HomeMy WebLinkAboutBuilding Permit #443 - 125 LANCASTER ROAD 11/30/2011 i TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: qg Date Received
Date Issued: I /-�g 0'1
IMPORTANT:Applicant must complete all items on this page
LOCATION 1Q Y L/1IJ(2A ST—_R d�� /� vl.✓�juZ,'
P ' t
PROPERTY OWNER M + (�L IezIq Unit#
// Print
MAP NO: PARCEL�lo ZONING DISTRICT: Historic District ye n
Machine Shop Village y s no
100 year-old structure s no
TYPE OF IMPROVEMENT PROPOSED USE
i
Residential Non- Residential
'J ❑ New Building 4�00ne family
I ❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
A'Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition _❑ Other _
ec]Di,...•
! Wafershstrict
(] Water/Sewers'.__ _ _ _ _
DESCRIPTION OF WORK TO BE PERFORMED:
i a
(Identification Please T pe or Print Clearly)
OWNER: Name: M i tj C ,s iCL�/ Phone:
Address: eks1 2E'2
CONTRACTOR Name: dh it ).A O�).�%,44 Phone: �i�>
Address:
a 't1,24 -C�(L�r��fi✓l 1212)
� � Q J`"f �
Supervisor's Construction License: (09 O Exp. Date: '
Home Improvement License: ,31) 05 r? Exp. Date: 1 "I -Z Z
ARCHITECT/ENGINEER Phone:
i
Address: Reg. No.
I FEE SCHEDULE.BULDING PERMIT.,$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 70° C-a FEE: $_
Check No.: kU3 Receipt No.:
NOTE: Persons on acting it unregistered conPna�
d of ha a access to the guaranty fund
, . re of r-,..
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL ti
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
I
CONSERVATION Reviewed on Signature
I '
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
Wafer& 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
' L
I
Dimension
f 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.$10041000 fine
NOTES and DATA-- For department use
Notified for pickup - Date
Doc:.Building Permit Revised 20117une/mi
na ure of contractor ..
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
MOTE: 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
g
VOTE: 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 2008mi
I
i
NORTFI
TO" of Andover
0
No. 411)
- _- --
o , * dover, Mass., f
I� COCHICHEWICK
Ids RATED
7 BOARD OF HEALTH
Food/Kitchen
PEKMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT...........�.. .1k00GOO..................S...........L...... o.
Aw.=v....................................................... ...... Foundation
.�has permission to erect...........:.:.......................... buildings on ....� ........Lexf� ..... ........................................... Rough
to be occupied as... ... .........+�....1. r../�0.... .................... ..
Chimney
' e
provided that the person accepting this permit shall in every res ct conform o the t ms 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 MONTHS• ELECTRICAL INSPECTOR
a
UNLESS CONSTRU O S S Rough
..................... ... ...........................................
...................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Null To Be Done FIRE.DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
- Street No.
SEE REVERSE SIDE Smoke Det.
The Commonwealth ofMassachusetts Print Form _
4= Department of Industrial Accidents
Y s
Office of Investigations
"a y 600 Washington,street
Boston,MA 02111
N www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information AlPlease Print Legibly
Name(Business/Organization/Individual): AUh
Address: 6 Z:. 1-C A< d(�
City/State/Zip: YM/k5 S Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1,2r 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
listed on the attached sheet. 7. El Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. F1Demolition
working for me in any capacity. employees and have workers'comp. E]Building addition
[No workers' comp.insurance comp.insurance�
5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.]
3.F1 I a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions
right of exemption per
myself.[No workers' comp. have
no 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we haave n13,a Other
employees. [No workers'
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation pglicy 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must 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: 0,rM My
Policy#or S elf-ins.Lic. (q (S(2-4-�1 0 Expiration Date:
Job Site address:
//'I /�.1�1L'�l'S'f �Z 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 p to$u 1, Year 500.00 and/or one- imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
p
e violator. Be advised that a co of this statement may be forwarded to the Office of
of u to$250.00 a day against the copy p
Investigations of the DTA for insurance coverage verification.
Ido hereby certify under a pains and penalties of perjury that the information provided above is true and correct.
Si afore: - _Date: . _l t�2 Y/217
't f
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#:
Inf®rma, ti®n 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 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 Commonwean of Massachusetts
Depwt=mt of Ind stdal A.eoido is
Office of Investigations
600 Washington Street
Briton,ISA 02.111
Tei. 4 617-7274900 ext 406 or 1-977-MASSAFE
Revised 4-24-07 Fax#617-727-7749
WWWMM—s,gov/dia
Construction!Sup ervtsor License
License: 0eu 69120
Restricted to: 00
pati.•..
JOHN W LANZAFAME
30 TEMPLE.OR
MET HUEN.MA 01644
Expiralrom 4131201-1
r ,rrNit.vi..11. Tr# 13449
Off ce of Consumer Affairs andiusitness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Rec7istration, 137057
Tvpe: DBA
Expiration: 10{212012 Tr# 204021
ALL UNDER ONE ROOF
JOHN LANZAFAME
166 A MERRIMACK ST.
METHEUN, MA 01844
Update Address and return:card. Mark reason for change.
Address Renewal Employment host Card
'lxn {o�rrins rrrt earfl�. n ._.° z . , 1Lr
Ufttcc of Consumer Affairs&8mess Kegarfinhran Licertbeor registration 4tttid€ar intiividut use oniti
NOME IMPROVEMENT CONTRACTOR before the expiration date_ If found return to:
Registration: 137057 Type: office of Consumer Affairs and Business Regula tion
sFr Expiration: 101212012 t7BA 10 Park Plaza Suite 51".0
Boston.MA 02116
ALLUNDER ONE ROOF
.tf?I-!N L.ANZAFAME
166 A MERRIMACK ST ._.
*, .
0.1ETHEUN.MA O18d4Not valid witho
MATERIAL PICKED BY MATERIAL CHEMD BY MATERIAL RECEIVED BY DATE RECEIVED #OF CARTONS
X
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R si ern'ti l & Cornmercial Roofing All Types Of
Siding Expert Masonry Mork
Mass Toll Free
Licensed & Insured
1-800-WAIT-4-US ,
r.�,cruy 61�,zr i tc c3E r«r rl SFf<.- IV 76License#034200, ;
(924-8487) Ca4e, wor"yo ae c"A_"r k==V We Work Year Round i
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Proposal To: Mike Sklar Date 11/19/2011
Street: 125 Lancaster Rd. 978-794-3740
N.Andover, MA 617-413-8108
Roof proposal msklar@blackdiamondnet.com
1. Protect house exterior and landscaping as best as Front and rear valley "catch all" areas:
possible, tarps etc. • Remove existing siding and corner boards.
2. Strip all shingles from entire roof. • Install WR Grace ice and water shield to entire
3. Inspect and re–nail any loose or lifted plywood. area and up the wall connection to prevent wa-
4. Any compromised plywood will be replaced at an ter infiltration.
additional cost of$50.00 per sheet of 1/2" cdx fir. • Install all new aluminum step flashing.
5. Install heavy gauge 8" aluminum drip edge to all • Install new corner boards to match existing
eaves and rakes. • Install new pre-primed cedar clapboard siding
6. Install 6' of WR Grace ice and water shield along to all removed areas.
all eaves, wall connections and top to bottom in all . Proposal does not include any painting but can
valleys. WR Grace best available for defense be quoted in the spring.
against ice dams.
7. Install all new pipe boots. Total ROOF cost: $ 22,800.00
8. Above the ice and water shield, install IKO syn-
thetic underlayment to the remaining sheathing up
to the ridge.
9. Install IKO Leading Edge starter shingles
10. Install IKO Cambridge AR Limited Lifetime or Balance due upon completion
Certainteed Landmark Limited Lifetime(not max
def) architectural shingles to entire roof. Referrals available upon request
11. Install new GAF Cobra ridge vents.
12. Counter flash chimney and skylights with ice and Hijjhly rated memberlof the accredited BBB and
water shield, tie into new roof and seal with clear An ies' List
sealant.
13. Building permit included. Thank you!
14. Removal of all work related debris.
15. Shingles covered under mfg. warranty. Not con-
tractor.
16. Contractor workmanship warranty=6 years under
normal wind and rain conditions.
Acceptance of Proposal—The above prices, specifications and conditions are satisfactory and are herby ac-
cepted. You are authorized to do the work as specifie . Payment will be made as outlined above.
Date of Acceptance: Signature:
r4 fa` CERTIFICATE OF LIABILITY INSURANCE DATE�iRNPO�I
""� 09f0T1201�R..
THIS tER1'MATE 33 ISSUED AS A MATTER OF INFORMATION
Percy Insurance Agency ONLY AND CORS NO RIIsM UPON THE CERTIFICATE
522 Chickering Road "OLDEW TIdWS CERTWICATE DOES NOT AIRS,EXTEND OR
9 ALTER TILE COVERAGE AFFORDED BY THE POLICIES BELOW,
NoMb Andover,MA 01845
TI ERS AFFORDING COVERAGE MAIC R
aauRT o DNSURERA: ATLANTIC CASUALTY INSURANCE
JOHN LANZAFAME msURER9: AIM
DBA ALL UNDER ONE ROOF
INSURER c
30 TEMPLE OR
"ColqwR a.
�
METHUEN,AAA 01844 ' INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LWED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.AOT W'IFMSTAtJOING
ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMrtNT WITH RESPECTTO WIACH THIS CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDMIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED$Y PAID CLAIMS.
T TYPE OF POLICY Ht"Asaft tumm
A GE,IEeAL LIABILITY L118000227 9/1112011 911112012 EACH occu tENCE S sD4=.00
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PERSONAL 3 ADV INJURY Y 300.000.00
GENERALAGWW"TE S 600.000.00
GENIAGGREGATELUT APPLIES PER: PRoDquctg,wwiopAm %000=OD
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CERTIFICATE I4OLDER CANCELLATION
TOWN OF WEST MEW BURY SHWJLO ANY OF THE ABOVE DESCRIBED POLIMS OR CANMLED B»oxE THE II71PRRf1T
ONE THEREW.THE RLISUING DO URE*WILL ENDEAVOR TO MAIL 10 DAYS VMIYT9
IA/SST firwas lav AAA A!*PC NOTICE TO THE CERWICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 SO SHAD
Location I ZS 6 0"4dTV]12--
No. Date
NORTH TOWN OF NORTH ANDOVER
0
Z.
F R
A
}�o Certificate of Occupancy $
sCMUs<� BuildinglFrame Permit Fee $ Y �_
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # �3
24647 Building Inspector