HomeMy WebLinkAboutBuilding Permit #313-11 - 107 COVENTRY LANE 10/18/2010 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: LL Date Received
Date Issued: — /0
IMPORTANT:Applicant must complete all items on this page
LOCATION 10 7 Co A
Print
PROPERTY OWNER Le-r r J 4R,O
/ Print
MAP NO: /0 C PARCELQ/` 0 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building W6ne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other.
'Septic: ❑Well ❑Floodplain ❑ Wetlands ❑ Watershed.District
f
❑Water/Sewer _
DESCFJPTION'-'u WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: rrV Phone:
Address: 10 7 o ir o, RS / ,
CONTRACTOR Name: 7�5LM V ��6,cce, Phone:
i
Address: Ianel &0rJ0PdeV- l '
Q
Supervisor's Construction License: Ex . Date:
p o zo
Home Improvement License: /P'd' 3�f Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No. i
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ASED ON$925.00 PER S.F.
Total Project Cost: $ �� FEE:
Check No.: ( � S� Receipt No.: 0�35
NOTE: Persons contracting with unregistered contractors do not have access to the giwanty fund
Slgnaturerof!Agent/,®�wner _ Signature of°contraeto`
r
Location v� Ca✓ rr-�
No. ..313 Date �U -� t�` ((D
MORTIS TOWN OF NORTH ANDOVER
3?O�tt`•o �•,hO
O
►O w
9
} Certificate of Occupancy $ _
Building/Frame/Frame Permit Fee $
sKINU 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # //
23561
Building Inspector
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1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL _
Public Sewer ❑ Swimming Pools .Art ❑ �
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
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I f
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
1 �
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
II
,
t
CONSERVATION Reviewed on Signature
I
COMMENTS
HEALTH Reviewed on Signature
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
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
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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
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NOTES and DATA— For department use
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❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
1
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)
❑ Muss check Energy Compliance Report (If Applicable)
o 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
❑ Certified 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 ( f l
Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign
off from Fire De artmen
p trior to issuance of Bldg Permit
p 9
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: Doc.Building Permit Revised 2008mi
i
Family !Roofers & Painters
'=OURNIEA JAMES DEBRECENI=
'MAPLE ST EXTERIOR PAINTING - CARPENTRY ROOFING
"HUEN, MAO!844 FREE ESTIMATES
978-683-5127
Ne w
I
�-c
Xt s1,
� �l Vcoq7 P�p, F7,1151cf5y
14// �jcf� ►a
yTOTAL 560
'- ON ACC£PTANC£
jWHEN STARTED3 dad.
HALF COMPLETE va CJ i
BALANCE //ll
WHEN'COMPLETE 3� w
� I -
ALL CHECKS TO ALBERT FOURNIER OR JAMES DEBRECENI
NORTIy
Tow' ' ofAndover
No.
L A K_ O dover, Mass., a • I • t o
A- COCHICME WICK �1%
7�p ADRATED
1`S V BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT............ '' ` �w........................................................................................... Foundation
...
has permission to erect........................................ buildin9son •1.0.. .........11roA. .. .. �.!`. r... Rough
}
to be occupied as �a �� Chimney
............
provided that the person accepting t is permit shall in every respect co rm to the terms of a 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 ONT^HDS ELECTRICAL INSPECTOR
UNLESS CONSTRU STAR S Rough
....... ..........................................................................
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To BeDone FIRE DEPARTMENT'
Until Inspected and Approved by the Building Inspector. Burner,
Street No.
SEE REVERSE SIDE Smoke Det.
• �� �,.�, �. #arirszia�u� •
.} - u�titsn S;uA�rvtsor•SAecial2 ,L�:::•. '
Ocense: CS SL 9968,5
Rc�# #o: RF
1
JAMES DEBRECENI 1
2 TANAGER WAY '
►-ONDONDERRY, NH 03053 +
Expir4Z"0 7:-12'6
,tom 711. -Peer! o� / aclucaelta
Office of Consumer Affairs&B°siness Regulation i
HOME IMPROVEMENT CONTRACTOR j
Registration:x%•122385 Type:
Expiration: -8/26/2012 DBA
. , �,..
JAMES DEBREC�NIF;`t=
2 TANAGER WAY
LONDONDERRY, NH0.3053= Undersecretary
t
s
' I
May-19-10 09:31 am From-
T-128 P.001/002 F-773
e
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IS CERTIFICATE 1818SEp A$A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON T
ERTFFICATEHOLDER.THIS CERTIFICATE'DOES NOTAMEND, HE
Y THE POLICIES BELOW.THIS CERTIFICATE OF(N$URANCE DOES NQTOCON8TRTU�TEEACOVERAGLff CONTRACT FFOEOR4DEN
E ISSUING INSURER(S), AUTHORIZED REPAESENTATIVE OR PRODUCER AND THE CERTI IC TE HOLDER,
MPORTANT: If tfte Cee Catehcldsri8 lifl ADDITIONAL INSURED,the poucyges)rr uat Do endorsed If SUBROGATION
n WAIVED, subJect to the tef7i18 and conditions of the policy,certain policies may require and andorsen>ent A statement
n this certificate does notconfe hts to the ceruffCate holder in lieu of such ch endorsenterlt
Degnan Insurance ABepxy
93 Salam St
Lawrance,MA 1843
II PINSURED COMPANYA GANITEST STATE CORDINg MANY
-
Jarnev Debmcerd
Dba Femlty Rcoitng&Pelndrlg
2 Tanager Way
Lohdondeny,NH 03063-0000
THI8 I8 TO CERnFY THgTTHE POUCIEB OF INSURANCE LIED BELOW HAVE BEEN 1680®TC THE ENSURED NRMED ABOVE FCR
THE POIJCT'PERIOD INDICATED,NOT WRHBTANDiNG ANY REDUIREMENT,TERIy10R CONDITION OF AMf CONTRACT 0 R OTHER
PCIUCDOCUrI 4 S D5S Rj i=HEFt N I1'di=�Cri CERr m"Tis MAW BE 10SUM OR iMy'LWAIi.THE INS
CiR4NCE AFFORDED THE
Pai rctES DE8CRI6ED I1EREr�Is SUBJECT TOALL.THETE",LXCLUSIONS AND CONDITIONS Olt SUCRt KUCIES.AFFORDED
SHOWN
MAY HAVE BEEN REDUCED Vy PAID CLAIMS. UMMS
co
L7R yon or Mp/RAM JO
A KEFCLIWYMUAI�lI FaUWTCITeaM DAR 1'CU L71r71AT1CW OA1!
RSCOMPFNEATA
DEM &L IL
PE PROPRErORf LIMITS
orrlcrRa ARTNERSIDrEWTNE
ARE:
WCL 0 EKCL❑ 2453385 5/i!1201 D
ER 51 9/201! ATumRY LIN ITS
rapAPFHnkN4 Opsaitms 0*.
A=COfT S -loom
L8MW POLICY LIWT S 300,00
DESCR�TIONOFOPERATIONSJV8fi14LE&SPEC MS IBJ •FACHEMPLOYEE 10000
RE:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE poR JAMES DEBRECEN,.
CERTIFICATE HOLDER CANCELLATION
MIKE PALMISANO SHOULD ARYOF THEAWVEDESCRISED POL CIES BE WWCELLED BEFORE THE
604 NORTH END BLVD E7�RATION DATE THEpEOF,IHonCE W1L BE VILWE MD IN ACCOROANCQ
SAUSBURY,MA 01952 WKr5THEpCL=yPxWriONa,
AUTHORRQBD PM'REBENTATNE
-OURNiER Family Roofers & Painters
JAMES DEBAECENI-
MAPLE ST EXTERIOR PAINTING - CARPENTRY ROOFING
11 1EN, MA 0184- FREE ESTIMATES
. 978-683-5127
Name _.
omptin ame
Street Addres (do not itse a Post Office Box d ss
C ) Contractor/Sal sperson/ ner Nsm '
/07 Co ve vi c
y�.rhe
City/Town St le Zip Code lusiness Address(must include a street address) '
Daytime Phone Evening Phone :try/fo%k�. State Zip Code
Mailing Address pl different from above) usioess Phone
ederal Employer ID or S S Number
Isco regwrea that mop home tm Home provemeot CoomclocaeQ'Number Expiation drte
PmWamot Bout actorr hive a I - .
Baa msi�tratioo oiaalra p
The Contractor agrees to do the following work for the Homeo ner:wesmue in
Required Permits-The following buildingpermits are required P q d Pro osed Start and
and will be secured b P Coroplellon Schedule-The following schedule
y the contractor as the homeowner's g will
agent, be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be �k,
excluded from the Guaranty Fund provisions Of >
MGL chapter 142A.) _ Date when contractorwill begin contracted work.
&"r.0r
Date when contracted.work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work,furnish the materiel and labor specified above for the total sum of: Sov (*)
Payments will be made according to the following schedule:
$ O upon signini contract(riot to exceed 1/3 of the total contract price or the cost of special order items,whichever is
? greeter)
S J/f5 66 byjd l�l�� or upon completion-of
S- 110 by _/_/_ or upon completion of /pe- PO
S J OO upon completion of the contract. (Law forbids demanding full payment until contract is-completed to both a
_ p rty's satisfaction)
The following material/equipment must be special $ to be paid fo
ordered before the contracted wart begins in order S =---�md
to meet the completion schedule.(**) _
NOTES:(*)Including all finance charges(•*)Law requires that any deposit or down-payment required by the contractor before work begins may
not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equip cat or custom
which must be special ordered in one-,third
meet the completion schedule. made materiel
E-1212- r n r arr e n ravlde he contract r
Yes (PLI.Jerms of(he warran
Subcontractors-Thevonlractor agrees to be solely responsible for complet ontX of the work described regardlessus llbe actions of any coe attached jo the ntract
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
1u0lerials and labor under this agreement
Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the
contract shall not imply that any lien or other security interest lies been placed on the residence. Review the following cautions and notices
carefully before signing this contract
• Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear.
• h1oke sure the contractor has a valid Home Improvement_ n_t Contractor-R Registration. The law requires most home improvement contactorsend
subcontractors to be registered wtUi tie Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or
1-800-223-0933.
• Does the contractor have insurance? Check to see that your contractor is properly insured.
• Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of die Consumer
Guide to the Home Improvement Contractor Law.
You may cancel flu's agreement if it has been signed at a place otfier than die contractor's normal place of business,provided you notify the
contractor in wdring at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not Is than midnight of the
third business day following the signing of this agreement See the attached notice of cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES!!!
Two identical copies of the contract must be completed and signed. One raspy should go to the homeowner. The other copy should be kept by the contractor. '
Z--
1101 net's SignatureS2 41 A
Con actor's Signature
Date
Date
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s The Commonwealth of Massachusetts
Department of Industrial Accidents
R 1. Office of Investigations
1 600 Washington Street
Boston,MA 02111
* � www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please PrintLegibly
Name (Business/Organization/Individual): Vary)eS: b(f�ire C c K
Address:_ .2
City/State/Zip: Lo,-iJcYdtf rv-11 IV, t/- Phone#: f ";7- 7
Are yopaii employer?Check`t�e appropriate box: Type of project(required):
1. am a employer with 7 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. 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 all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12,[2Kof repairs
insurance required.]i employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 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.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. r
Insurance Company Name: rte.6c'L,
Policy#or Self-ins.Lic.#: 1 L/1-3 3 0 Expiration Date:
C-� t
Job Site Address: l �7/ �Je� 4City/State/Zip: /to An J., M/
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required 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-year imprisonment,as well as civil penalties in the fonn 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 insurance.coverage verification.
1 do hereby c under the ain an enahies ofpeijury that the information provided above its true and correct.
Si nature: Date: /0
Phone#: —6
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or buildingappurtenantthe eto shall not because of suchemployment
e deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sur6,that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pen-nits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or pen-nit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia