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HomeMy WebLinkAboutBuilding Permit #780 - 116 MABLIN AVENUE 6/9/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ��SS�cHuSe�iy Pen-nit NO:_7!q1h Date Received: Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION &I Ave PROPERTY WNER 3ckvi Print / Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building )�gzne family ❑' Addition ❑ Two or more family !j Industrial ❑ Alteration No. of units: �2epair, replacement ❑ Assessory Bldg ❑ Commercial /!' Demolition ❑ Moving(relocation) ❑ Other ❑ Others: Foundation only DESCRIPTION OF WORK TO BE PREFORMED a / lv_no Identification Please Type or Print Clearly) OWNER: Name: :Da-vid RI0 �c 4P Phone: � � - As Signat re /Q Address: (D NA �ln �lr/ ,A/�d 12l l-1 CONTRACTOR Name: VI9Bone: �- �Address: UuU inOh (VA Supervisor's Construction License: Exp. Date: Home Improvement License:.. ib 4Elo Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$10.00 PER 41000.00 OF THE TOTAL ESTGNATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ & 5a- to x10.00=FEE:$ _ 6 Check No.: 71d Receipt No.: 19y4'1P__ Pau Iof4 r-- i 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 a Copy of Contract o Floor Plan Or Proposed Interior Work Addition Or Decks I o Building Permit Application ❑ Surveyed Plot Plan o 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' CalculationsPp If Applicable) ( ❑ Mass check Energy Compliance Report (If Applicable) 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 (If Applicable) a Copy of Contract ❑ Mass 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 Dor.INSPECTIONAL SERN ICES DI?P,VYPNII?N'I':I3PfORN105 hae 4 of 4 TYPE OF SEWARGE DISPOSAL — Tanning/Massage/Body Ail '_ Swimming Pools Public Sewer Tobacco Sales F ng,%Sales Well u Permanent Dumpster on Site F- Private(septic tank,etc. V '1 l tMc eter location to 4 project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fhhnd Si mature of Agent/Owner Signature of Contract Ca Plans Submitted Plans Waived ' ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR4PFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM , DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit I ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE,APPROVED, CONSERVATION ❑ ❑ I I COMMENTS f DATE REJECTED DATE APPROVED I ----' HEALTH ❑ ❑ 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 Temp Dumpster on site yes...no__�d Fire Department signature.'date Building Permit Approved and issued by: Pape 2 of 4 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: _ Total square feet of floor area, based on Exterior dimensions. Total land area,sq. ft.: NOTES and DATA—(For department use) II I Pa,_e 3 of-t Doc:INSPECTIONAL SERVICES DEPARTMENTMFO RM05 Crr.,ncd AW.Lm.200b Location mG -`'' No. Date 2.0- 1 D NORTh TOWN OF NORTH ANDOVER Ctr. o yeti O? • -rrOOe " + ; . Certificate of Occupancy $ 41 Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check # 1 94u2 —Building-Inspect45r! F NORTH �9i Town of RAndover No. '7480 zoA dover, Mass., z=- COCHICHEWICK �d�oRAT E D P Pa` -`C, 1v BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT............ er.......... ....... ...... Foundation has permission to erect........................................ buildings on ...141.4......... ....... .. Rough to be occupied as Chimney provided that the person acceptin is permit shall in every respect conform to the terms of the application on file in Final this office, and to the provision 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 TARTS i Rough ...................... ..................................... ................ Service BUILDING ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rou�t�gh No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner E Street No. SEE REVERSE SIDE Smoke Det. DAVID CASTRICONE ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845 7 HILLSIDE ROAD,BOXFORD,MA 01921 In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 978-374-7314 Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to famish all necessary materials,labor and workmanship,to install,construct and place the improvements ac c din t the following specifications,terms and conditions,onpremisesbelo described: l G )G6�—S38 /4?? Owner's Name..... Va .. ..ItU.P4, +2/'...•..•...•......................................Telephone#.....�a.gS.:... ..�.S.l... ....... Job Address...(..[..Sa.... 1.i.►w...J..Lv.e.,.........................City..�k....?�1,-V.R i.................State................ Specifications: .................••.,•............................................. .. w9trip existing shingIe41) Apply new drip edge to all edges. ......................•..•.......................................................................................................•.................................•......•...................... ✓Apply feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. ::...:......... ............•..•......•..........••...•.......•..,. r.,.• ...... ......... -Apply felt paper unde yment. u4nstall ridge vent to e n, ..............l11gf`• a. ....... .. T.-Y........................... ...................... . L � goof using shingles with a _year warranty I.&Ounterfiash chimney. `'l eW vent pipe flashing. legal disposal of all debris. .. ... n ii Area to be worked on: �,.�.. .................................. ....... .........................................•.....................,....,..........•... 111/.......r...a.p....... �. .......�� �.�.�� .�.........................................•...................... ..•PCy.�. �......�F......�. ,... Q��ovc &-p vlsSms& CF Rcni= TI/147V7aV1V# ................................................................................................................................................................................................................... ... .............................•.................................•...•................•.............•....I.•...................................................•........................................•........... ................................................................................................................•............•........................................................................................ One Year Workmanship Warrant Not Transferable Manufacturer's Warr as sp�ecifled by ma facturer Materials and Labor to cost$...d-l.g.Q........ ........ Payable �• 0........on Payable............................. .................... Balance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job is in 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,water stains when roofing shingles have not had adequate time to cure), 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 d agree that,if permitted bylaw,contractor shall be paid by the owner(s)all reasonable costs attorneyfees and expenses,in addition to the amount due and unpaid, P P . that shall be incurred in enforcing the terms and conditions of the contract and/or an lien in connection herewith. Y .. 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. 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: Director,Home Improvement Contractor Registration One Ashburton Place Room 1301,Boston,MA 02108 Tel:617-727-8598 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 shall be excluded from access to the Guarantee Fund7/NL/S'DF%/fG=ESS�s�Gc Approximate starting date of work..................................................................... Completion date............................................................... Receipt of a copy of this contract 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. Owner has three business days to cancel this contract and incur no penalty. !,1 IN WITNESS WHEREOF,the parties have hereunto signed their es this............. .........day oft........_..20,V..U... Accepted: � � Signe ..f..4 .. ...... ..Owner Signed.........................................................................................Owner Per...... ................ ......................................... Representative The Commonwealth of Massachusetts Department of Industrial Accidents M Office of Investigations 600 Washington Street Boston, MA 02111 s�•` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers"-,- Applicant uilders/Contractors/Electricians/Plumbers,Applicant Information Please Print Legibly Name (Business/Organization/Individual): V) Address: t f"tc1 b l t Yl City/State/Zip: d �� ' l NAMPhone #: q 7 g (� S^ 026,sq 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 I employee's(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 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 10.E:1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 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 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 tContracton 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. #: Y V Y Ct0 OO l T 6 OQ I AU D T Expiration Date: Job Site Address: �' t�bll �- City/State/Zip:_��r`�'hQ�°/ 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 tine 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 coverage verification. I do hereby ce ' nder the7ins andpenalties ofperjury that the information provided above is true and correct. Signature: p Date: Phone#: Oficial 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#• and In ructions InformationInst 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 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-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 pemut 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 fax 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 Town of North Andovero� 0ORT11 4Z~�� 16R 'YO Building Department a L 27 Charles Street North Andover,Massachusetts 01845 (978) 688-9545 Fax(978) 688-9542 �� `°"'" ~K• ' �` AcwUS 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 c11, s150a. The debris will be disposed of in/at: H P , Facility location Signature of Applicant 6 G Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector.