HomeMy WebLinkAboutMiscellaneous - 88 COLGATE DRIVE 4/30/2018N
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No. > Date
NORTH TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
•, JACMUSEt� Building/Frame Permit Fee $ tri
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ J
Check #
f I Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATF2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING
4
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BUILDING PERMIT NUMBER: DATE ISSUED: 1,6
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SIGNATURE: C l
Building Commiss' er/I for of Buildings Date
SECTION 1- SITE INFORMATION
1. Property Address:
1.2 Assessors Map and Parcel
Map Number
Number:
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft
Q—S 3
Front Yard Side Yard
Rear Yard
Required Provide ReqWrcd Provided
R
'red Provided
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1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private D Zone Outside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record
Nam rint)
Address for Service:
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Q—S 3
Signature Telephone
2.2 Owner of Record:
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Name Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
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Licensed Construction Supervisor:
Cj It)
License Number
AI k-72 oo
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable C<
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Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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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 all applicable
New Construction ❑
Existing Building ❑
Repair(s)
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
S CS, Qs sem S
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
I . Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
/ O �-
(D
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
Check Number m
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR APPLIES FOR BUILDING PERMIT
<CONTRACTOR
1, ./ 4� as Owner/Authorized Agent of subject property
LauthoTrize0 to act on
Htbelhialf,
Ml afters relative o work a ed t� building permit application/ y
Si rat caner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
L— W^ 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
`�. ,,"'- n
int ame
yl s a�
e of Owner/A Ient Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1sr2ND 3RD
SPAN
DIMENSIONS OF SELLS
DI1vIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRVWEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
PROPOSAL SUBMITTED TI
NAME
ADDRESS
PACIPOSAI, NO
SHEET NO.
DATE
WORK TOBEPERFORMED AT-
We hereby propose to furnish the rinaterials and perform the labor necessary for the completion of
All material is guaranteed to be as specified, and the above work to be performed in accordance with the draw5is and spe:
cations submitted for above work and completed in pubstantial workmanlike manner for the sum of
Dollars ($
with payments to be made as follows.
Respectfully submittea
Any alzeration or deviation from above specifications involving extra costs
will be executed only upon written order, and will become an extra charge
over and above the estimate. All agreements contingent upon strikes, ac- Per
cidents, or delays beyond our control.
Note —This proposal may be withdra
by us if not accepted within )da.,
ACCEPTANCE 0 F PROPOSAL
The above phuns, specifications and conditions one ^�nd are hereby accepted. You are authorized to do the '.'.
as specified. Payments will bemade aeoutlined above.
` .
Si atu
Z — NC 3818-50
Signature
ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY)
04/15/2004
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
M.P. Roberts Insurance Agency Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1060 Osgood Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
North Andover MA 01845
978 683-8073
INSURED ARTHUR ALLEN CONSTRUCTION
A.ALLEN & SONS CONSTRUCTION
369 WAVERLEY ROAD
NORTH ANDOVER, MA 01845
COVERAGES
INSURERS AFFORDING COVERAGE
INSURERA: WESTERN WORLD INSURANCE COMPANY
INSURER B:
INSURER C:
INSURER D:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY rHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YY
POLICY EXPIRATION
DATE MMIDD/YY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $1,000, 000
X COMMERCIAL GENERAL LIABILITY
FIRE DAMAGE (Any one fire) $ 100, 000
CLAIMS MADE F V1 OCCUR
MED EXP (Any one person) $ 5, 000
A
NPP832817
5/28/03
5/28/04
PERSONAL& ADV INJURY $1, 000, 000
GENERAL AGGREGATE s2, 000, 000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $1, 000, 000
POLICY PRO LOC
17 JECT
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY $
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY $
(Per accident)
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR CLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
WORKERS
WC STAT OTH-
TORY LIMITS ER
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
TOWN OF NORTH ANDOVER
BUILDING INSPECTION
27 CHARLES STREET
NORTH ANDOVER MA 01845
ACORD 25-S (7/97)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
CORPORATION 1988
North Andover Building Department
Tel: 978-688-9545
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
c11,S150A.
The debris will be disposed of in:
n of Facility)
v I!" (Sa 9--,� - I
Signature of ermit Applicant
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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