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HomeMy WebLinkAboutBuilding Permit #591 - 148 SANDRA LANE 4/14/2008 BUILDING PERMIT oFr►ORT1itt�bo $6�ti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . Permit NO: Date Received �gSSACHU`'���5 Date Issued: - 0 V IMPORTANT:Applicant must complete all items on this page LOCATION `a'. ,,.. Print PROPERTY OWNER ca �► Print MAP NO: 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 PREFORMED: d d o c w rS' I e ✓�.��✓P/i2- T6d fnJ Identification Please Type or Print Clearly) Y) OWNER: Name:,,,,��� '�''� Phone: Address: CONTRACTOR Name: , Phone:L1 - — Address: v""/ Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ,f ) 3 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: $ Check No.: �GL tow Receipt No.: U NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contracto Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL A- 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 r x r 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 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 NOTES and DATA— For department use P(L^j Ceti n 5 r;� C, ❑ 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 a 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 o 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 Li Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 I I _ � a�.no�,uc a�✓G�iaacluoetta _. Board ofBuilding iegulations and Standards HOME IMPROVEMENT CONTRACTOR License or registr ° before the expirai Registraiion 1..12799 i Board of Building ,Expiration 4%27/2009 Tr# 128743 ! One Ashburton P r Type 1;E-A Boston,Ma.02101 WO#URN CONSTRUCTION 1 J°.:1 STEPHEN DELARUE = _.__ � " 1 CUTTING AVE 4 y NOBURN,MA 01801 __ Administrator Not valid ` %A RTH '9 ® of T ZO L A © dover, Mass., - ' .'t- C'. COCMICMEWICK A0R.4TED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... j r�`'........................ ..f............1...............................:................................................................ Foundation has permission to erect.............. ......................... buildings on .....1 ......... ,f? {,�I .....� ................... Rough to be occupied aS..� ... .,7/..^+ � .....' ..... ... .�.. .`.0..! ........................................................ Chimney provided that the person ac pting this permit shall in every respect con 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 q PERMIT EXPIRES IN 6 MONTHS. UNLESS CONSTRU S TS ELECTRICAL INSPECTOR 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. Information ani d 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 p=rson in the service of another under any contract of hire, express or implied,oral or written." i An employer is defined as an individual,partnership,association, corporation or other legal entity,or any two or more tn of the foregoing engaged in a joint enterprise, and including t3ie 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 apattrnents 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 stats that"ever state or local licensing agency shall withhold the issuance or renewal of a license or permit to,bpexattem business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." ' AdditionaIly,MGL chapter H2, §25C('1)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-contiactor(s)name(s), address(es)and phone number(g)along with their certificates)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. Han LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 youare 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 sureto fill in the pemlit/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"Sob 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 perrnaits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or p-r t not related-to any business or commercial venture i.e. a do license or permit to burn leaves etc. said person is ( g Pe ) p I-JOT 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 Commonvvealth of Massachusetts Department Qf IndustriEd Accidents Office of Investipti&ns 500 Washi%� Street Boston,MAi 02111 Tet.#617-727-4900 ext.4.06 or 1-877 mASSAF_E Fax # 617-727-7749 Revised 11-22-06 t ?;'.mass-gov/dia 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 Le•'bl Name(Business/Organin ion/Individual): Address: 11011 y,, p, City/State/Zip Phone.#: d51 / ry / Ar �ou an employer?Check the appropriate box: 1. I am a employer with ' 4. Q I am a general contractor and I Type of project(required}.� employees (full and/ -{� * have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or er- listed on the attached sheet 7, ❑Remodeling . ship and have no employees These sub-contractors have working forme in any capacity. employees and have workers' 8• ❑Demolition [No workers'comp.insurance comp.insurance.: 9. 0 Building.addition 3.❑ required-] 5. We are a corporation and its 10.0 Electrical repairs or additions I am a homeowner doing all work officers have exercised their ` myself. comp. 11.0 Plumbing repairs or additions ys [No workers' co right of exemption per MGL inc„r ,ce required]1 c. 152, §1(4), and we have no 12.0 Roof repairs employees. [No workers' 13.0 Other comp. insurance required:] "Any applicant that checks box#1 must also fill out the section beiow showing their workers,compensation policy information. t Homeowners who submit this affidavit indicating they aro doing all work and them hire outside contractors must submit a new affidavit indicating such. +Contra,-tors that check this box must attached an additionai sheet showing the name of the s employub-contractors and staff whether or not those entities have ees. If the sub-contractors.have employees,they must provide their worloR s'GO TM policynumber. I am Ph'yer that is providing workers'compensati information. on insurance for my employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#:' A6 / Expiration Date: Job Site Address: /, q Z .S y lnou 1wJ City/State/Zip: � Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date Failure,to secure coversa as r )• g equi ed under Section 25A of MGL c. 152 can lead totheimposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the foam of up to$250.00 a day against the violator. Be advised that a copy of and a fine this statement may oof f forwarded to the Office a STOP WORK ORDER aa Investiations of the DLA for inc„rs,nce coverage verificationof I do hereby certify under the pains•and pe 'es of perjury that the information provided above is tr a and correct Signa L L g` Date: Phone Off,14al•.use only. Do not-write in this are¢, to be completed by cizy or town official City or Town: Permit/License# Issuin;Authority(circle one): .Board of Health 2.Building Departm 6`Other, ent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector - 6 Contact Person Phone#: === ray =� _ - - = --= —_- " III - - - — —- - - _ PRODUCER — THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION— ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hub International New England,LIc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 299 Ballardvale Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Unit 1 Wilmington,MA 01887-1013 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Stephen Delarue 1 Cutting Ave Woburn,MA 01801-0000 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Co LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE A WORKERSCOMPENSATION D EMPLOYERS'LIABILITY LIMITS HE PROPRETORI ARTNERSIEXECUTNE OFFICERS ARE NCL O EXCL 0 2262153 9/25/2007 9/25/200$ STATUTORY LIMITS OTHER Coverage Applies to MA Operations Only. CH ACCIDENT $ 100,00 ISFASE POLICY LIMIT $ 500,00 ISEASE-EACH EMPLOYEE $ 100,00 DESCRIPTION OF OPERATIONSNEHICLES/SPECIAL ITEMS RE:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR STEPHEN DELARVE. CERTIFICATE HOLDER CANCELLATION CTcpuC:ni nclj_e BOE ., - 'ULG "•"O 7ii�"OVE 0 'Zr. "CLr ES BE OANr-ELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 1 CUTTING AVE DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT WOBURN,MA 01801 FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Page# of pages V)roposal WOBURN CONSTRUCTION 1 Cutting Avenue Wobum, MA 01801 Home Phone 781-932-3371 Cell 617-512-2197 0) _` Q / S �` 1' , f Proposal Submitted To:- - I/ /,, Job Name Job# o i ( '�c) D Address Job Location f Date Date of Plans f Phone# c G -- Fax# Architect 66 -1� We hereby submit specifications and estimates for: STRIP OFF ROOF GO OVER EXISTING ROOF 173 25 YEAR SHINGLE OW30 YEAR SHINGLE ICE WATER SHIELD A/TAR PAPER DRIP EDGE INSTALLED i NEW VENT PIPE BOOTS INSTALLED RIDGE VENT INSTALLED 'CLEAN UP/REMOVE DEBRIS r LI t! We Propose hereby tofurnishfurniis`h material and dllabor—complete in accordance with above specifications,for the sum of: $ .tA`l �i 9 l . ;lr 1&ZVOLlT'4) -- ' — �rJ Dollars with payments to be made as follows, t Any alteration or deviation from above specifications involving extra Respectfully costs will be executed only upon written order,and will become an extra `� r - Dr� / +/ char a over and above the estimate. All agreements contingent upon submitted , strikes,accidents,or delays beyond our control. Note:This proposal may be wdhd n by us if not accepted within days. P 3aeptanee of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Signature Payments will be made as outlined ab e. / �` Signature Date of Acceptance / ) ! Location l ( � Y4,0 No. Date �` w NaRTM TOWN OF NORTH ANDOVER Certificate of Occupancy $ CMU sE<�' Building/Frame Permit Fee $ i Foundation Permit Fee $ Other Permit Fee $ i TOTAL $ Check # 21071 � Building Inspector