HomeMy WebLinkAboutBuilding Permit #123 - 121 COLGATE DRIVE 8/18/2008 BUILDING PERMIT Of"°pT bgti
TOWN OF NORTH ANDOVER ?Lbf;i�. , _: '.�6 0-
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date Received
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Date Issued: g%'r0�
IMPORTANT: Applicant must complete all items on this page
LOCATION 21 Q Y G'e'l e
Print
PROPERTY OWNER U 1 L
Print v
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteratio No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Tune or Print Clearly)
OWNER: Name:Tkn�4,1 �4 41 Lra Phone: 3Z SZ--')
Address: 1Zl (2o ( &Wr1'1>fU ULA
CONTRACTOR Name:AbVt.4f l 5 Mdp IA.)(, Phone: 7 '- &eS�
Address: () �1"e-(LH 111 �A 0 6" C
Supervisor's Construction Licenser C> Sr ; Exp. Date: t? Zc
Home Improvement'License: 5 Exp. Date:
ARCHITECT/ENGINEER A Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $2 2 FEE: $
Check No.: /36110, Receipt No.: cQ/4/
NOTE: Persons contracting with unregistered contractors do not have access to the ar zty fund
Signature of Agent/Owner `-- Signature of contractor
Location /,,j �b��G�'f �/''
No. Date /--r O
NORTp TOWN OF NORTH ANDOVER
F? ° • OR
i 3
• ; , Certificate of Occupancy $
9
Buildin /Frame Permit Fee $ /? h~
s,+cMust
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
V
Check # /A
r
` ! �� Building Inspector
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
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes Lb
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 2008
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
a Building Permit Application
a,'Workers Comp Affidavit
photo Copy Of H.I.C. And/Or C.S.L. Licenses
o-<opy of Contract
❑ Floor Plan Or Proposed Interior Work
NlR' ❑ 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 DEPARTMENTMFORM07
Revised 2.2008
9 4C ✓fie Vr aminwauaea/l/z o�✓�oae/xc..aelZa
oard of Building Regulations and Standards
Construction Supervisor License
h°s r License: CS 75608
Birthdate: 5/2/1971
Expiration: 5/2/2009 Tr# 17349
Restriction: 00
ROBERT D ARMSTRONG
31 STRATHMORE RD �j:
METHUEN,MA 01844 Commissioner
Board of Building Regulations and Standards
lug HOME IMPROVEMENT CONTRACTOR
Registration: 146855
Expiration: 5/20/2009 Tr# 129560
Type: Private Corporation
MCD, INC.
ROBERT ARMSTRONG
190 HAVERHILL STREET SUITE 1 C:;)-A�
MhTHUEN,MA 01844 Administrator
The Commonwealth of Massachusetts
Department of Industrial Accidents
Tw - Office of Investigations
600 Washington Street
Boston, MA 02111
V www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1'h C D l P�_ .
Address:_1 I& -Rot4�,� 1 UL_
City/State/Zip:Rf 7?Gt&U' . !�- Ol�Zf Phone #: ss-
Are yo n employer?Check the appropriate box: Type of project(required):
1. I am a employer with l 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 emodeling
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] Electrical repairs or additions
required.] officers have exercised their
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#1 must also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this affidavit indicating titey 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.
/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. #: 012;'j Expiration Date:
Job Site Address: F-Lue City/State/Zip:ly 'WD
Attach a copy of the workers' compensa on 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 f r insurance coverage verification.
1 do her c rtify u er ins and penalties of perjury that the information provided abo a is tr andcorrect.
Si nature: Date: 5 e8
Phone#:
Official use only. Do not write in this area,to be completed by city or town gfficial.
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#:
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 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 permit to burn 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. # 617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
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1. SUPPLY AND INSTALL CEDAR IMPRESSION VINYL SIDING TO FRONT OF HOUSE.
COLOR TO BE: r,3.iA V irE_
2. SUPPLY AND INSTALL 4 INCH EXPOSURE ViN SIDING TO REMAINDER OF HOUSE.
COLOR TO BE:
3. SUPPLY AND INSTALL VINYL SOFFIT TO ON SOFFITS AND RAKES. COLOR TO BE:
4.COVER TRIM BOARDS,DOOR CASINGS,WINDOW CASINGS WITH ALUMINUM COIL STOCK.
5. SUPPLY AND INSTALL 2 DOUBLE HUNG ALL VINYL WINDOWS IN BEDROOM
(REPLACEMENTS WITH LOW-E INSULATED GLASS)
6.REUSE EXISTING GUTTERS.
INCLUDED: SIDING: $9400.00
REMOVAL OF WORK RELATED DEBRIS. WINDOWS: $ 550.00
SIDING PERMIT. TOTAL: $9950.00
**OPTIONAL EXTRA TO REMOVE WOOD SIDING AND APPLY HOUSE WRA : $900.00 **
**GARAGE POSTS TO BE DETERMINED**POSSIBLY REPLACE AND PAINT OR WRAP WITH WOOD
COMPLETION TIME: 1-2 WEEKS WEATHER PERMITTING
WE PROPOSE hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of:
Nine Thousand Nine Hundred Fifty and 00/100 Dollars dollars($ 9,950.00).
Payment to be made as follows:
50%DEPOSIT TO ORDER SIDING AND WINDOWS ($4975.00), 25%WHEN WINDOWS ARE COMPLETED($2487.50),
BALANCE WHEN COMPLETED($2487.50)
All material is guaranteed to be as specified. All work to be completed in a professional
manner according to standard practices.Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders,and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes,accidents or kol—'4-/t 'A
delays beyond our control.Owner to carry fire,tornado,and other necessary insurance.Our Note:This proposa ay be
workers are fully covered by Worker's Compensation insurance. withdrawn by us if not accepted within 20 days.
ACCEPTANCE OF PROPOSAL—The above prices,
specifications and conditions are satisfactory and are hereby accepted. You are Signature
authorized to do the work s specified.Payment will be made as outlined above.
ff Signature
Date of Acceptance. (Ok I.
08108/2008 09:53 5067555412THOMAS WOODS INSLPAN PAGE, 01/01
__.__ ... ...vr -1 vvv A IXA QQL YU1
ACORD. CERTIFICATE OF INSURANCE DATE(MMpDDtYY) os-ma8
PRODUCER THIS CERTIFICATE 13 WUED AS A)BATTER OF RtFORWT*N
ONLY AND CONFEK5 NO R UH75 UPON TME CERTIFICATE
THOMAS I WOODS INS AG HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
20 PARK AVE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P()R[)X)ojo COMPANItS AF-FORDING COVERAGE
WORCEST17.&MA 01513
COMPANY
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INSURED COMPANY
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MCD INC
COMPANY
190 HAVBRWLI.STREIT C
MUTIMN,MA 01884 COMPANY
0
COVERAGE
7W ID YO OCATIFY THAT THE POU61:4 9ft hSURANGE L:B I'LL t1hI MHAVE BEEN ISSUED TG''HE INYURBD NAMED Ann FOR THF POLtOY P ERIOD NtHCATEU.NOTIWTHETAACINC
ANY REQUIRKIAWT,TCR16R CCNOIT.ON OC ANY Cw FACT OR OTHtR DCCUVM'W14 RESPECT TO VAMH 7HIS CfRTI CA71 iAAY B6ISSUDD OR M.AT P6RTAAII 74 AtA'lRAClCE
AFPORrtpBYTMPOLIC'�%MCRIOEUIJERE:NISSUB.lECTTOALL INC 724 8,6XCLUSIONBAMOMOnUMorSUCH p0001Fa.EJWfV40" 1AYNAVEgfiE/I.C#&jRA,4
PND CLAM
CO Policy EPF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUkI2AjR DATE(Y11IIT,DOIYY; OATS(IANIDOIYY) LIIXTS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LABILITY PRODUCTS-coupt0P Av0- S
CLAM MADt OCCJR PERSONAL i6 AV.MJURY $
OWNER'S bi CONTRA=TORS PROT, EACHD-_CURFD NCE $
F1Ry DAMAGE(Any mo tire) S
AUTOFAoaaE uAeIuTY MEG.EXPENSE(Any one ps-4n) S
ANYAVTO COMBNED SINGLE 041T $
ALL OWNED AUTOS BODILY INJURY(Pw Person) S
SCHEDULEAUTOS 90DILYINJURY;Per•Aui]eotl S
HIRED AUT0.5 PROPERTY DAMAGE S
NODI.OWNED AUTO@
GARAGE LIABILITY
ANY AUTOS AUl"O ONLY-EA AGGIDEIVT S
OTHER.THAN AUTO ONLY:
EACH ACC DENT $
AGREGATE S
rlcOr-=LIAGIU'FY
UMBRELLA FORM EACH OCCURRENOF q
OTHER THAN UMBRELLA FORM AQCAREGATE q
WORKER'$COMPENSATION ANO
A ESAPOL.YER'9 LIABILITY UB-0 i 1A M950.09 05-07-08 05.07-00 STATUTORY L WITS X
THE PROPMETOW EACH ACCIDENT S 100 600
PARTNERSIEXECUTNE X MCL DISAASE-POLICY MT S 500.000
'JFFICrM AnG: EXCL DISEASR-nACH EMPLOYEE S 100,000
OTHER
DESCRMtt(vA OF rWERAT1CNSiLOCA-110NSN041CLEEJRCS`T171 IMNRMPEC1AL 17M!j
1=RfilUCRUC ANY PMO1R 0MTMCA78IX=I0'IM CERMMAT°HOLDER AFPPJ--MG WOFJMRS COMP CO'VERAOE.
CERTIFICATE HOLONP CANCELLATION
sHOULe ANV OF THE A30YE D ROOD POUCIE91lrr Wg%MLLEDBEFOK T►F
T� r�OWN.ANI70VE>z, GMRAMOX DATE THEREOF.THE fC5UM COMFANY*ILL ENDEAVOR TO NAL 7D
DAYS NRRTEN NC71CF TOTFt c riumcATE HOLw R RAVED TO THE LEFT"BUT
F"_LWE I U MML SkXH NQTI CE SHALL IMP05M Y0 QMCArOk OR V ABILITY OF ANY
1600 OSGOOD ST kin*vaaNT.-Ie comPAAv rr5 AGE N79 OR REP"VENTATltirs.
N.ANDOVER,MA 01845 AWFHORiZED REPRE8ENTATIYE
ACORD 29-0(3183) Qarles J Clark
XAORTH
Town of dover
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No.
C% 7 0 dover, Mass.,—
e 11-1416wo_
C CHICHEWIC
TE D P"? C
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT.............h. �e_ / BUILDING INSPECTOR
. a h�-/,--,C'A/
................................................................................................................................ Foundation
has permission to erect........................................ buildings on .... ...... Rough
to be occupied as.......... _X, Chimney
z/ ..... .................... '�y
4:ZA.. 4C
in Final
provided that the person acce Ing this permit shall in every respect conform to the terms the application on fileI
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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU= TART Rough
............. W �'_.. *****'****...... Service
!7 TART Rough
INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
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.