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Home My WebLink AboutBuilding Permit #230 - 125 OLD VILLAGE LANE 9/24/2009 BUILDING PERMIT O* NORTH q tttur0 46T TOWN OF NORTH ANDOVER 03? " 0p APPLICATION FOR PLAN EXAMINATION w Permit NO: ;�3 Date Received 7 "�RgTD cy �SSACHU`�� Date Issued: MPORTANT! Applicant must complete all items on this page ;LOG ' drat PROPERTY D1Y�E9Ft PARCEL_ , ZZONING STI R'I�CT HlikoncDas#riot yes no acl ine chop Mage 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 , Wirl! lopclpait / tlancls > / rsht7astrict.' Wiotbr/SeWar,, . DESCRIPTION OF WORK TO BE PREFORMED: r 71 /'\J Identification Please Type or Print Clearly) OWNER: Name: to :�i,�.AL 0 C14A,-" PQ fJ S Phone: Address: 1Sy f-O J LnJ ,, ' ►, fir + �` 7 C011T A TOR;..�I;ame_ .Phaar�� Ad S to pWisox"s C-o fttru-bWa.LJ:cense;� t. lc� p. . Date, _ ` n oar� txnpr�.veaaaerat Liderse.w P. fDe.. f 1 ARCHITECT/ENGINEER 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: $ �� FEE: $ �/r/Jn_ i Check No.: 37 Receipt No.: 2 �� NOTE: Persons contracting '1" u' regi st contractors do not have access to the guaranty fund n'bre of.Ag xe rhe w g tore o contractor J 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 f e sP I'1-ENT, " ar Dumwster�t ite Ve . h Coca#e t�12#:�laira tteet < q �reT Ppa°r aileMat, CO3MME-NIT5-- i 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 li ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location 2� 211 No. 2 Date �aRTM TOWN OF NORTH ANDOVER 3? . o a + ; ; Certificate of Occupancy $ Eta Building/Frame Permit Fee $ AO sACMUs Foundation Permit Fee $ Other Permit Fee $ `TOTAL $ Check # -2-3 3 7 e- 4 G Building Inspector WORTH Town of : Andover . No. 2 _ . - - A K E dover, Mass., •o L .z- COCMICMEWICK �� ADRATED PPS\ �C `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ Z2P �, .�'l A ...... ... rw .yin.s.................................................................. Foundation I has permission to erect........................................ buildings on 171-4.07.4?1�l..v� .. ...f.' ................................... Rough to be occupied as......,?� ...... t Chimney ' ..... . . . . . . . . . .. . .. .. .. . . . . . ................................................................................... provided that the person accepting this permit s. every respect conform to the terms of thea lication on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final Y6 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU T 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 Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. NORTH Town of : 4 over . 0 No. o -- A K E dover, Mass., l •o g COCMICME WICK AERATED p`Pa\ �y `S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... S ....Q.I��I ... ............� ..!'!? .y...in............................................................................. Foundation has permission to erect........................................ buildings ................................... Rough to be occupied as � �' Chimney ..... . ...... ......... ...... .................. ......................................................................................................... provided that the erson ac tin this per sh�4l.ia�eve respect c of p p p g p every p o orm 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 Y6 ' PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU T S Rough _a__ ............ .................................................................................................. 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 Wall To Be Done Until Inspected and Approved by the Building Inspector. Burn FIRE DEPARTMENT er Street No. IF_sEE REVERSE SIDE Smoke Det. 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): J Address: City/State/Zip: f"l �'`� /�s'� Phone Are you an employer?Check the ppropriate box: Type ype of project(required): �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.❑ 1 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 any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 101-1 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' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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. Insurance Company Name: Policy#or Self-ins.Lic.#: C `� T'b 't 1 J Expiration Date: Job Site Address: �4-`� � � '� �-� City/State/Zip: A_r4 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. Ido hereby certify ender a pa s and p nalties of perjury that the information providedBove ' true and correct Signature: Date: of 2 z 0 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#: 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 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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia s M,"u y s x' y 3 Ac's@ 4.. . �` _ c Residential & Commercial Rocifing All Types Of Chiana�ey�: CHIMNEYS PoINTEQ-REButL,`T'-CAPD U � Sacl<Axaa I Expert Masonry Work x;= �� ,�f �a�c� �.�,�a��r �' Licensed & Insured Mass Toll Free f�ceilly 0u+n�d a$Operated Sice,1976 License#034200 1-800^WAIT-4-US �\ r (924-8487) IKOau' 'J t7iGrt� f?- ', Vh" C=* W- Work V--- 1RO-nd Uff UM I 4 o ,k - Proposal To: Donald Champions Date 9111109 Street: 125 Old Village Lane N. Andover, MA Roof proposal (Rear dormer and wings) 1. Strip all shingles from rear dormer and wings. i 2. Re—nail any loose or lifted roof boards Total cost: 3,500.00 3. Any compromised boards will be replaced at an option-.Cut and install new lead flashing on additional cost of$2.25 per linear foot. 1 st 1 b' thrree . re- e sides of chimney$34(1.0(1 additional cost placed at no additional cost. 4, Install heavy gauge 8"aluminum drip edge to fall b eaves and rakes. 5. On dormer: Install.Certainteed"Flintastic"base Balance due upon completion sheet. Install 2nd layer, Certainteed"Flintasti6" SBS cap sheet. Excellent product for low slop applications. Referrals available upon request b. On wins: Install full WR Grace ice and water shield.Best for winter protection I gi rhly rated member of the BBB 7. Install IKO Cambridge AR-30year architectural shingles to wings. 8. Building permit included. i Thank you! 9. Removal of all.work related debris. 1.0. Shingles are covered by the manufacturer up to 30yrs.(Pro-rated after 5 years.) € 11. Certainteed Flintastic warranty is a full 1.5 years on material i 12. Contractor workmanship warranty=10 years�7- Ill— House Crew, NO Sub Contractors± der normal conditions. r i I ceeptance of Proposal--The above prices,specificati ns and on are s 'sfact and are herby ac- epted. You are authorized to do the work as specified. ayment w. I a de outlin - above, Date of Acceptance:_ /rt/Af Si at `a 4 RWda 01 i:m Ashburton Pie � � 13 Boston_ 02108 . improvement Conte' rz►c', �mp�v tt� r� 1 `.E -ALL UNI R C?tf4L R00ff- � JOHN AME 166 A MERROACK S-1 MgTHEUN, MA 018" tr�m�ta A�d� aOd rctttsat es€a.AQ srl.€ewer+ tu€ .11nev�, s��'. w;tl �tp(tipftARttt f.tett C :e€F: - ft.�.,�...sN.+�`' , � rralirA lost its1 tsltt trete 1Fwrrd esf !�+��wavi'..Ffw�tt�*� !,t[a+lse��- f'Elits!but 'd1162- tI`t� tout w� Tt�a 1! i ilk ua 13 i:)t, Urs.eXpkaooM Jt *11w i121w*lo Yr! z7 5tO mss IiRs; tt ( i Type: F . s 00 JOHN � f�:1fM,T':l.Ia� ' j � -� � rte• s I S 1 t E { g i # t t F f � 11a.•_aa:t€t•c.t� !h'6a.�ittttc;rt �' 1'trtsfi. �.rl•`• i r tied€trio€tf., >Es�tis f: tsaal {ic,st.E„f F4tt€ltfstt.; f[a�t �` 4T LAN 1 - y 3Q TEMPLE OR MET"LiEN.MA 01844 { f S f I r { 1 S - ISSUE DATE 0911&12009 ODUCER insurance Agency LLC TTH,CER' I TE is i6ED AS A MATTER OF INFORMATION ONLY AND CO 5N RIGHTS IIAN THE CERTIFICATE HOLDER.THIS CERTIFICATE 922 Chickering Rd,Rt 125 DOPgNOT _ OR ALTER THE COVERAGE AFFORDED BY THE POL11tM AELOW. Nowh Andover,MA 01845 { COM' NIES AFFORDING COVERAGE UNNURED #j g. 7 +J1 Under One Roof/Pest in Peace t 30 Temple Drive COM!ANY A.I.M. �1jItAlal Insurance Co VkLETTERIhuen,MA 01844 t; f 9 I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B W 1 E BEI hISUED M,THE INSURED NAMED ABOVE FOR THE POLICY PENIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERMOR NDIT ION=OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TQ WHICH THIS CERTIFICATE M.AY BE..LSSUED OR MAY PERTAIN,T19E.INS CE AFFORDED BY T14E.POLICIES DESCRIBED HEREIN IS-SUBJECT Tfl ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLI _S. _ >t LIMITS S Y HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLIC411EFFECI'ItitB POLICY I"-"TIoN DATE(MMIDI iff' DATE(A$iIDD" LIMITS i GENERAL LIABILITY S f ? GENERAL AGGREGATE COMMERCIAL GENERAL LIABILITY t } y PRODt<'IS-COMPHIP ACG. PERSONAL&ADV.INJURY Q QCLAIMSMADE QOCCUR i I. I� EACH OCCURRENCE OWNERS R.CONTRACTORS PROT. I S ERIE DAMAGE(A%.fire) EA'PENSE(Anw-pawn) AUTOMOBILELIABILMY AtBtt'ED SINGLE ANY AUTO +ALL OWNED AUTOS WDILT INJURY SCHEDULED AUTOS HIRED AUTOS NOT-OWNED AUTOS - BODILY INJURY GARAGELIABILrrY - .� Olaraco"ca) C t I PYtOPk7tTY DAMAGE EXCESS LIABILITY 4 s } EACHOCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM ,,,, L � .� WORKERS COMPENSATION AND EMPLOYERS LIABILITY TAT LIMITS STATE THER�` � � � _ MA FROPRIE MR/ A s%-xEcvnvE � ' EL EACH ACCIDENT 100,000 WFICIERS ARE: rNCL tgExCL 7009464012008 11/0012008 I I109�.1 E�9 Es DISEASE--POLICY LIMIT 500,000 EMPLOYEE 100,000 "ALMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS: cy UNDER ONE ROOF/PEST IN PEACE IS NOT COVERED BY THE WQRICE 'COMP,EI SiA!ION POLICY. t� t � t l I I � f S � s SHOULD ASQY OF'. EL D ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE BHN LANZAFAME OF,TuE L4SUOMP L ENDEAVOR TO MAIL,j&WRITTEN NOTICE TO THE CERTIFICATE LDER 1NA MED r0EPI B IIAILIJRE 7 O MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION R LL0.BILI Y OF, ANI,KIND UPO 4 E COMPANY,ITS AGENTS OR REPRESENTATIVES. { ; 1 TEMPLE DRIVE t t 'I H UEN,MA 01844 JAMORLZWATi f