HomeMy WebLinkAboutBuilding Permit #542 - 15 MAIN STREET 2/9/2007 TOWN OF NORTH ANDOVER NORT1�
APPLICATION FOR PLAN EXAMINATION of
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Permit NO: fJ7� Date Received
Date Issued: Too
IMPORTANT:Applicant must complete all items on this page
LOCATION -
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PROPERTY OWNER 047Tf
Print
MAP NO.:—,kJ,4- PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
0 New Building Me family
0 Addition 0 Two or more'family 0 Industrial
WAIteration No.of units:
❑ Repair,replacement 0 Assessory Bldg 0 Commercial
0 Demolition
0 Moving relocation 0 Other 0 Others:
E
0 Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
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Identification Please Type or Print Clearly)
OWNER: Name: coikm Phone: Ne s
Address: /Y Li-51?
CONTRACTOR Name: /�6A 6QUAf-I ��' ► ,v�Stiff NOLIAW Phone:
Address• (/0
Ji71 iJ ✓ ����l '
Supervisor's Construction License: 1-3' Exp. Date:
Home Improvement License: J 3-2 qq3 Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg.No.
FEE SCHEDULE.BOLDING PERMIT. $12.00 PER 51000.00 OF THE TOTAL ESTIMATED COST BASED ON 5125.00 PER SF.
Total Project Cost :$� Vis-- FEE:$ ; Q,± -
Check No.• 3 Receipt No.•
Page 1 of 4
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools 11t�
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
ster on Site Permanent Dumpe ❑
Private(septic tank,etc. ❑ Electric Meter location to
project
NOTE: Persons contracting w h u r end contractors do not have access to the g ara ty nd
Signature of 4'b.>"'Owner
�, / �� Signature of contract
Plans Submitted L� Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
a
MIRE DEPARTMENT -Temp Dumpster on site yes no
Fire Department signature/date
COMMENTS
Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer ConnectioNsianature Date Driveway Permit
Building Setback ft.
Front Yard Side Yard Rear Yard
Required Provided R uired Provides Required Provided
Dimension
Number of Stories:_Total square feet of floor area,based on Exterior dimensions.
Total land area,sq. I:
NOTES and DATA— For department use)
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e 3of 4
Doc:INSPECTIONAL SERVICES DEPARTMEN T:BPFORMOS
Geeted JMC.Jan.200b
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
o Building Permit Application
u Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
v Copy of Contract
o Floor Plan Or Proposed Interior Work
Addition Or Decks
o Building Permit Application
o Surveyed Plot Plan
a Workers Comp,om Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations(If Applicable)
o Mass check Energy Compliance liance Report(If Applicable)
New Construction (Single and Two Family)
o Building Permit Application
u Certified Proposed Plot Plan
u Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned)to Include Sprinkler Plan And
_ Hydraulic Calculations (If Applicable)
u Copy of Contract
u Mass check Energy Compliance Report
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 most then get this recorded at the Registry of Deeds.
One copy and proof of recording most be submitted with the building application
Doe:INSPECTIONAL SERVICES DEPARTMENT:aPFORMOs
Page 4 of 4
Location ,/5 ��s•4 �ti
No. 7 1 Date " D
�aRTM TOWN OF NORTH ANDOVER
Certificate of Occupancy $
�'�s" °•'t�'
Building/Frame/Frame Permit Fee $ 0
s�CHust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
19901
V Building Inspector
CONTRACT Customer Name
SKETCH Customer Signature
Contract Date �t/� (o Sales Representative Signature I
ATTACHMENT Customer Phone
Contract Price t
s d ] 0 9 10 11 @ ly 1. 15 16 17 18 19 20 21 22 21 i
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'Each box equals one foot unless otherwise noted. This sketch is a good faith
representation of the work to be done, it is understood that all dimensions
derived from this sketch are approximate,and that all locations of outlets, light
fixtures,plugs,jacks and/or switches are subject to change if necessary.
CONTRACT Customer Name v
SKETCH Customer Signature
Contract Date Lt/1 (e Sales Representative Signature t
ATTACHMENT Customer Phone
6 7 8 9 10 tl
Contract Price t
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I 26. 2a 30 31 32 33 31 3s 38 37 38 39 b 41 e2 43 4.
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'Each box equals one foot unless otherwise noted.This sketch is a good faith
representation of the work to be done, it is understood that all dimensions
derived from this sketch are approximate,and that all locations of outlets, light
fixtures,plugs,jacks and/or switches are subject to change if necessary.
NORTH
0 4 over
Town
No. f4 Loo _
C. dover, Mass.,�•
COCHICMEWICK V
7d�oRATED PP �
7�a ` BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT........ ......C.O.Y+�................................................................................................... Foundation
has permission to erect.............................P-C
buildings on...I.S.......�.,L .f..�.....(AA.-C....................................... Rough
to be occupied as., Lk�► chimney
...... .........................................................................................................................
provided that the person accepting 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 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ST TS Rough
.. ... . ... . .. Service
................ ...........................
BUILDING INSPECTOR Final
Occupancy Permit Required to Ocmpy 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.
CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM
Owens Corning Basement Finishing Division(the contractor)hereby submits this proposal to sell and Install the Owens Corning Basement
Wall Finishing System and related Items as described herein at the residential premises set forth below.This proposal shall not become a
binding commitment unless and until it has been signed by the Contractor and the Customer.
Contractor:
Owens Corning Basement Finishing Systems
a division of Bay State Basement Systems,LLC.
60 Shawmut Road,Canton,MA 02021
Telephone#(781)821-0060
Facsimile#(781)821,-8552
Federal Tax ID#144855297
Mass.Home Improvers t Contractor Reg.#137943
Customer:
Customer Name n aeA
Street Address
City,State,Zip �✓-e,--
Telephone
eTelephone I
This is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing
System and related items specified herein at the Customer's residential premises identified below:
Installation Premises:
Street Address_ CL
City,State,Zip
Scope of Work:
Are Sketches and/or specification sheets attached? ❑Yes' ❑No
'All attachments are Incorporated Into and becomeart of this contract I I
Description of Work/ pecifications: F 1 -0— !_ ILA C (e{� Q! �(J�!
t S
�u' �h I r
Cale-
- 7V-e—Work'schedule**: I.IJ I Of.✓ �U '
Approximate Commencement Date: �.
Approximate Completion Date: , V
"The proposed work schedule is approximate and subject to change.
Contract Price: 2 yn
Total Contract Price:
Deposit with order: $ 3y•U ` t' C3 Cash IL Check# {��
Balance Due:
Terms: ❑Cash ❑Finance a.' raq,.i, r •a ,'i• t
(Cash terms are 10%deposit,50%on commencement,40%on completion)
t J a
,I ,wn r r./N1„tq;:%:A.o') i . ^Vp,:,d gym_i., -
$ Due on Commencement r r uib ...
$— 6 Due on Completion
DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ
AND UNDERSTAND THE ENTIRE CONTRACT,INCLUDING ANY ADDENDUM ATTACHED HERETO,AS WELL AS ANY ATTACHED
SKETCHES,MATERIAL LISTS OR THE LIKE,AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT.
"YOU ARE ENTITLED TO A COMPLETE,FULLY EXECUTED COPY OF THIS CONTRACT AT THE TIME OF EXECUTION.
Witness our hand(s)and seal(s)below on this f�h day of G n V' L
Bay4m �
ement Sys ,LLC./A thori ed Representative:
1--4
S
L L
Print Name
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Customer***:
Customer Signature
6--/off
Print N
Customer Sign
06/08/ 006 15:05 FAX 1 781 659 4725 Andrew G Gordon Inc 16001
V
AR
WCIP �- Liberty
I5S ING OFFICE 354 ,Mutual... Workers Compensation and
ORMAMON PAGE Employers Liability Policy
ACCO NO. SUFI ACCT NO. Liberty Mutual Insurance Group/Boston
1. 44359 0000 1 LIBERTY MUTUAL FIRE INSURANCE CO.
POLICY NO. TD,`CD SALES OFFICE CODE SALES CODE N/R IST
WC2-31 344359-016 XX X WESTON 102 REPRESENTATIVE 3000 2 YEAR
ASSIGNED 2003
Iten 1 1.Name of BAY STATE BASEMENTS LLC
Insured DBA OWENS CORNING FINISHVD BASEMENT SYST FEIN 14-1885527
Address 960 TURNPIKE STREET
R
CANTON,MA 02021 ISK ID 000162837
Status 46 LIMITED LIABILITY CO
Other workpla-xz not shown above: SEE ITEM 4
Mo.Dap Year Mo.Day Year -
Item 2.Policy Period:Froin 05-24-06 to 05-24-07
12:01 AM standard time at the address of the insured as stated herein.
Iten.3.Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:
MA '
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits of
our liability Hider Part Two are:
Bodily Injury by Accident 500,000 each accident
Bodily Injury by Disease 500,000 policy limit
Bodily Injury by Disease 500,000 each employee
C. Other States Insurance: Part Three of the polity applies to the states,if any,listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4 Premum - The premium for this policy will be determined by our Manuals of Rules ClassificaliM Rates and hating
Plans it information required below is subject to verification and than e b audit
Premium
t3as;Y Rues LINE 110
Fstimated Per 5100 Estimated
Code Total Annual or RE- Annual
Classifications Ab. Premiums
munernlion Premiunn
SEE ENSION OF INFORMATION PAGE
11Tnim Premium $ 500 ( MA ) Total Estimated Annual Premium
Interim d'ustment of premium shall be made. ANNUAL
This po icy,including all endorsements issued therewith,is hereby countersigned by
AagharizeA Re zentntive Dale 05-L�;=�� �`•-
RE.CEIVED _-
lar ('aide Ten. Opml ANDR Ve Payment Rauag[iasis Pd,liG. Home State Dividend RENEi
05-22- NR MA WC2-31S-344359-015
GPO 4Ci0 U Copyright 1987 National Council on Com =_
p@`iSatlOrl( WC 00 00 01 A
BROKM Copy
JUN 08,2006 01:31P 1 781 659 4725 paqe 1
Board of Building Regul ons and Standar&
One Ashburton Place-Rei -1301
Boston- Massachusetts 02105
Home Improvement Contractor Registration
Reaisbaftr 137M
TWw SVWkment Cab
Elation: 1t2�007
OWENS CORNING BASEMENT FINISHING --
DANIEL WALSH
960 TURNPIKE ST. -
CANTON, MA 02021
Update Address and retnn cud.Marts reason for ratan;
WSW a 500a0400441vt:16 0 Address ❑ Reaewral � Eatptoya"t [� Log Card
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Pissed a[ Retatafiaai and Sardwdt -
NOME WPROYEmEMT C0NrRAC[OR License er ic&Oadam valid for iadividal ase emir
before the espiran date. Nfound retarte to;
Rog b* foal tia137 3 Board of Bnidin=Bcpla&m sad Standards
_EzpiratJcni /� 07 One Asfebnf m Place Rat 1301
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MEW MIMC'�:
ON Tuivolm ST.
Gtld fON,1dA 02021 -
Not ra6d wont 3at0�
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
W www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): &6;Q; 6"Ir "kc— ��!S
Address: 60 S ic- 0.0
City/State/Zip: C ;A) /j ?o, Phone#: 7 -1-Jf-2e —606
Are you an employer?Check the appropriate box: Type of project(required):
1.NJ I am a employer with Zy 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. 1 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
officers have exercised their 10.❑ Electrical repairs or additions
required.]
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 till out the section below showing their workers'compensation policy infonnation.
t 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. l
Insurance Company Name:
Policy#or Self-ins.Lic. #: t. '- )S— 3.�5-5/ ��J��, Expiration Date:
Job Site Address: '� /S% � i>�� City/State/Zip: . IA60j �daj? (
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 ertif and r the d penalties of perjury that the information provided above is true and correct.
Signature: Date:
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#: