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Home My WebLink AboutBuilding Permit #401 - 120 BRENTWOOD CIRCLE 11/15/2006 TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXAMINATION ot<t�•' •;'�o o - Permit NO: 6 Date Received -/ * P, <OCMKMrK•V Date Issued: S'd �1SSAGHU`''��9 IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER_ d(j4, K- � � �1 ?n-41-14 L / Print MAP NO.: !� PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residenti Non- Residential ❑New Buildinge family ❑Addition ❑ Two or more family ❑ Industrial ❑ Alte 'on No. of units: P-iZe-pair, replacement ❑ Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving(relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION.OF WORK TO BE PREFORMED S%� p c-i,,-- PLC ax)o Identification Please Type or Print Clearly) OWNER: Name: (,A Lk) t d-aA S -c t eA w4t,)s Phone: (P 52 :S� Address: 0 CONTRACTOR Name: ,� P �1S Phone (9 f/? G 3 r� Address: � .� Ce A-,' Supervisor's Construction License: / ' '� 7 S (0 Exp. Date: V Home Improvement License: z Exp. Date: U ARCHITECT/ENGINEER ame: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMAT D OST BASED ON$125.00 PER S.F. Total Project Cost :$ 1Z 0o v " `" _FEE:$ Check No.: 0) Receipt No.: / �d Page 1 of 4 I Location No. Date r HpRTN TOWN OF NORTH ANDOVER - 04�..w ,•,tip L R F S I certificate of Occupancy $ i 'ss,cMusE`� Building/Frame Permit Fee $ Foundation Permit Fee $ l Other Permit Fee $ TOTAL $ 41 Check # ©� I� 1 9`&07 wading inspector Y TYPE OF SEWERAGE DISPOSAL Public Sewer F1Tanning/Massage/Body Art ❑ Swimming Pools 11 Well ElTobacco Sales E] Food Packaging/Sales ❑ Permanent Dumpster on Site El (septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the gyaranty fund Signature of Agent/Owner Signature of contracto �-- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 FIRE DEPARTMENT - Temp Dumpster o it 1' MV no Fire Department signature/date 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 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 Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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:BPFORM05 Page 4 of 4 F NORTH Town of t _ 4Andover No. 0 - �` = dover, Mass., ISOLA COCMICMEWICK y 7� RATED C2 `s BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THATw� �/'� C�W�!Ir.......... ......... .. ................ .........�................. Foundation ..... Ver.:••............. ......... has permission to erect.................................. ..... buildings o ...... ........................................................ � Rough to be occupied as.... t Chimney 4�...... ............ ... . . ................................................................. ................... .... .. provided that the person accepting this permit shall in ev respect conform to the terms of theapplication 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 �1�q- PERMIT EXPIRES IN 6 M THS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCT I N Rough �-- CTOR..... Service BUILDFinal Occupancy Permit Required to Oca tpy 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. Bumex Street No. SEE REVERSE SIDE Smoke Det. Page No. of Pages Tom DeFusco 23 Dutton Road Pelham, NH 03076 Home Improvement Reg. # 117756 Tel 603-635-3017 Constr. Lic. #071037 Fax 603-635-3751 PROPOSAL SUBMITTED TO PHONE DATE tSTATE JOB NAME C� -o ) 'z AND ZIP CODE n JOB LOCATION J ARC TECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: .............................._......... ..........................................._..............._..................................................:..._:........................................................................................................................................................................................................._......................................................................_...._..................._......._.................... ..._..........._............................. ......... .... ..... ........ ............... �f.T.�....i .. ...............................�.._. ........................ .........`#- ...1................._s......._ _................................................. /1 Uve/ G .H ,��' J% . . .. %mss L j .....................................f ... .......4 ....................-4 ..................... ... ....... ...Q..(J...................................................................... ...._N/... ... ............ ..._._........................ ..................._........... , - } ..................................... �J. ..c �......._........... ......_.....cam M_ _ f_.�.............._�s1,�,. :._.).._.__.............................................. ..... ues n ............ 1 ,- s .... lw�.......... _ ._.._..................................... ......... ........ .. .... .. ... ....................................._.................................._........... . orl OIL , ........................................f e...................Q.............................. e ..c�r, J4 �....v.......:..:.1..................................................................................1 .....1�......1 ` ,_..._....:......................_ ._..._.._.._.Cr.if�U............................................. P 11raygSE hereby to furnish material and labor 1.�cordanhe above specifications, for the sum of: i. ~dollars ($ ay m nt to a made as follows: _ cc ti 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 above Signature specifications 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, Note:This proposal may be accidents or delays beyond our control. Owner to carry fire,tornado and other necessary withdrawn by us if not accepted within days. insurance. Our workers are fully covered by Workmen's Compensation Insurance. �Xrpyfaurr III FropQSal—The above prices,specifications Signature and conditions are satisfactory and hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature Bee+►xti.ns and Standards Board of Building F--..r ,ONT,ZACT0 HOMEIMPROVEM Reflistration ,,, g--t ation 1 11512006 ' Tj►pe DBA L CONY TOM DEFUSCO'•GENERA l Qfl6 �l DEFUSCO x 4—f 23 DUTTON RD pdmm+stralor-"' PELHAM,NH 030'6 -- -- – �le �omimauuea�i a�✓�aao�/i.,�ae�a a BOARD OF BUILDING REGULATIONS License:,,CONSTRUCTION SUPERVISOR ` Numbet9.GS 071037 Birthdate *06/18/1950 Expires;�06i18/ 007 Tr.no: 11773 Restricted;€00 THOMAS A DEFl�SCO:' 23 DUTTON ROAD PELHAM, NH 03076 Commissioner SEP.28.2006 09:33 19184590488 WILSONINS #3228 P.002 /002 SORA CERTIFICATE OF LIABILITY INSURANCE 09/28/2006 ►kooctcRrM (979)4S9-7744 FAX 78 4S9-0488 THIS CERTIFICATE 19 ISSUED AS A MAIM Of INFORMATION Wilson insuranceTriC. ONLY AND CONFERS NO.RX TS UPON THE CERTIFICATE AgencY HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 6 Courthouse LaftO Suite 14 ALTER THE COVERAftAFFORDED BY THE POLIC ES.BEL Chelmsford MA 01824 INSURERS AFFORDING CQVERA6E NAIL# INsumD Tam Defusco dba Tota DeFusco Ceneral INSUrOZA. Scottsdale insurance• -�~+ _ .,_ Contracting UFSURERe: Liberty Nutual Insurance _ 7 Austin Street iNSLIRfRc: __ - 14etMm 14A 01844 uISu+ttH t: CONMRAM THE POLICLES OF INSURANCE LISTED BELOW HAVE BEEN LSSLIM70 THE INSURED NAMED ABOVE FQRTHE POLICY PCRIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONiDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WW.H THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESMDED HEftiN IS SUBJECT TO ALL THE TERmS.EXCLUSIONS AND CONDfflONS OF SUCH POLICIES.AGGREGATE UMJTS SHOWN MAY HAVE BEENREDUCED BY PAID CLAIMS. MM�t •- TYtEOTOM'URANCE POLICYNUMBER �TECTI1rE PMzYE70t6iAilON LIMR$ eaffiQu LIABILITY CLS1289326 03/03/2006 08/03/2007 EACH OCCURRCNC.0 s 1 X000 j 0001 X cau"�IcaAtcl�rornlllnmlrry DAMMMTOm�m a 50,40 maw"Acle ®(AN M MCO CXP(My onn Ppcan) $ S.000 APMB SONA1 A ADV INJURY s 1 000,0 GFNFRA)AGGREGAT t $ Z ono, GFM AGORFOATF 11MR ADPL s PER: MET!-COMPIOP AGG s 1,000.00 X r�vLlcw LOC AUT090GILE UAWLOY (gni)NGLE LIMB S A~0 _ ALL UWT7t3)AUTOS AOISILY IM,IUpV s I', W.=..DIAF.D AUTOS HIRW AUTITS BODILY IMLIRY i (Per atwldent) UONw WQPED AUTOS PROPERTY UAMAGt $ . (►'erecoffit) MABIUn, AUTO ONLY-EA ACCIDENT $ FAAC(: $ ER ANY AUIO ZTHOONTLYN AUG 3 CACiIocclw== S 1)CCtlR n Cmus UADC A pT f;A1ti S LWOUCTIe1- RtTENWP► I+ $ WQPJWtiS0NIPS SATOMAND lfn-315338466-0I5 I0/1812005 10/18/2006 sTA o - to1016MtLIA9WT4' E.L.CMIIACCIDEPTT y 100,00 I Arty vTiorxilerorvPArmaeroexrctrl'Ivl: e OFFICCRIMEMDCR IDMLLIOM? E.L.olsBARE•SA a uPLrnF s W0,00 IrvesdeeWbe ower t l_utStASt-I+OLrCY LNUR 1 E 500,00 I scul,PRrnnswNl:ltwrnv ord:R � i i 0lSCRIlTIDN OF OPpG71QM81 I„QCA7IWIfi/VtlXq.US10N8 ALIQE�D 6Y END0R8B#I�MTl SPCCMAt =or information purposes for proof of insurance. i CERTIFICM-HCILQlFR CANCELLATION i i i SHOULD ANY OF THE ABOVE DEAD POLICIES Be CANCELLED BEFORE TME � i OWAATIpM HATE 7HEREOF,THE ISWMG INSURE WILL 6NOMOR TO MAIL 0 aAYS WNTM W OV&S TO THC CEfNMCATA HOLD NAMea TO T HE LEFT, i i SLIT FAILURE TO MAIL SUCH NOTICE SMALL 11AF03f PIOOBLIGATION OR OF ANY IOND UPONTHE MtWftkT8PQVTS ATIVES. / f Sample AUn1ORlti M REPRFaENTA10ark N. l v ACORD 23(200UM81 ®ACORD CORPQRATiOjY9888 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 Legibly Name(Business/Organization/Individual): 732j M R)e j7u 5 C o Address: ,:;;,) 1 D v Ti 6,J D=4 City/State/Zip: a-UL 4 h Jr Phone#: 0 ', rr 3 Q Are you an employer?Check the appropriate box: Type of project(required): L❑ I 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. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in arty capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.0 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.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other *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 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. r7' Insurance Company Name: Pj e U Policy#or Self-ins. Lic.#: C�>tr- „3/3-3 3 ?, /_/ Q J Expiration Date: ` t Job Site Address: [ 2—o f C l Wit_ City/State/Zi . 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: