HomeMy WebLinkAboutBuilding Permit #540 - 12 Heath Road 5/24/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �! "
Date Issued:
IMPORTANT:
Date Received
must complete all items on this
LOCATION 12, dr=h:7!4 • i ►Qv:
Print -
v Stere.. '6t ryO
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Villaqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
✓One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair,epiac
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
OW -20.0
Identification Please Type or Print Clearly)
OWNER: Name:n G F AILEX Phone:
Address:
CONTRACTOR ' • ` '
Supervisor's Construction License: Exp. Date:
Home Improvement License: 16 Y&a Z Exp. Date: 7f/'f f a8
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: $ ,S--8' SO FEE: $ -71
Check No.: ,) U.79 Receipt No.: 0?/0 / a—
NOTE: Persons contracting with unregistered contractors do not have access -to the guaranty fund
Sig to rn uu a 6f 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
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 Driveway Permit
Located at 384 Osgood Street
v
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at 124° Main Street
Fire Department signature/date
COMMENT
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 - Date
Doc.Building Permit Revised 2007
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)
❑ Mass check Energy Compliance Report (If Applicable)
❑ 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 (If Applicable)
❑ 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
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
21 0a1 �-
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LocationNo..54Date
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Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 104569
Expiration: r7/14/2008
Type. 'Private Corporation
DAVID CAS'rRICONE ROOFING; SIDING &
David Castricone
200 SUTTON ST SUITE.226••�-
NORTH. ANDOVER, MA 01845 Deputy Administrat:n.
4
ORD,., CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
9/25%2007
CER Phone: 508-651-7700 Fax . 508-653-8099 THIS CERTIFICATE IS ISSUED AS A MATTER, OF INFORMATION
stern Insurance Group LLC -Commercial Lines ONLY AND CONFERS NO RIGHTS UPON 'THE CERTIFICATE
33 West Central Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
atick MA 01760
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURERA:Citation Insurance 40M
David Cast.ricone Roofing & Siding Inc
200 Sutton St INsuRERB:The Insurance Co of State FA
Suite 226 INSURERC:
North Andover MA 01845 INSURER D:
INSURER E:
CnVERaGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOP. THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR'OTHER DOCUMENT WITH RESPECT TO.WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR
ADD'
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
EACHOCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE F7 OCCUR
DAMAGETO
PREMISES EaoZenwa $
MED EXP (Any onePerson) $
PERSONAL a ADV INJURY $
GENERAL AGGREGATE $
GEN'LAGGREGATE LIMITAPPLIESPER:
PRODUCTS -COMP/OPAGG $
POLICY JEC LOC
A
AUTOMOBILE
LIABILITY
ANYAUTO
07MMBDTNKT
$/1/2007
8/1/200$
COMBINED SINGLE LIMIT $
(Ea accddenp
ALL OWNEDAUTOS
X
SCHEDULEDAUTOS
BODILY INJURY
(Per Person) $ 250000
}{
HIREDAUTOS
X
NONd7WNEDAUT09
BODILY INJURY
(Peraodderd) $ 500000
PROPERTYDAMAGE
(Peraocldenq $100000
GAR AGE LIABILITY
AUTO ONLY -EA ACCIDENT $
OTHER THAN EA ACC $
ANYAUTO
1
AUTOONLY: AGG $
EXCESSIUMBRELLALIABILITY
OCCUR CLAIMS MADE
EACHOCCURRENCE $
AGGREGATE $
$
DEDUCTIBLE
$
RETENTION $
B
WORKERS COMPENSATION AND
EMPLOYE RS' LIABILITY
WC72222389/23/2007
9/23/200$
X WCY AT OTH-
ER
E.L.EACHACCIDENT $ 100000
ANYPROPRIETOR/PARTNERIEXECUTIVE
11 yes /MEMBER EXCLUDED?
II yes describe wider
SPECIAL PROVISIONS below
E.L DISEASE - EA EMPLOYEE $100000
E.L DISEASE - POLICY LIMIT $ 5
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
VI..— 1 IV 1\
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORI]EDREPR
ACORD 25 (2001 /nAl
w—VVIIYVVIIrVIIl111VI\ laww
311 -11 -IOW
DAVID CASTRICONE
CASTRICONE ROOFING & SIDING INC.
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 97&370-7314
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below described:
Owner's Name......Y,k..�uvs ....... .c, F. W. ' i ...................................................... T lephone #... r�.b'G..:.:. �� �..` ............
Job Address........ / /..i a .....� ty...c.....a. tlG d' .................. State.....
Specifications:
................................................................................................................................................................................................................
Strip existing shingles....(/�..✓Apply new drip edge to all edges. 131"'a' 9 "
............... ..................................................................................................................................................................................................
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.
,."Apply felt pap��Yj(
...............t/tr...l. Y:
rReroof using _,
........................
�...........................................................1... 14....................................................................................................................................................
ounterflash chimney. -Now vent p}re flashing. gal disposal of all debris.
..................................................lJ r.. }.....................................................................................................................................................
Areas) to be worked on: �//�. —'
.............r...............................� • i•l.1��t:p......G%—!`L'.+Qt,.........� .i.1.,S.2..- n,
......(..�. ru .........J:......... Q.1:'krt.l .<.�........ .8+.r..?............................................................................................
.................. ,. ../.C,.. ...... B.lrA.lk........................................................................ ......................................
.................................................................... Cv�......... �1 ..............
........................................
................................
Roof board replacement if necessary a I, Z) /sheet or�.y `=/foot.
..................................................................................................................................................................�............................................
--�
Two Year Workmanship Warranty (Not Transferable) Manufacturer's Warranty as spec' ad by ,uactut
The contractor agr s to perfomt the work fitip'sh he materials sp .i led above for the SU of $... .4... .. ll...........
�tayable�.......... on .... ,�-,
----
Fa .......... .............. on.................................. �alance payable on completion of job
Owner or Owners am not responsible for Property Damage or Liability while job is to 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). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. 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
agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. 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 of the parties. The undersigned warrant(s) that he is (they are)
the owners(s) of the above mentioned premises and that legal title thereto stands ofrecord in his (their) names(s). There rue no rep rscntations, guaranies or
warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is die 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 is excluded from the Guaranty Fund provisions of MGL c. 142A.
Approximate starting date of work ................................................ Completion date.........................................................
Receipt of a copy of this contact 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 (see -notice of cancellation).
IN WITNESS WHEREOF, the parties have hereunto signed their names this ....� ti./.lz.. day of .,1.�i4i.i.- ...... 20... S p
Accepted:
Signg!!�;;��,........... Owner
Signed............................................................................. Owner
David Castricone, President
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
mpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �I Please Print Legibly
Name(Busuiess/Organization/Individual): IAV 1h C�_&;N R► C O N C , to t� t- l 7J 1 to t o
Address: o 06
S u TTO&S
S TRL _T
— Su I-rE ;J. %L.G
City/State/Zip: N,
Dov -R ,
W-1 A 0 t X45
Phone #: Q Z S (O 9 3 3 4 a 0
Are you an employer? Check the appropriate box:
1. M I am a employer with $ 4. F1 I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. oo repair
13. ❑ Other
*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 -contactors and state whether or not those entities have
employees. If the sub -contractors have employees, they mast provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 7he— , n5y'f ncc. Co of 5+4L VA
Policy # or Self -ins. Lic. #: W C, 1 a ai g � fi 0 Expiration Date: `'} lob, 310 $
Job Site Address:_��f L fib, l+�t/9 City/State/Zip: �/ b if�iQ Wi/j bLB
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 coverage verification.
I do herebyunde"e pains and penalties of perjury that the information provided above is true and correct.
P(k „ _A—
3/J.//0
Phone #:�3-
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 #: