HomeMy WebLinkAboutBuilding Permit #324-11 - 104 MIDDLESEX STREET 10/19/2010 BUILDING PERMITOf "ORT"
TL1D 167 "YO
TOWN OF NORTH ANDOVER 3? O
APPLICATION FOR PLAN EXAMINATION y
Permit NO: 2 ( Date Received
of a
Date Issued: 0- I �9SSACH�ISE�1 v
IMPORTANT Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building —One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
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DESCRIPTION OF WORK TO BE PREFORMED:
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J Identifi�on Please Type or Print Clearly)
OWNER: Name: Phone: Irj.
Address:_ 6 �t ad telex SA-(,eC_+ nom Mi U111d r
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ q Ln 0 • ° FEE: $ 5q--
Check No.. P a
'�—
Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
i S�natur��f.Agerit/Ouuner �. � _'_ Signature�i3f cod raetor -
Building Department
The following is'a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or..Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from.Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Geh"ed Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2008
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools
Well Tobacco Sales Food Packaging/Sales.
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTIS
HEALTH Reviewed on Signature
COMMENTS
ti
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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
tRE� ►RTNIT�T Tern 3Dupsterr� �te yesy n fl
located 6t 9- Ulain S#reet '
Fire ear arae ts�graa aMiala e
CDNI1VIElT.S
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE:. Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup - Date
i
Doc.Building Permit Revised 2010
Location U L/
No. Date
TOWN OF NORTH ANDOVER
4' 1 Certificate of Occupancy $
5
MUS Ll
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 9
23572
Building Inspector
NORTH
own of over
0
No. 3� - o /� -_ _
dover,
Mass.,] ® '
Q -- IAKE
2COCMICMEWICK
0RATED FPat��
7 v ` BOARD OF HEALTH
Food/Kitchen
Septic System
-PERMIT T D
-� BUILDING INSPECTOR
11 \\
THIS CERTIFIES THAT..................... U... ............�.e.`.v.. .......................0q,j"Ar,
.. ..... .. ............................................ Foundation
. /has permission to erect........................................ buildings on .......... `�..........'. . ..... - ......... ..................... Rough
to be occupied as.........�...... ......-. ............. X41!1,$ .. .. ....................................................
Chimney
r....!...�. ........................
provided that the person ecce ting this permit shall iii every respect conform to the terms of the application on file in Final
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
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUC S ARTS ELECTRICAL INSPECTOR
Rough
.....................................................................................
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Ocatpy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT'
Until Inspected and Approved by the Building Inspector. Burner.
Street No.
SEE REVERSE SIDE Smoke Det.
DAVID CASTRICONE,PRES.
CASTRICONE ROOFING&SIDING INC.
ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845
In North-Andover 978-683-3420 In Boxford 978-887-6147 In Haverh111978-374-7314
I/we the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary
materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and
conditions,on premises below described:
r
Owner's Name.... x ..... l`�..e -...... Telep e#....6117:7, .ALGA.:
Job Address.....14✓.� .....i..:.1.1. ��5.>=1�.... �............City...... 0.r.. 4 0 12.1.........State.......
Specifications:
....... .........f........................................................... .........................
s*.v�'•4(?..... J.3 � .Z1. �.. ... /!tS ....
// .. ........ �..
............f••F• .4.t/�........6.... ............ ....... . . .`...... ....c'.fL......... ......•�.a"'F .�+` •• i
............. ..Elod.......f�..........W•�:Ly.... ..1� ...... ....r...........Y...
.�.C...1..... :. .../....................................................
r ....... . d.. .. .......... ....,..1 • .a.t',i...............................te . ...................
.............. :....... ....... . .l .... . � ...... .. ./
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......................................................................................................................................................................................................................
:.. ............. U
....................
..... .... ...............
................... ...........
Two Year Workmanship Warranty(Not Transferable) Manufacturer's Warranty as specified m nufacture
The actor agrees to perform the work fum* the materials specified above for the SUM of ....�...0 .... ........
payable...:rZ.Z. ......on.... ........
Payable............' ............on.........................I........�alance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability whilejob is to operation.
Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or
conditions resulting from application of materials specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living
spaces). Items in attic may need to be covered by homeowner.All materials are property of contractor. Any dumpster placed by contractor is for his use only.Upon
completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested by
contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It is
agreed that,if permitted by law,contractor shall be paid by the owner(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.Property may be subject to mechanic's lien if unpaid.It
is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the
parties.The undersigned warrant(s)that he is(they are)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)
names(s).There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the
contract dependent upon or subject to any conditions not herein stated,Any subsequent agreement in reference hereto shall be binding only if in writing and signed by
all parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration
should be directed to the Office of Consumer Affairs and Business Regulations,Tel.(617)973-8700.
Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction-
related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c.142A.
& �2"46, v tl 10 i 13— I a
Approximate starting date of worOk'A''�...k}hi�!� Completion date.........................................................
Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
This contract may be cancelled,without penalty or obligation,within three business days of the below-referenced date.Mail or deliver
a signed and dated notice or send a telegram to Castricone Roofing&Siding Inc,200 Sutton St.,No.Andover,MA 01845.
IN WITNESS WHEREOF,the parties have hereunto signed their names this....R day of...Q. ............20.10.
Accepted: p
Signed .............U241.0...... Owner
nSigned............................................................................. Owner
David Castricone,President
5�•I -b`i3`3°S�
Town of North Andover
Building Department o -
� m .
27 Charles Street A
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542 °�
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t° �
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$ACNUS�
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a 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 cl 1, s150a.
The debris will be disposed of in/at:
�. Z, l
Facility location
Signature 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
�F ► Department of Industrial Accidents
Z.. ' Office of Investigations
600 Washington Street
Boston, MA 02111
ov/dia www.mass:
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): AV i b C RST R l c u 1J t= r'�o 6 t= i N 6- a S /n/N& 11Y c-.
Address: U 0 S c.;—, --o fJ S rz 1- -- -c 2.2..
City/State/Zip:J�o . A ii 1� D i S q Phone#: 9 r7 .3..3 Y'2
Are you an employer?Check t,:ie appropriate box: Type of project(required):
1.R1 I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or par'-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or pa.tner- listed on the attached sheet. # �• E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any car-acity. workers'comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] - . officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing a'I work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12 Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: L 14 Pr r<T )S
i.
Policy#or Self-ins. Lic.#: N 0, o o ;q (6 rlo�3 Expiration Date: 9 ''0(
Job Site Address: I � 6�t Q�C� K � � City/State/Zip: Iv NX0
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as regi:.red under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-yrar imprisonment,as well as civil penalties in the fortn of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insL ance coverage verification.
1 do hereby certify under the pairs`and penalties of perjury that the information provided above is true and correct
Signature: Com Date: o �
Phone#: C � 3 3 g Z Q
Official use only. Do not write in this area,to be completed by pity or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Buildirg,Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
t
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