HomeMy WebLinkAboutBuilding Permit #164-2016 - 11 OLD FARM ROAD 8/6/2015 e
BUILDING PERMIT of "°oT" qti
TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATION
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Permit No#• Date Received
�SSACHU`���
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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LOCATION
PROPERTY OWNER t . L(40
t 1oo_Y
Print ear,Structure yes prate
MAP PARCEL ZONI.NOUSTRICT Histonc:Distncfi , yes' , no
Machine ShopVillage
-- - = - 9- yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New BuildingOne family
El Addition El Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑:Wetlands ❑ Watershed District
0 Water/Sewer-
,YN .{
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: C y(-z 1`5 �O t I`��=Z Phone:S/.-q
Address:
Contractor Name-)AA -- Phone: �)I, J� J"J(
Address:
Supervisor.' Construction License %` Ex Date:
rg p
Home Improvement Licensee ' Exp : Date: `z
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: $ FEE: $ `-2")c-:)
Check No.: Receipt No.: 2'!�AN \(P�-
NOTE: Persons contracting wit unregistered contractors do not have access to the guaranty fund
Signature A Agent/Owner Signature of contractor .
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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
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 Os ood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
j Located at 124 Main Street
Fire Department signature/date _
COMMENTS
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 Call Email
I
Date Time Contact Name
Doc.Building Permit Revised 2014
c
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
o Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o Floor Plan Or Proposed Interior Work
o 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
,I ❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass 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)
o Building Permit Application
o Certified Proposed Plot Plan
Li Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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
1ri 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
m vst be submitted with the building application
Doc:Building Permit Revised 2014
Location 1 + (old A�---)v v,/\ eri
No. Date
. - TOWN OF NORTH ANDOVER
S��TI ED
• Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL $
4
Check# 5-7 d
`�/4eo,
r ; r Building Inspector
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Town of n over
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No.
soh ,� ver, Mass,
COC -A
NICNEwtC�c
A�RATEO I►PP�,�S
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BOARD OF HEALTH
Food/Kitchen
PERMIT L D Septic System
AM �� Z BUILDING INSPECTOR
THIS CERTIFIES THAT .............
6— ii ...........................................................................................
AID a
�.. .�,............... Foundation
. .t
has permission to erect .......................... buildings on . ...... ..OW..FAf.
Rough
to be occupied as ............ ........... ....... .................................................................. Chimney
provided that the person accepting this permit shall 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO STARTS Rough
Service
.............. ..... . .. .. ..... . .. ., .................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
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a r
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Residential Commercial Roofing
Ch r net's .Ill Types Of
1
Siding HEIVINEYSExpert Masonry Work
Mass Toll Free � �� r��'� �� � ' �...� Licensed & Insured
L'ca iy Owned< CJj�ersrterd �F-:rc� /!776 ""`
1-800-WAIT-4-U-S License#034200 }
(324$487) ��tx t�2 +zzdY�2 9Jue Work Year Round
a€-v .e,.It x (�P ✓B, •�"'�`� v, .."EYr 'rl� f ` s*�, tf E�....� A � ,� ? Z 3
�.•,x t E'€ 8..:V:""s�,°a',li+Y gB.rig..e, £ .t>: .X14 ..:'.els..r.. S,9.Y�rs .,3.�.,s' ..F•r"'r 7 ,r�,z .� ,Mf,+.>
Proposal To: Chris Ramirez Date 8/4/2015
Street: 11 Old Farm Rd. 857-891-4642
` N. Andover, MA
Roof proposal Chris_ramirez89@hotmail.com
IKO Cambridge/Certainteed Landmark
1. Extra caution will be taken to protect house 12. Building permit included.
exterior and landscaping as best as possible. 13. Contractor workmanship warranty: 10 years under
(tarps etc.)Magnets run at final clean up. normal wind and rain conditions.
1 2. Remove all shingles from entire house. 14. Install (1) diverter if wanted.
3. Inspect and re-nail any loose or lifted plywood. 'Total IKO cost: $10,20 '1 ,C
Any compromised plywood will be replaced at
an additional cost of$65.00 per sheet of 1/2" Total Certainteed cos $10,800.0
Ij CDX fir.
4. Install heavy gauge 8"white aluminum drip Both IKO and Certainteed direct ex non
edge to all eaves and rakes. pro rated 20 year fully transferable warranties
5. Install 6' IKO Armourguard or Certainteed included in this proposal. Please refer to
Winter guard ice and water shield along all pamphlets in estimate package. Offered and
eaves anmd top to bottom in all valleys. Install included to our local referrals in this proposal
full coverage on rear low slope roof line. at no additional cost.
6. Install IKO roof guard or Certainteed Diamond Skylight option: Install(1)M04 VS manual.
Deck synthetic underlayment to remaining venting skylight and flashing kit.
sheathing up to ridge. additional cost. Some minor cosmetic interior
7. Install all new pipe boots. finish work may be needed.Not included in
8. Install IKO Leading Edge or Certainteed Swift proposal
Start shingles to all eaves.
9. Install IKO Cambridge Limited Lifetime or *Note*: Please be advised if applicable, valuables in the
Certainteed Landmark architectural shingles to attic should be moved or covered due to minor debris,
entire house. 15 year non pro-rated warranty by dust and asphalt particles that will accumulate during
Mfg. 10 year if Certainteed is chosen. All the stripping process. All Under One Roof not
shingles will be installed and fastened according responsible for any damage or clean up that may
to mfg. specs. occur in attic.
10. Counter flash chimney lead with ice and water
shield,tie into new shingles and seal with clear Balance due upon completion
Geo-cel sealant.
11. Install a new GAF Cobra ridge vent capped with References available upon request
color matched IKO or Certainteed hip and ridge
shingles. Highly rated member of the accredited BBB and An-
aie's List
Tha�
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): Al UA /n CA
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Address: 6 y L
City/State/Zip: �-l-c-�v�{^'` yw�/}�tS Phone#: `�'�� 9 7f-� '7J—'
Are you an employer?Check the appropriate box: Type Of project(required):
1.[]1 am a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers comp.insurance required.]
9. ❑Demolition
3.E)I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sok 11.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13❑Roof r airs
These sub-contractors have employees and have workers comp.insurance.t
14.00ther
6.E]We area corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'corp.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.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
informadom
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: CSL 1�/1-'"t_ 2� /yI!� City/State/Zip: IV4- .
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal 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 WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify un theists ap"penalti s of perjury that the information provided abov is due and correct
Si ature: Date: 2i�f S
Phone#: �(� 975— - 73-3
Offwial use only. Do not write in this area,to be completed by city or town offieiaL
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 building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency sball 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-contractor(s)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 sure 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 permit/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 permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY)
5/2=0THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER? THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER T.HE COVERAGE AFFORDED BY THE POLICIES }
MLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
�ERRESEMTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poNcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the 1
"I-iiia and condf2lo,-ts of the pohcy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certifrcate holder In fieu of such endorsement(s).
CONTACT e.
Utiivarsal Insurance Agency Inc g�+e Berkley Assigned Risk Services
374 Belmont St 634-4589 /Arc.Na): 866 215 8118
Worcester,MA 01604 ADDRESS. PolicYSerrices@berkieyrlsk.com
I tRER AFFORONG COVfRA E MAIC a
�Kf/TIED IM REK R
ILIGG Construction Inc rvuRER s
S3 Congress St IM URER C:
Wiford,MA 01757 INS A
DZ RER E:
�OYERAiGES INSMER F:
_ CERTIFICATE NU11dIF3ER: _ _ REVISIDN NUINBER:
76tIS IS TO CEFFffFY THAT THE POiiCtES OF INSURANCE uS 6Ep gE�py4,ljAy�gg�p�C��j TO THE INS[}RED tWiNID AgpVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER QOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY O ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDFf10N&OF SACH POLICIES.LlortrTS SHAWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
cs��R TYPE OF INSURANCE A
_LTR SUSR
WVD POLICY 14UMEER LK 1 F POLICY EX
GENERAL LIABILITY lMNrDDIYYY (MMP0DIYYYY LIMITS -
AUTO NOBILE UABILITY f
WORKERS COMPENSATION i $
AND EMPLOYERS,LIABILITY WN WC STATU- 0TH-
ANYPROPRIETORIPARTNEF/E1tECtfT(VE s--■ TORY LIMITS ER _
nc. OFFIC E/MEMSER EXCLUDED? T--' NtA ❑ WC_20-20-OM5j9-00 /20/205 }U5/2af20y6 EL EACH ACCIDENT S 1,000 000
(Mandatory In NH) f
If yea,describe under E.I. DISEASE
-EA EMP OYES ! 1.,ODO,OQ0
OCSCRIPTUN OF E.
OPERATIONS Etter i
�1^i�.CRIPTgN CF OP£RATKTNS I LO CATE
tCN5!YEHtCiEw lllRsslACORD tQi-fd:iknryt Remarks Schels�!-E mere
- L.-DISEASE-.POLICX UMtT 1.QOO,000
sere is required)
pan Category Elect.Status Nam-_ Coverage
State(S)
OMcerIndude Maria Guaman '-'
A MGG Construction Inc
93 congress St Milford,MA 01757
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THEABOUE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
k1l Under One Roofing ACCORDANCE WiTH.THE POLICY PROVISIONS.
19 Temple St AUTHORIZED R PRESEKFATiVE
Aethuen, MA 01844 _
Signatures ---
i
ORD 25(2010/051
RRA( 411A
Massachusetts - Department of Public SafeV,
Board of Building Rccqaiatioins and Stanuarus
License: CS-069120
JOHN W LANZA"LWM
30 TEMPLE DR
MITHUENMA 018441,
Exo gar
Commissioner 04/03/2017
Click on the registration number to view complaint history. You can also view arbitration and Guaranty un
history.
The list is current as of Wednesday, October 8, 2014,
Search Results
REGISTRANT RESPONSLEWE REGISTRAT11ON N
ADDRESS EXPIRATIOSTATUS
NAME INDnWUAL NUMBER DATE
ALL UNDER ONEROOF LANZAFAME, 1370!2 L7 166 A MERRIMACK ST 10/02/2016 Current
JOHN METHEUN, MA 01844
Q 2012 Commonwealth of MassachUSOH-S-
mass.Gove is a registered service mark of the Commonwealth of Massachusetts.
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