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Home My WebLink AboutMiscellaneous - 33 Coachman's Lane.� Is '1� TOWN OF NORTH ANDOVER BUILDING APARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING � ins 'z BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/12ERector 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: 1.4 Property Dimensions: 5.11 1.2.17 A le - / 2 - Zoning Distrid Proposed Use Lot Area sf) Frontage 11 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required ovided Re red Provided 0 4 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone ln1 1.8 Sewerage Disposal System: Public C�- Private ❑ Zone Outside Flood Zone 1 — Municipal On Site Disposal System ❑ JEl 11VPI L - YKVYERI Y VWIVEKJlilY/AU ll1UK1GEll A(GL1V'1 2.1 Owner of Record no esFav AV- 6 L to 04 Prr I Ra-me(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 icensed Construction Supervisor: Licensed Construction Supervisor: Address Telephone 3.2 Registered Home Improvement Contractor Company Name Address Address for Service: Not Applicable ❑ License Number D,SIv - 741 Expiration Date & ,l�- D/ Not Applicable ❑ Registration umber 7 /Z sFMW UU I MM 200 t R111R Dli�(a DEPa TMENT s 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 g, Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �J(j��>�Ta �Ox � �f'G �.G�r �lir� TL �//J�.rri.✓a 1 od � r U4 Lr-7-c�s.,�d G•�-T _S� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant t%FiCIAi USE ONLY--. _ - 1. Building �Q (a) Building Permit Fee Multiplier 2 Electrical DSU ,.. i (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC /D DD 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, 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/AUTH�ORIZED AGENT DECLARATION I,�'_ t as Owne /Authori� zed 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 I GbC Q. Print Si ature o er Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS iST 2 ND 3 RD SPAN DMIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHPVNEY IS BUILDING ON SOLID OR FILLED LAND IS BUIL DING, CONNECTED TO NATURAL GAS LINE b b W t v r ^7 V u �l ', G COB - VO l I f �b R a► v Nowwoo m -:: ZEj —7 ... � -1• • V }` m -:: 711. �om>/rno7ecue o�'✓i��acl,.uae _ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 056174 Birthdate: 03/16/1945 . Expires: 03/16/2001 Tr, no: 8013 Restricted To: 00 RICHARD E BENOIT 54 CUSHING HILL RD NORWELL, MA 02061 Administrator HOMEIMPROVEMENT COMTRA r Registration 105485 Fj- Tree - PRIVATE CORPORATION ` Expiration 01/17/00 SOUTH SHORE GUNITE POOLE SPA RICHARD BENOIT �Q,�t2 iWEY ST + ADMINISTRATOR °`�- BILLERICA MA 01862 Department of Industrial Accidents O1Ace a1 A7YesUgatlaJ7s Workers' Compensation Insurance Affidavit ,m a homeowner performing all work myself. -: a sole proprietor and have no one working in any capac:ry 4. am ar, employer providing workers' compensation for my ernoloyecs workma on this job. SOUTH SHORE GUNITE POOL & SPA, INC. camnanv name: 12.HADLEY'STREET address: NO. BILLERICA, MA 01862 800/649/8080 city: phone insurance co. LAKESIDE aofiev WCC .:14478.4' 68. -' 1 1 am a sole proprietor, general contractor, or homeowner (circle one) and have hircd LLte concac:ors listed below who lave die followin- workers' compensation polices: nhonr , insarsnce co. tioif comp.anv nam I . city: phone" insurance co. otiliev" tta •a ons — _ EMMA Failurc to secure coverage as required under Section 15A orNICL 151 can lead to the imposition of criminal penal des of a fine up to St.500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine 0rS100.00 a day against me. I understand that s copy of this statement may be ror+vard4o the 0mcc or Investigations of the DIA ror.eoverage veriGeation. 11 I do hereby certify under Signatur_ ur/br natiolt provided above is truz a corn�i i Glace ?ring RUICHARD E. BENOIT e-800-649-8080 Phone afTicial use only do not write in this area to be completed by city or town OM621 c. H rcity or:own: permivlicense -Building Department It ^Licensing Board C chrk if immcdiatc response is required L,Seleetmen's Ofriec w: - _Health Department contact person: phone 4: "Other S ik ,UNq .. _ s E:. '•'3�Y-`T `,( `Y nig.: e -i- s{t (^,- +• n '1 ' sm 1 rpt y- 3� y �•:.t ,s �. �T Y tT �.i~AfS.�.. .cR '--b ,w-- a4� .1; M1•y + 4 f Kati i"'a•'sLf;§r a+_#' , t"•i5� d -` _ The Commonwealth of Vfassoichusects Department of Industrial Accidents O1Ace a1 A7YesUgatlaJ7s Workers' Compensation Insurance Affidavit ,m a homeowner performing all work myself. -: a sole proprietor and have no one working in any capac:ry 4. am ar, employer providing workers' compensation for my ernoloyecs workma on this job. SOUTH SHORE GUNITE POOL & SPA, INC. camnanv name: 12.HADLEY'STREET address: NO. BILLERICA, MA 01862 800/649/8080 city: phone insurance co. LAKESIDE aofiev WCC .:14478.4' 68. -' 1 1 am a sole proprietor, general contractor, or homeowner (circle one) and have hircd LLte concac:ors listed below who lave die followin- workers' compensation polices: nhonr , insarsnce co. tioif comp.anv nam I . city: phone" insurance co. otiliev" tta •a ons — _ EMMA Failurc to secure coverage as required under Section 15A orNICL 151 can lead to the imposition of criminal penal des of a fine up to St.500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine 0rS100.00 a day against me. I understand that s copy of this statement may be ror+vard4o the 0mcc or Investigations of the DIA ror.eoverage veriGeation. 11 I do hereby certify under Signatur_ ur/br natiolt provided above is truz a corn�i i Glace ?ring RUICHARD E. BENOIT e-800-649-8080 Phone afTicial use only do not write in this area to be completed by city or town OM621 c. H rcity or:own: permivlicense -Building Department It ^Licensing Board C chrk if immcdiatc response is required L,Seleetmen's Ofriec w: - _Health Department contact person: phone 4: "Other S / FORM U - LOT RELEASE FORM �t INSTRUCTIONS: This form is used to very that all necessary approvals/permits from - Boards and Departments having jurisdictic..Ri h8v6 been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS APPLICANT QaTA ' GAC4LL C—:, • ,m GUQLS PHONE 4 �' LOCATION: Assessors Map Number PARCE_ SUEDIVISION LOT (S) STREET�47�a �i,�4,�s f! 1h-�.1 U ST. NUMBER X33 OFFICIAL USE , DATE REJECTED " COMMENTS ,!) V" S V� `oi I TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED 1'71 2 d 0 C DATE APPROVED DATE REJECTED SEPTIC INSPECTOPC-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUELIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED EY BUILDING ii ISPECTCR Revised 919; im A T i 5 • I� U L5 i; DATE 3 1 2000 IF BUILEANG U'EFr� RTMENTI