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Home My WebLink AboutBuilding Permit #250 - 112 SAW MILL ROAD 10/2/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 0 DT06. 'tip 0 X Permit N0: obDate Received Datc Issued: SACHus� IMPORTANT: Applicant must complete all items on this page LOCATION /12 st'ltj /Ao-(- A�- _ Print PROPERTY OWNER S?-��— �CNrr?e'Lwl Print MAP NO.: I o & PARCF.I.: 4Z- ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building w--'One family Addition = Two or more family = Industrial C Alteration No. of units: /Repair, replacement Assessory Bldg Commercial Demolition !_ Moviniz(relocation) Other --j Others: F Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: S TC--j-C Cc=n 1-2 Phone: Address: 11 Z .S/ ✓M �'c.L �� CONTRACTOR Name:— TA"'A"' Phone: Address: 3 d T'---'Pl., ,/JZ Supervisor"s Construction License: 00 !Z O Exp. Date: Ilon-tc Impiv anent Licensc: J11 as7 Exp. Date: k-17-10 6 ARCHITECT, ENGINEER Name: Phone: ,^address: Reg. No. FEE SCHEDULE:BULDING PERMIT:510.00 PER 51200.00 OF THE TOT,4L ESTIMATED COST BASED Old 5125.00 PER S.F. Total Project Cost :S 16 . Zoe , 40 x l2.00--FEE:$ Check No.: Receipt No.:�0 Pais lol I TYPE OF SEWERAGE DISPOSAL _ Tanning,'Massage,Body Art Swimming Pools Public Sewer Well — Tobacco Sales Food Packaging/Sales Permanent Dumpster on Site Private(septic tank.etc. Electric deter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guuranty fwhd Signahtre of Agent/Owner Signature of contracto Plans Submitted Plans Waived J� Certified Plot Plan i_' eamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ -0i [-]Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMNIENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ! CONINIENTS x c DATE REJECTED DATE APPROVED HEALTH j J CONINIENTS Zoning Board of Appeals: Variance. Petition No: Zonirnu, Decision:receipt submitted ycs Planning Board Decision: Comments Conservation Decision: Comments 11;ater& Sewer connection,Signature& Date Driveway Permit i Temp Dumpster on site yes_no d Fire Department signature date Building Setback (ft.) Front Yard Side Yard Rear Yard Required Pro\ ided Required Provides Re aired Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA—(For do artmcnt use) :;!c �'�PGC"I:� `..\(.Si_I.`,it_'L-.;i!)I_f/�fi I-VIL.V I':I•;'F(-I:.`.1ii 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 Cornp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application j Surveyed Plot Plan ❑ Workers Comp Affidavit o 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) New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit :i Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract ❑ tilass check Energy Compliance Report 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 Ooc:1\611("HONAL SERI R I'S DEVAR'I'VBV'r:iwi,oR\IOS Location No. 1 rJ Date l ) 2�6G 1 3?o.,N�oT:,�eL TOWN OF NORTH ANDOVER F F A • .��_. Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 19640 Building Inspector I I NORTH c s, Town of { 0 .1 dover, Mass., �� • 2. O!s LAKE �, T COCHICHEWICK 7d0RATED 7 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System C^ BUILDING INSPECTOR THISCERTIFIES THAT........ ..................................../��. !.......................................................................... Foundation has permission to erect........................................ buildings on .lI...Z�.....SI.l.h0.... ....... .. l.............. Rough tobe occupied as......1s7)%.g0.*......... ............................................................................................................................... Chimney provided that the person accepting this permit shall in 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 9uildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final Z Z tow PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC TAR Rough ....... ........................................................................................... Service BUILDING INSPECTOR Final OccupancyOcmpancy Permit Required W Ocmpy Building GAS INSPECTOR Rough Display in a conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done j FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. FnT t � S11 l°� i1K 1T >� �aaa OPT co c.� c�co CEnfaunrtncays Residential & Commercial Roofing G.�ti¢��IIIlg CC'�llti MEMS POINTED-REBUILT-CAPPED Ali Types Of *Raaf Leaks Ex erts* Eupert Ma~3onry Work Mass Toll Free —— Licensed&Insured 1-800-WAIT-4-US Locally Owned So Operated Sirce J076 f a License#034200 ( �(92�4-8487) IKON 43=ff W-Vons vtz 7vh- We Work Year Round CJ�JI:l a '.-rte., ';Y�� ;{y A:_ •�;t�r'�?�� 77 i- • irk l�. �_�rtl:t:•;t.�j�+vim 1 :i 7 C1J uauL+Wi= Proposal Submitted To„rl�� Phone Datc STCtJG= L'cN91)y-Cyr) /7 S b'fa6 Street Job Name / City,State&.Zip Code Job Location Job Phone V /U trtn �u cip,ts We Propose hereby to furnish and labor in accordance with specifications below,for the sum of: \ 3TC% /-Mem Dollars /.V/Z, - S CafTtA tJ o Z s.j 2 oo,�o All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from specifications be- Slgttature: CJ low involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents NOTE:This proposal may be or delays beyond our control,Owner to carry fire,tomado and other necessary insurance. Our workers are fully covered by Workmen's Compensation insurance. withdrawn by us if not accepted within_6o days. We hereby submit specifications and estimates for: sTl';�' IQ install 3 feet of special"Eave Seal”ice and water barrier protection along all bottom edges of roof and top to bottom in each valley. r.gf is stripped,we will apply conventional ice and water shield ( � )ft. high in the same locations previously described and tar paper will cover the remaining bare wood.Any rotted or damaged boards will be replaced at( — )per linear ft. or( So,oo )per sheet of plywood. i.!/stall heavy gauge aluminum drip edges along every edge surface of each roofline. gCovef entire roof(s)with 1 D. �,l asphalt,cam-fiberglass,premium grade shingles (Color of choice).T„e_j_z-S 34 42 OdReplace all pipe boots where possible. lidSeal all flashings with clear Geo-Cel sealant. No black tar unless previously applied. Remove all work-related debris. EcContractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. &Local current references and proof of workman's compensation insurance gladly given. lidRemarks-/�)e"T t-T,1s 7*-1- Glv C6Qn4 fi'•o c= (/c=�?" _ Xrn� ITS -L112-fc-K nQ_ t?--4 c7 C/— �Ct�c✓%}�G�Z / 9 3a/J 0 Acceptance of Proposal-The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.Payment Signature: will be made as outlined abov . Date of Acceptance: J Signatuire• __ The Commonwealth of Massacnusens I Department of Industrial Accidents W Office of Investigations 600 Washington Street Boston, MA 02111 3vww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): G Address: 3lt�. j_C�OL_t- VA City/State/Zip: /ft 4--i-J Phone #: IJ--1 J_J Areyouan employer? Check the appropriate box: Type of project(required): 1. E? l am a employer with 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. $ F-1. Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its officers have.exercised their 10.❑ Electrical repairs or additions required.] 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 12.0 Roof repairs insurance required.] t employees. [No workers' 13.❑ 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 xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'conrpensatiorn insurance for my employees. Below is the.policy and job site information_ Insurance Company Name: Policy# or Self-ins. Lic. #: G '7 0O9 �4 4,5( Z o o I Expiration Date.. It Job Site Address: S4,-) /-k City/State/Zip: P A 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 form 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 insa6n.ce coverag..verification. I do hereby certify//under the ains andpenalties ofpeijury that the information provided above is true and correct Signature e- — Date: t ° Phone#: 0 94�• 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 LL_ 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 6r 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 shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth A 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. Re 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 perm�t/liceuse 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 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 tax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia