J
Signature 2-� p 3 1�1/0atik
.
Print name C� c� c e `� Phow it
Oftw use only do not write In this area to be completed by city or town olAdal'
City or Town PamitlL+ +�+�
❑ Sukft Dept
[]Check M Immediate response IS requked ❑ So"
❑ Selectmen's OftG
confad Parson: Ph" t ❑ HOWWI Department
13 Other
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
a
Number CS,, 081948
Birthdate: 08/18/1956
Expires: 08/18/2005 Tr. no: 81948
a Restricted: 00
KEITH J CORMIER,
35 MAPLEWOOD AVE-. L.
METHUEN, MA 01844` Administrator
I
HOME IMPROVEMENT CONTRACTOR
Registration: 125049
Expiration-' 10/1/2005
{ Type DBA
f �
K.J. Cormier Construction
Keith Cormier
f 35 Maplewood Aver
Methuen, MA 01844
Administrator
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c s 0eS54,
t , a condition
on this work shalng l beermit
Number is that the debris 9
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
(Location of Facility)
ature of Permit Applicant
2gZ/
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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Date.... -.! ..o Z' ..
° TOWN OF NORTH ANDOVER
PERMIT FOR CAS INSTALLATION
This certifies that .^...........
has permission for gas installation �'-? '�': ............
in the buildings ofJ. .�.,:� ............................... .
1
at . ... .. ............ -- �a`" yz�i�S:I�S
.... , North Andover, Mass,
Fee:Z...... Lic............
INS C R
Check #
4104
4
MASSACHUSEM UNIFORM APPUCATON FOR PERMU TO DO GAS FIrnNG
(Type or pmt) Date' — �...
NORTH ANDOVER, MASSACHUSETTS
Building Locations _ _/3 v -J -e11
F Permit # __l Z{
} � Amount $^ �!
Owner's Name ^�
New Renovation Replacement Plans Submitted 0
(Print or
^�one:: Certificate Installing Company
Z . G u wt ' 2 �-� . - Corn• C=X e
Partner.
ri Firnn/Co.
Name of Licensed Plumber or Gas Fitter Im
II3SLTRANCE COVERAGE Check ane:
I have a ctunent lrabrlrty.insrnance policy cries substanfi- W equnralenL Yes [ ATo�
Ifyou,have checked- Blease indicate the type ooverige:by checking the appro}xiate bok
liability insutanee policy Other type ofrndeimiity Bond
Owner's Insurance Waiver. I am aware that the licensee does not have.tbe Insurance coverage required by Chapter 142 ofthe
Mass. General Laws, and:that my signature .this permit applicron waives this raquirncrrt:
`: Clieclt crne:
Sig"ature ofOwner orOwner's`Ageait pyo, Age
I hereby certify that ail ofthe details and in ormation I have submittedor
( entered). m above application are'true and. accurate to the
best of my knowledge and that all plumbing work and installations der Fernsit Issued` for this application will be in
compliance with all pertinent provisions of the Massachusss State Q94ode and Chapter 142 of the General Laws.
ature of Licensed Plumber Or Gas Fitter
Plumber
)wn Gas Fitter License Number
Master
.OVED (oFFieE USE ONLY) ID Journeyman