HomeMy WebLinkAboutBuilding Permit #476 - 122 FOREST STREET 1/8/2010 TOWN OF NORTH ANDOVER
/' APPLICATION FOR PLAN EXAMINATION
.Permit NO: (r Date Received
Date Issued: 4-` U
IMPORTANT: Applicant must complete all items on this page
LOCATION 122 .F of&4 S f Aidy 'r
PROPERTY OWNER (-P S Print 1-7L
Print T
MAP N01& PARCEL: ZONING DISTRICT: Historic District yes no
!Machine Shop Village yes 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, replacement ✓ Assessory Bldg Others:
Demolition Other
Septic Well floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
�fTS �I ��rt( 1G 90� over
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: -- Dsc 4cro Phone: (17 4) 2V8) - 6 � )
Address: 10 C /, e4�e Ok kvc
Supervisor's Construction License: qct X31 a Exp. Date:
Home Improvement License: /6 03- V Exp. Date: T/'16/Zot o
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASE ON$125.00 PER S.F.
J c�
Total Project Cost: $ FEE:
L1g66-- a
Check No.: 5 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the g aranty fund
-z ✓�
`s-
Signature of Agent/Owner (SDe,;,o Signature of contractor ,
Location
No. Date
�aRTM TOWN OF NORTH ANDOVER
3: � •SOL
~ s
' Certificate of Occupancy $
Its CMus Building/Frame Permit Fee $
�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22" `/ ani
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
K
HEALTH Reviewed on Signature
T -
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 no
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
1
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
❑ 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: Doc.Building Permit Revised 2008
NORTH
To _ Andover
o _
No. ------ .....
=-� -
ti _- dower, Mass.,
O� COCMIC ELA KEMCK A.
S RC
ATED Jk? SC
�i BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT....... ,.S............. /c.... .:..... ... ...f..� . .
Foundation
has permission to erect........................................ buildings on ...f. 2........ . °. .......`5............................. Rough
himn
to be occupied as..... . . .I C ey
provided that the person acc ting 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
�-- PERMIT EXPIRES IN 6 M THS
J ELECTRICAL INSPECTOR
UNLESS CONS*(c
TI N S Rough
..... Service
......................................................................................................
BUILDING INSPECTOR
D Final
Occupancy Permit Required t0 Oca4py Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
4 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.
Dec 21 09 11:17a Valued Gateway ClientMIC 781-595-4044 p.6 �
gewEngl oof.com q s
. ".T 6� LIFETIME ROOFING SYSTEMS
Agreement Between �Q 26?INTERLOCK INDUSTRIES, INC. � � ��� .-C/
' 25 Walpole Park South. Walpole, MA 02081
M usetts Home Improvement Contractor Registration#139640
Customer Service: 1-866-588-ROOF(7663)
Name ll/f1�r/�t/t (''Buyer") Date
Job Address �/Z _ - ("Premises")
City/Town �'• �(/' /� 2> Zip Code Qe��1;,-�—
Mailing
Address 9i<� �_ E-Mail
Work Phone ( ) Home Phone
The Buyer is the registered owner of the Premises and hereby contracts with Interlock Industries, Inc. (the "Contractor") authorizing the
Contractor to furnish all necessary materials and labor to install, construct and place the improvements accordin he following
specifications, terms and conditions(the"Specifications")at the Premises:
(cirdeOne!: SHINGLE SLAT
SPECIFICATIONS Color:
YES NO ROOFING MATERIAL YES NO OWNER WILL -
✓ Supply adequate electrical power.
Low Slope Roofing-Color:
_ Flash Skylights - # ��T ✓ Be responsible for all rot damage and other necessary
Flash Vents roof repairs. (ie)roof decking, fascia boards,etc.
dedayment -.Pi's Roof repair work will be undertaken by Interlock
ow Guards Industries, Inc. at a cost to be mutually agreed upon in
Ridge Vent Se21X advance between the patties.
OF REMOVAL LOCATION OF SHIPMENT:
—_� p existing roof(ciroe ore):� 2 3 layers
Pply V2"plywood C./ START DATE*: �ac�G
Haul away roof debris and pay refuse fees. SUBSTANTIAL C M LETION DATE*:
Note location for disposal bin: *Start and completion dates are weather dependent and subject to
change
CL vc c�L
THIS CONTRACT INCLUDES:
LIFETIME LIMITED WARRANTY,TRANSFERABLE,NON-PRORATED FOR MATERIALS MANUFACTURED BY INTERLOCK ROOFING LTD.
PLUS 10-YEAR L MITED LABOR WARRANTY PROVIDED BY INTERLOCK INDUSTRIES,INC.
LIFETIME LIMITED MATERIAL WARRANTY FOR IB ROOFING,PROVIDED BY IB ROOFING SYSTEMS
Financing Requested Yes o Sales Price $ ��� a
Sales Tax $
Interest Rate: 4e.9112, Sub-Total $ O.;1
Down Payment(not to exceed 113
of total contract price) $ C> A
Payment not to exceed$ Total Balance on Completion $ Z_Y! toa
O.A.C. (on approved credit)
MAKE ALL CHECKS PAYABLE TO: INTERLOCK INDUSTRIES, INC.
All Contractors and subcontractors must be registered by the director of Consumer Affairs and Business Regulation and any inquiries about
a contractor and subcontractor relating to a registration should be directed to the director.
IN WITNESS WHEREOF, the Buyer and Contractor have hereunto signed tInmeshis day ofd -20Do Not Signact If Ther Are Any Blank Spaces
INTERLOCK INDUSTRIES, IN
Sign
Per: aeL Buyer
i
(P/itnameLIII65 ���G}/ hY[�r Signed
Unit 7,15 Waip6Kr'P-a'rVSouth Buyer
Walpole, MA 02081 Witness ' anim
HIC. # 139640 Print Name �)
d -Q This Agreement is a binding agreement and contract between the parties. This is not a credit transaction and will not be financed by the Contractor. If
financing is required, the Buyer hereby authorizes the Contractor to obtain credit information and the Buyer hereby agrees to provide and sign all necessary
documents required by any third party financial institution to complete the fnancing,Immediately on request. The Buyer hereby acknowledges receipt of this
Agreement. See reverse of Agreement for additional terms and conditions.
CRSC MA 0909 All surplus material is the property of the Contractor.
pA �� �O � J
7 WORK ORDER N
CD
CUSTOMER NAME: �'yiV C C , ,� _ /��/10, AMOUNT TO BE COLLECTED ON COMPLETION: $
INSTALLATION ADDRESS: � � - S TELEPHONE (RES.) o,
(BUS.)�
CITY/STATE: �• .tib o ZIP CODE e-> ��
CHECK LIST
m
PICTURES ;t—YES ❑ NO G)
aD
Ll Fascia Board
❑Fascia Cover Color
Q Roof Type ` �� i
Roof Color
b,.11 Pitch of hoof '5—/ob
s 0 Present Roof C
❑No. of Layers
0 Air Vents
r
Ridge Vents
U No. of Skylights -4"` C
13 No. of Chimneys �
5
0 Ice&Water �6,
QSnow Guards y
❑Valley Footage V.
0 Endwali Footage
❑.Height 1-2-3 Storey
Sign for Job ' ,
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
I Registration: 160383
Expiration: 7/16/2010
Type: Private Corporation 270872
ACE ROOFING INC.
JOSE ACERO
10 CLAUDETTE DR#8
MILFORD, MA 01757
Administrator
dtuss.achuWtts- De-teart.
nac.nt eiF.i'trittic S tide
Board of Buildi'h Regulations ancLS>undaetls
ervisor Spec
Construction Supialty License
Licerise: CS SL 99810
Restricted to: RFI.
JOSE ACERO r`
10 CLAUDETTE DRIVE#8 ;
MILFORD, MA 01757 -
Expiration: 6117/2012 : i
Tr#: 99810
(unngi„inner- ---
Ac 's CERTIFICATE OF LIABILITY INSURANCE °ArE`MJDON-)
r-�CER 5/20/09
��`�`` THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
H & K Ins. Agency, Inc. ONLY AI4D CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 344 HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
182 Main Street ALTER THE COVERAGE AFFORDED BY THE POL161ES BELOW.
Watertown, MA 02472 LIN�S�U��RWRA:-
RERS AFFORDING COVERAGE NAIC 0
IIs IJRm •-------..__... ._: . ..._
Penn- erioa ins Co
Ace Roofing Inaa e; Libert Mutual
C/o Jose Moises EftG:
10 Claudette Drive Apt #B _.__ .....::.::..._....
INSURER D
Milfor , MA 01757 _
INSURER E;
COVERAGE$
THE POLICIESOI:INSURANCE USTE)BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWTTHSTANDIN3
ANY REQUIREMENT,TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WH*i T141$CERTFICATE 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.
ANCIN I D1SIS`. Y EFFE VE
TA Tyr P or INMIR
POLIkY NUMBER T LIMITS
GENFRAL LIABILITY raa+OCCURRENCE_ 0 0 000
A X COMNERCIALGENERALLIABIUTY SUB1D21666 5/12/09 5/12/10 . s O-9 000
CLAMS MODE FX]OCCUR MED EW jArty are aam S 5,000
PERSOFAL9 ADVINJURY i 1 000 000
- GENERAL AGGREGATE s 2.0 0 000
DERLAGOREGATELMITAPPLIESPER PRODUCTS-OOM?lOPAGG S OOO OO
Q_:
POLICY PR1-1
I.00
AUTOMOBILE LIABILITY
ANYAUTO COWBN£DSINGLE LIMIT '
(E o acdd�rt)
ALL O WNED AUTOS
BODILY INJURY =
SCHEDULED AUTOS (Purpanon)
HIRED AUTOS y�
BODILYINJURY S
NON-OWNED AUTOS (P�r>tOcitlOnt)
PROPERTY OAMAGF t
er aoddert)
GARAGE LKABILITY
AUTO ONLY-EAACClOENTANYAUTO 6
OTHER THAN EA ACC =
AUTO ONLY: AGG I
EXCESS I UNBRF.LLA L1AMUIY EACH OCCURRENCE _
OCCUR _CLAIMS MADE AGGREGATE
s
DEDUCTIBLE
REFFNi
n N
WORKERS COMPENSATION WC STAru OTH-
AND EMPLOYERS LIABILITY YIN }(
B AWPR°PRIIETORPARTNEWE>ECutivE TO BE ISSUED BY CO 5/15/09 5/15/10 Ek PCHACOCENT _ =y 100 000
OFTERkEMNREXCLUIJED? J
R•�aeeUe��eNln6or EL.DISEASE-EAEWLoYE P 100,000
AL PROV IoNsednw
OTHER E.L.MWE-PO ICYVMrT s 500,000
DESCRIPTION OF OPERATWNB I LOCATIONS 1 V EHICLES I EX CLUSIONS ADDED BY ENDORS EMOrr I SPECIAL PROVISION&
The original workers compensation certificate will be issued by the carrier,
Fax:508-660-6928
CERTIFICATE HOLDER CANCELLATION
$Ht)ULD ANY OFTIEABOVE DESCRIBED POLICIES BECANCELLEDBEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS Wf4TT£N
Interlock Industries NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
25 Walpole Park south IMPOSE NO OBLIGATION O L.ITY THE INSURER,ITS AGENT&OR
Walpole, MA 02081 REPRESENTATIVES.
Faean
UTHORIZED REPRESENTATIVE
Boon
ACORD 26(1009/01) ®1988 ACORD CORP TlOhl. AB r resw%ed.
The ACORD name and logo are registered marks of ADIM
J
The Commonwealth of Massachusetts
zX Department oflndustrial Accidents
Office ofInvestigations
600 Washipcgton Street
Boston, A"-02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ��C t 1C�GGI� 1yS 4l( j &C
Address: 017;1 1, 05 Lvdil the folk Soy�
City/State/Zip: Ulcd Bole o-11 Phone#: (Sad' )
Are you an employer? Check the appropriate box: Type of project(required):
I.Q 1 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 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.F] Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.[D'Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp.insurance required.].
].
*:ny a"yplicaat that checks pox#;a:u;�also 811 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.
1contractors that check this box must attached� an additional sheet showing the name of the sub-contractors and their workers' Y
comp.policy information.
I am an employer that is providing workerscompensation 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 coverage verification.
I do hereby cerd un er the pains and penalties of perjury that the information provided above is true and correct
Si ature: gip!O
/ Date:
Phone#: �5� 66 0 -- L' 3 .
Official use only. Do not write in this area,to be completed by city or town offwiaL
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, of 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 Iocal Iicensing 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 anddate 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 permittlicense 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 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 021.11.
Tel. 4 617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
wm-A,.mass.govfdia