HomeMy WebLinkAboutBuilding Permit #126 - 15 MIDDLESEX STREET 8/17/2006 '6. O
p TOWN OF NORTH ANDOVER
` 4 .0
. APPLICATION FOR PLAN EXAMINATION
,SSACHU`�Et
Permit NO:-42h Date Received:
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION J� M 1 d d l e se X Sig e ej-
Print
PROPERTY OWNER O�,V 1'U �,b W - •� -- -' -
Print
MAP NO.: PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
❑New Building �-'One family
❑Addition ❑Two or more family ❑ Industrial
❑ Alteration No. of units:
xRepair,replacement ❑Assessory Bldg ❑Commercial
❑ Demolition
❑ Moving(relocation) ❑Other ❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
S+rl' role- 0-Ad gcfe-jc.
Identification Please Type or Print Clearly)
OWNER: Name: -Roa r I U L.0 Phone: 4 Z 7 r
Address: t acl �Q&tSC SA-re C_� 1Q OY AA aL1E,,- & k U 1 9 q J'
CONTRACTOR Name: 2s:--
r ns—ItL Phone:—( -Zy -
�f_ (dYIC- na �
Address: Z C)b S � Dh S So,`� zve �o6� A� ager Ah .
_ y
Supervisor's Construction License: Exp. Date:
Home Improvement License: S�o`7 Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.•$10.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ftff D ON$125.00 PER S.F.
Total Project Cost x.1.8'0=FEE:$ q
/ q
12-
Check No.: � � tC� Receipt No.: � 1
Page Iof4
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
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
i
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan
And Hydraulic Calculations (If Applicable)---
u
pplicable) -❑ Copy of Contract
❑ 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 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 DEPAUVIENTMFORM05
Page 4 of 4
TYPE OF SEWARGE DISPOSAL Swimming Pools [ITanning/Massage/Body Art
Public Sewer 11
Well ❑ Tobacco Sales r l Food Packaging/Sales ❑
Permanent Dumpster on Site
Private(septic tank,etc. ❑ Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fluid
Signature of Agent/Owner �� aQ � i Signature of
Contractor '
Plans Submitted 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 ❑ ❑
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION = ❑ -
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Zoning Board of Appeals: Variance,Petition No: '
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Building Setback(ft.)
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided
Water
& Sewer connection signature&date
Temp Dumpster on site yes—no— Fire Department signature/date
Building Permit Approved and Issued by:
Page 2 of 4
DIMENSION
Number of Stories: Total square feet of floor area,based on Exterior dimensions.
Total land area,sq. ft.:
NOTES and DATA— For department use)
i
I
Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPAR"TMEN"T IFFORM05
Created IMC..Ian'006
Location S Vhto Ce,I
�`
No. Date
�ORTh TOWN OF NORTH ANDOVER
F 9
• s
+ i : , Certificate of Occupancy $
sACNUS Building/Frame Permit Fee $
f
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #)368
y
`� Building Inspector
C NOIRTH
Town of
o L A� o lover, Mass. • 0
�.
C OC MIC ME WICK
ADRATED P` "♦Cl
S G
4 BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT......8Arrol. ......�Q.�.,.....,.,.„.............. BUILDING INSPECTOR
............................
[Rough
undation
has permission to erect........................................ buildings on i .td .* ..............................
to be occupied as......ST)%0% ........}.... . . . ... .. .
Chimney
provided that the person accepti 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
I
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION S - TS ELECTRICAL INSPECTOR
LDRough
.................................. ............. B INS
Service
I R
Final
Occupancy Permit Required to Ocatpy Building
GAS INSPECTOR
Display in a Conspicuous Place on the Premises -- Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done I
Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Town of North Andover a� ttORT11
Orb
Building Department
27 Charles Street
North Andover,Massachusetts 01845
o
(978)688-9545 Fax(978) 688-9542 °� COtpl[„lwKK
Scus����
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Building permit# the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in/at:
�Z, t
Facility location (�
Signature of Applicant
A
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
t Boston,MA 02111
�,M s�•� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual): CQQ { S/
Address: �d0 SuAbh S�� SU l.� ZZ (.-
City/State/ZipA d (�d V°u �� M."Phone #: 91F
Are you an employer?Check the appropriate box: Type of project(required):
1.Di am a employer with g 4• ❑ I am a general contractor and I
employee's(full and/or part-time).* have hired the sub-contractors 6. New construction
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 me in any capacity. workers' comp. insurance. 9. EJ 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.❑ 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.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill 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'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: � •
11,24
Policy#or Self-ins.Lie.
#: Y V V C �p QQ 7 6 OO I 04-U Expiration Date:
Job Site Address: IS �`'�1 d�l e R)e City/State/Zip: I V& l7 d/ �
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
tine 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: / C Date: 112b 6
Phone#: 7 7 0 6 6 5 ,34)—"
Oficial use only. Do not write in this area,to be completed by city or town ofciaL
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 fine;
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:'
in a joint enterprise, and including the legal representatives of a deceased employer,or the
of the foregoing engaged J rp g g ep mP
g g .
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 theSr ounds 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-contractors)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 foryour 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
,p� ✓1ze rianynzaruueall�i o���aaaacl+,uaetla
�\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 104569
u,p Expiration:,, 7/14/2008 j
::Type: Private Corporation
DAVID CASTRICONE:ROQF(NG;SIDING&
David Castricone
200 SUTTON ST SUITE 226
NORTH.ANDOVER, MA 01845 Deputy Administrator
6
i
DAVID CASTRICONE
ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845
7 HILLSIDE ROAD,BOXFORD,MA 01921
In North Andover 978-683-3420 In Boxford 978-887-6147
In Haverlii11978-374-7314
Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary
materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and
conditions,on pre 'ses below described: !� Q 7 /�
Owner's Name... .Lid�`�`........ ...`-�,0„11.x................... Telep ne#.....(/1..P.C9.."..L..r.�.1..
r
_Job Address....A ... .... .A .�.6Z ......... -i.:...City......./•.1t.G.�... „l R.:�t-,e f�.......Slate...........
Specifications:
.trip existing shingles.......tiApplynew drip edge to all edges.
.......................................................................................
.. ................. .............................................................................................................................................................................................
I,a*'pply y feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane
In valleys and bottom ed es of any unheated areas of house.
........................... .. .................................................�............ i..........
Apply felt paper unde i ment. ✓Install ridge vent to 3 G
......I.......1..�'.}, ..... r .............................. ................................ ......... ............... .......
Aeroof usingshingles with a year warranty.
......................................................................
............................................................I..................... .... ..
,(II60unterflash chimney. a.J►&vent pipe flashing. c--Ugal disposal of all debris. COI,— iC_
Area(s)to be worked on;
r' t ..
..................... .. -1 ....... �... ............................................ ...
....., �. ... ......... .�....... .. .. ..... ..... I
..../I,P.�.t,��. ...l f4M........f. �.. .. 1 ;. .�. ,,�, . ` 1�.�?. ..........................
.
- �
.................... �---......2..Y.o. ?.... -....1 �.... .....V. .".... ...... .g..k"L oo.............................
One Year Workmanship Warranty Not Transferable)
Manufacturer's Warranty ,fc fled na eturer
Materials and Labor to cost ...... .t�.s} ...,..... .. Payable............. ......on....... ..........
Payable.............................on.................................. Balance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or
conditions resulting from application of materials specified above (i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living
spaces,water stains when roofing shingles have not had adequate time to cure).
Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested
by contractor.Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It
is agreed that,if permitted by law,contractor shall be paid by the owners)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,
that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.
It is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates.
The undersigned warrant(s)that he is(they are)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)names(s).
There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract
dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all
parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:
Director,Home Improvement Contractor Registration
One Ashburton Place
Room 1301,Boston,MA 02108 Tel:617-727-8598
Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction-related permit or deals with
unregistered contractors shall be excluded from access to the Ouarantee Fund.
Approximatestarting date of work..................................................................... Completion date..............................................................
Receipt of a copy of this contract is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said patties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Owner has three business days to cancel this contract and incur no penalty. jj
IN WITNESS WHEREOF,the parties have hereunto signed their names this........1 b:... .....day of 44 71
t,R ..,.,20...dt .
Accepted: 4--
Sig . ..... .............................Owner
Signed....................... ................................Owner
Per ...
Representative