HomeMy WebLinkAboutBuilding Permit # 6/9/2015 BUILDING PERMIT ao prH a o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit Nolo I."� Date Received '' l"f f� *asyssq osE th
r:
Date Issued:
IMPORTANT:Applicant must complete all items on this age
LOCATION v J,
f Print
PROPERTY OWNER P-LC .�Gvi c`L iil'j
�1 _r Print ,J loo Year structure yes
MAP'("', "' PARCEL(;1=i=� ZONING DISTRICT:_ Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
XNew Building Kone family
/Addition [i Two or more family ❑Industrial
❑Alteration No.of units: ❑Commercial
❑Repair,replacement Assessory Bldg ❑ Others:
❑Demolition a Other
DESCRIPTION OF WORK TO BE PERFORMED:
11
t T . 't��
d
Identification-Please Type or Print Clearly
OWNER: Name: S5iec, 9 c _ Phone:
Address: � 11 j.vuj �JJ. ,f �1 41 ?f, i L)i
Contractor Namek lulH �C01S(. t�I D DS� Phone'
Email Itenn wi21 9' A e cz,vN
Address: 1 ae (-
Supervisor's Construction License: 01033C) Exp. Date:
Home Improvement License 11 S ca Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg.No.
FEE SCHEDULE BULDING PERMIT$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost:$4137x' FEE:$ 6 52—� M'
Check No.: '�-d(Y Receipt No.: J
NOTE: Persons contracting with unregistered contractors do not have access to-the guarantyfund
AUS
Plans Submitted Plans Waived❑ Certified Plot Plan 1,R Stamped Plans❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Mosage/Body Art ❑ Swimming,Pools f
ZOY31.
Well ❑ Tobacco Sates ❑ Food Packaging Sales ❑
Private(septic tank,etc. � Permanent Dumpster on Site ❑
�
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
PLANNING&DEVELOPMENT Reviewed On Signatures
COMMENTS
t
CONSERVATION Reviewed on Sri S�f 5 Signature,T C F/�-
COMMEN T S_
c C-nl �S y c� P�0.Ckd O �o
HEALTH Reviewed on - ''%,'
t,;'�5 Signature' t 1,
r'
COMMENTS
Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes_
Planning Board Decision: Comments
Conservation Decision: Comments
Water&Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer:Signature:
Located 384 Osgood Street
FIRE;DEPARTMENT Temp Dumpster on site yes _ no
Locatetl at 124 Main Streets A����A AA���.���`
A
F.�re�Department signatyure/date
COMMENTS`�_. ,.,. �
Town of
f µ,,W
, Andover
No. 0 ® ® 1t y rIppm� 22
* Vel'y Mass, 9IJ 11�
��9 QOanreP„e"Rg9
S U T Tu ILUBOARD OF HEALTH
PER Food/Kitchen
Septic System
THIS CERTIFIES THAT.................... .LS.,i;.K�r...-P.A.K BUILDING INSPECTOR
�1�� Foundation
has permission to erect..........................buildings on..... ...... . 1 M
ryry Rough
to be occupied as.Qft0...Y,3.4t...... ... ( .....f b.&L..t...................................... Chl—y
provided that the person accepting this permit s I in every respect conform to the terms of the application Final
on file in this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and '..
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
rj PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTITA Rongh
..................... ................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
OccupancV PerTuit Required to Occupy Building Rongh -
Display in a Conspicuous Place on the Premises—Do Not Remove Finel
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No,
Smoke Det.
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The Commonwealth of Massachusetts
Department offindustrialAecidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www amss.gov1dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriciansiplumbers.
TO BE FILED WITH THE PERNHTE`NG AUTHORITY.
A licant Tnformntion Please Print Le'bl
Name B,sines,/OrganiaaflodlndMdnat): -Pc1M.1 E'C7'S
Address: O
city/state/zip: r�� Phone, gqk-b�fr-�3G�
Are y....employer,Chcclr the appropriate box: Tyrpr��wwf pr0)¢Ct(Yegni[¢d):
1 I aempleyar'r*'rtiremployees(full and/e[part-rime)° 7. ew construction
2 Qlamuselc proprietor or parmersldp andhave no employees working formai, 8.❑Remodeling
a,y capacity.[Noworkers comp.ivs,rancc raquimdd 9.❑Demolition
vL]lam ahomeowner doing all work-yself[No workers'comp.insumvice"Mad.lt 10 Building
addition
4.Q lam ahomeevmer-d will be hhi,S ceutractors to conduct all work on my property.[will 11. Electrical Te aii9 or
additions
re that all contractors either lrave workers'compensation;,.lance o[arc sole ❑ p
propdemrs wim no e,nployeea. 12.❑Plumbing repairs or additions
5.❑Iamagenewl coMractorantl Ihavehired We sub-contractors luted on the attached sheet I3.❑Roofrepairs
Thesesub-cnntractors bave employees and have w.rkc,1'comp.;,.ranee.% 14.R10tlea
6.❑Wca[e ecorpd we have nomemffi�ers haveetworkasthcompmsurencemregvired]MOLa 1
152,§t(4),av poyees.[No
°Airy applicant that checks box#1 must also fill out the secdov below showing tlrevworkem'compensation Policy mformatiom
t Homeowners who e,bmit this affidavitivdioatwgihey are doing all workavdtlrev hire outside contmctoa must.Emit v new affidavit indicating such.
iCo,Vmt,rs that check this box must az[achedanadonal sheet showhrg thename ofthe.b-cont a.and liofewheffi or not dro.entities bave
employees Ythe subwntracmrs bave employees,they must provide their workers'comp.policy muvbar. -
ZamanemployerthatisprOvid;ngwort[ers'compensationinsaranceformy ployees.Belowisthepolicyandjob site
information. f /
insuranceCompany Name: N Ll'I
policy 4 or Selfins Llc;k 1! 1�`TIE' �'+�'� Eapimtio
Job
Site Adds—. S4' lti i b o�����9 n lL I airy/stn emp Y[,I 7f �t�l'�
Atfachacopy of the wor enation poBcy declaranou page(shm mgChe polity,mbe,and capita tion
Failure to,acme coverage we required under MOL a 152,§25A is a crtninai violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP W ORK ORDER and a fine ofup to$250.00 a
day against the violator.A copy ofthis statement maybe forwarded to the Office oflnvestigations off ve DIA for insurance
ernge verification.
Z do hereby certify under the pans.()d peryalRes ofperjury that the information provid el above is true and correct
Siat c: A
/ Date: V 't3 ds
Phone#:
Official use only.Do not write in this area,to be completed by city or town ojfrciaC
City or Town: - Pma it/Licease#
Issuing Authority(circle one):
1.Board of Health 2.Buildi g Department 3.City/Town Clerk 4.IOlectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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Office o-&&sumer Affairs and Business Regulation
10 ParK Plaza-Suite 5170
Bo
stoay Massachusetts 02136
Home Improvement Contractor Registration
FAMILY POOLS&PAT tm uo�'ziFPp emeni Cartl
GLEN WIGGIN O5'n'C -
705.BROADWAY ------ ---_ _
LA'JVRENCE,MA 01843
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192M ntl Rus ness Re„ulat nr
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WHAAAM C POULOS _
70SBROADWAY _
LAWRENCE MK 01843
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_,. 07/192015