HomeMy WebLinkAboutBuilding Permit #331 - 114 LACY STREET 10/25/2006 „0RT#j
Of
0 , TONN, 'N OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
APPnOVED
Permit NO: Date Received:
Date Issued/6-
IMPORTANT: Applicant 111LISt complete all items on this pate
LOCATION —hoz
PROPERTY OWNER '1-nnsow
I t
PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 11
TWE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
Ne%k Building 19 One family
A,Additioli Two or more family Industrial
Alteration No. Of units:
Repair, replacement Assessor}' Bldg Commercial
Demolition
Nilo Other
ving(relocation) Others:
Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
1 ,A D,44
v
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Signature
Address: C-
CONTRACTOR Nanie: i4vuL-1, Phone
Address: gq &,,”" I" (W 06}32-
Supervisor's
4-32-
Supervisor's Construction License: 5-7 —Exp. Date: Ll
flonle llliproenlcnt Licclise: —[--xp. Date: &1-Z4'- 2,aof'
Name: Phone:
Address: Reg. No.
FEE SCHEDULE:RULDL%fG PERMIT:510.00 PER S1#00.00 OF THE TOTAL EST1.,11ATED COST BASED ON
512.5.00 PER S.F. 1") 190,
I Z,- J�
Total Project Cost ,iCt O F1EE:$
Check ;No.: Receipt No.:
r
TYPE OF SE\k,XRGE DISPOSAL i
Tanning"Massage Body ,art SwIminln� Pools
Public Se\'VCI•
Tobacco Sales - Food Packagings Sales
eli i
i Permanent Dumpster on Site
rl
ri�ate(septic tank, c c. i
NOTE: Persons contrat•tin�; with a ter (I •ontructorc do not hcrne tweess to the�;uart t rend —
Si"nature. of Agent/OWner Signature of Contractor
Plans Submitted Plans Waived ❑ Certified Plot Plan Stamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY j
INTERDEPARTMENTAL SIGN OFF- U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
❑Water Shed Special Permit
L-1 Site Plan Special Permit
❑ Other
CO!\,IMENTS
;DATE REJECTED DATE APPROVED
CONSERVATI -
COMMENTS` D � �,� (� �f 1/ _
/ohn �
DATE REJECTED DA PPROVED
r
HEALTH ❑ F] d 7/04
COMMENTS /�
Zoning Board of,lppeals: Variance, Petition No:
Tonin , Dccision,'reccipt submitted yes _
Plannim, Board Decision: Comments
Conservation Decision: Comments
lwater& Sewell-connection si-naturc& date — --- —
Temp Dumpster on site yes __no_ Fire Department i`,nature'date�`jam — , ill-,, �
Building. Permit ,approved and Issued by:
Building Setback (ft.)
Front Yard Side Yard Rear Yard
RcgLIircd Provided RC Uircd Pi.
ovides RcqUil-Cd... Provided
DIMENSION
Number of Stories:-- Total square I'eet of floor area, based on Exterior dimensions.
Total land area. sq.
NO TI and DATA—(Iordepartment Use)
1
i
Building Department
E
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
t
I
Roofing, Siding, Interior Rehabilitation Permits
`Building Permit Application
0 u Debris Removal Form
\Workers Comp Affidavit
Photo Copy Of H.I.C. And,'Or C.S.L. Licenses
Copy of Contract
e- 1 loon Plan Or Proposed Interior Work
Addition Or Decks
❑ Building Pen-nit Application
❑ Form U
❑ Surveyed Plot Plan
Debris Removal Form
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)
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Form U
❑ 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 (If Applicable)
Copy of Contract
j Mass check Energy Compliance Report
In all cases if a i ariance or special permit was required the Toi,n 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 RegistrN of Deeds. One copy and proof'
of recording must be submitted H ith the building application
Doc:INSPECHONAL SEIRN ff ES DF.P.IRTMENT:HPrORN105
L } -
Location
No. / Date L�
NORTH TOWN OF NORTH ANDOVER
Certificate of Occupancy $
sswcMust�A Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # _
19731
Building Inspector
NORTH
Town of t We. 4Andover
Cs r.. .r to
No. 3 /
dover, Mass.,LAKE
O COCKIC EWICK
x,95 RATED PPa`y�y
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT.......... ...Ql.%....... elao........................................................................................... Foundation
has permission to erect........................................ buildings on...140.9%.......L4. ... ........V ............................. Rough
to be occupied as .&%.00!*t4.....�:�.�... 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
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
b�Z PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTR " S TS Rough
......... Service
.. .. .. .. . .. . .....................
BUILDIN R
Final
Occupancy Permit Required to OcLupy 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.
16
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Name.and lie.gistration No.of any Salesperson who solicited or neitubated this contract:
Sig C9
gncd rhi,� 2—j day of �.P—fm—
20
,115;i ti'it in dw pusul=t)],--
Witness
J2- r�GC(
,i�gnatur
"natul
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The Commonwealth of Massachusetts
Department of Fire Services
Office of the State Fire Marshal
P.O.Box 1025 State Road,Stow,MA 01775
PERMIT Date:_fv'� v 6
North Andover Permit No Dig Safe Num er
(City of Town) (If Applicable)
In accordance with the provisions of M.G.L.1 4 8 Chapter 10 as provided in section 5 7 7 CMR 34 Start Date
This Permit is granted to: i 1;
Full name of person,Firm or Corporation
Pernissionto locate dumpster for construction/renovation/demolition of building.
Comments: dumpster must be . 25 ' from structure if unable to place with required
Restrictions:clearance `dumpster must be covered with plywo.
od or tarp end of work day
at
(Give location byrstreet and no.,or describe in such manner as toZ��41
d adequate identification of location)
Fee Paid$ 50.00 � Fire Chief
This Permit will expire/130 Signature of offical granting pen-nit) 0ffical granting pemut (Title)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
`{ www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual): V'►
Address:
City/State/Zip: ak_a_4L1d WC. o cf,7.2-Phone#: Q�y'��s � Y` f>
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.g_I am a sole proprietor or partner- listed on the attached sheet. t ® 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 11.0 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.❑ Other
comp. insurance required.]
*Any applicant that checks box#I must also till 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 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.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 insurance co e verification.
I do hereby cer ' nder t pains nd pena ies of perjury that the information provided above is true and correct.
Si nature: Date:
Phone#: f1
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#:
A 1-4 W*6-1"'w-Ilk Arlil-7111kTIN'
/A%-v K FA741VIVAN I
de 20 11, ring,of Sent- 06 1 11 nt--
Kpvin D.nip.K arU
Trim Cnona
thu Owiler-
Wllum�elh,that the UonLraclor and the Uwrier lot the cunsideralior<n-;YXK,,.-'a,.,luflows:
Article L Scope of the Work
11"c' CGntraetlir shall all '-'I brig all i lil- ;hown o •"ic-ra'Orgs �n"Unrw
described in the Specifications entitled Exhibit A.as annexed hereto its it pertains to work to be performed on property al
102 Lacy Si-Nonh Ando-er Ma
Mimic,I'Time of Uctimpit'llou
The wurlk!v be perF=ed under i-hi il Curl ft,--!sh A I be corninenced up urr beff,.Lre 1011 r 21ji 06 il"d hnffl Ill.-
sub:;Itanfiadly un or thvJOrr,1711 2111 06 i-,of thci�:isoncc,The lu-11owing ccmisfilmto'.;
stliv;mniiul tl-'work pursuant.it t illis fir'll—vil
Cofiifm.Lof iu 5uppiy A-1: il,piod by
homeowner ai their expPrinp. Grlrlitarinr wilt fiqLsh aii wm.to the.extem timt the pi
AtvSnhnwin dpiail einy omerwor{:wititte di!-,nmccd and
cr'st -d pilar to(Joinp any additional work outside of mritiact.
The 0%vvi,-shall pav the Contincinr for the inateetal and labor to lic ri-crEnrTIc"t unlcf t!!L Cotlr!--rt thc suln of
tmv six thousand T I nMf.ir'mn".r.::1Z-:bF;.UUu.uu
D'oduciiUnh Pill twalli to audluLiI.Cd ullallg'r Ui Litt.
Avzi'A.e 4-R.
p
lbt-CoWract lInce sh�r!J ba uniiat in the,TjL-jnnFr)bJli-vvir.-:
20,000 due uponmirbN praicci
25000 due when al!tmmino motina:siding and tic ins to
i 1AV!OLI up�•i,:t! 'A-.;:.--
Any alteration or dc-,vkinJun ft--un mh; ant-R7, Oval intris, inchidim-� Din out finiited to any such aitevaticin, ui
&viaden addi,kin-d material 211djor Inbor 00sts'WH! hC LYLC-17m'd C-Oy"Ann wrinjon order for s'nlnc''Riglicd by
Owns.-and Contractor.and if there,is,any charge,ivir stt,,n alteration or dmarimm the addihonai Charge.Wilt n:added io the
01114W.W."
U Puylilelli is lit'!Illait,wholl due"cuui!eciu.Illay muspelld walk Lill flit'-Uh in.61 hush little as ad payminuih duehave
been inacic.A failum-to P.iA-r paynienm fora puicrd in execs of 2 days from the line date,of the
paymefit Shaft be dee=d L T"le-rial breach o!(hL ounitract.
In 1.01.16rin,T.n,-TOHOWMA grnrr i nMVKlnM rf1ply-
L All wL-trk AtiLil he ce-wiett!4 va ,wurkn'�"--!Ake M-unngl�'qd-i"(:om-pliatnet.Witb all 1 timiding and�.'(hvr
uppliu;,lillu laws-
The oofmu(cirshall himish a elan and scale,drawinry showing the shade,s±ir dimensi(ins,;Inc!COnM"117fion and
zilmilum,ii sprulicafil.ruh lul ituirte 1111pluvrillellis, a drsulipiwir uf fl M,Wutk to be dullu aini Lir"ctividull ul
materials to he used and the ccaliviiient to he used or instilllcdt and the aeref-A coiWderntinn for the work.
3. 1,C.int"extent-ec,"ireA. law a!,.work shah be perlorrrie-d y oh-ul",licensed and Iy law to
ocirforn)said work-
k"T may at ifs q
_..t... .. ..Conahll
hullv pay sriid Suh-cvintrlictor and in all toStsnces remain req)ansNC tilt,the proper Completion Rt this Convict-
-actor!;hal! Ovvn-r apprupriate,rete......., or w'aive.!; ofLenfi�r;.-,! worl•. ptWlw=t%-' 0;illateitil';
pmvidon nt the time the next periodic pnyn)eotChrili he due"
(i AH ch�uvgt�urders!Ia-ll Le m c.=od both by(.Unner and wnd�baffl b�M_-'Uq'--nndL-j
and hoer inc flarr of the ConTIMct-
7- Vu'nlr�--iur W-urnmts A is adeqwaitt5ly insultd k'r ininry f,i it,—l" Oht'rs iricilirring, LQss Qr injury.as a
R (-.--rnntr shall at its nwn nxnnn,e nlitnin MI orirmim fnr th�.wnrk-to Jv,.w.rfornincl
Y. Culiftactut tlgltm-'1 iu ttuiuvz all dubtil,wid leave
me PlellaNct,ul
10- in the event Chvncr Oinil fail to Y na nnv n iodic or instillment p yiI umn:due hereunder,Contractor may M'),.c
� par n�
wurk-witehuli'bread"Pending payrkerii-w resolution of any disvi,fte.
[I. All rikont,cs henvocirir shall be raqolverl liv Nindine al-hitriltion in nocorrinnee with tube of the American
L
12. Con". not he linhIc few ativ&Iav due to circumstalacc,bevoll'i irS CrintAll inclurliflj%5GYkCS,".wla(tv or
- gzrw7u!;:-n;%vai labiLty Wr
ri. 12 months foilowing completion.
Article 6.Additionai Tpxin;
1
�,� Coamn��mu ✓
License or registration vald for individul use
Board of Building Regulations and Standards before the expiration d te! If found return to only
HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards
) Registration, 152740 One Ashburton Place Rm 1301
Expiration: 9/2612008
Boston,Ma.02108
Type: Individual
KEVIN DANIELS
KEVIN DANIELS
Not valid without signature
84 BENNINGI"ON ST
HAVERHILL,MA 01832
Deputy Administrator
� rrO9t10)tP'nuK'-2ff�t O�.:Y%lUdillCc�CldC�..'.
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 057485
Birthdate: 1111411970
Expires: 1111412007 Tr.no: 9869.0
R Restricted: 00
KEVIN E DANIELS G
84 BENNINGTOA
HAVERHILL, 01832 Commissloner