HomeMy WebLinkAboutBuilding Permit #712-13 - 162 Kingston Street 4/29/2013Permit N0: 71o� —1-3
Date Issued: 7 0? / 15
BUILDING PERMIT 3r
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINATION
*
-
.M
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
A Two or more family
❑ Industrial
❑ Alteration
No. of units:
'Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
11 Septic ii Well
❑ Fiood lain Wetlands ; `
a Watershed District
o Water/Sewer
(N7�>ocvs
Identification Please Type or Print Clearly) I q
OWNER: Name: Fq\O 10 Vr `ACV, Co Phone:
Address: t6� ��� S�'-c>,A v�oY A FSLiS
CONTRACTOR Name: _Phone:
Address: D, 4444p ,000-1
Supervisor's Construction License: "Exp Dae:
�A!'
Home Improvement License Esc, Date,
ARCHITECT/ENGINEER �>5:,5 Phone:&(7B, 00�6 -7526
Address: a UloOP44jWp!�— Reg. No. 3 4eg
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 2-171=( 00 FEE: $ ��•
Check No.: & ff 2 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to t
riapre irif Agent/4wnertgnature of contractor
g
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
IMPORTANT Applicant must complete all items on this page
P,nnt►
OWNER
PROPERTYf - "yes no r
_ Pnnt?
00 Year Old
1 , } 'Structure '
MAPNO:,..PARCEL'.ZONLNGiDISTRICT :_HistoriclDistnctt :yes; no
,lMbch'he Shop�Village�...yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Commercial
❑ Others:
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Other
0(iFIbddplain� ❑ Wetlands
.-.� �rnrn�1111Gr1•
E Watershed District:.
❑ Sisptic' .❑Well
Dt5GK11' 1 1UN yr vvvr%rx i v v- —.1%,
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $
FEE: $
Check No.: Receipt No.:
NOTE: _Persons contracting with unregistered contractors do not have access to the guaranty fund
Si nature of contractor
Signature of Agent/Owrier ., 9..__._._.:._..
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF -SEWERAGE DISPOSAL
Palle Sewer ❑ Tanning/Massage/Body Art ❑ .. .Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales 0
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
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_._
Planning Board Decision:
Comm
Conservation Decision: Comments
Water & Sewer Connection/signagure � Date Driveway Permit
DPW Tow,- Engineer: Sign
FIRE ®EPRTMI'T -Temp Dumpster on site yeas
Located at -i24 MainStreet
Fire Depa0Mer t signature1&te
COMMENTS
Located 384 Osannd StrPafi
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 966 Section 21A -F and G min.$100-$1000 fine
)oc.Building Permit Revised 2010
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
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
o - Engineering Affidavits for Engineered products
dOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp. Affidavit
o 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 Report (If Applicable)
o Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
K)TE: 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm:ated with the building application
Doc: Doc.Bui?ding Permit Revised 2012
Location_ /-I !t �. �l S�U�/ <-,-
No. W Date
Check #41
26333
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $---
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
3 ,-
Building Inspector
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The Commonwealth o Massachusetts Print Form
- — Department of Industrial Accidents
-j Office of Invesdgations
I Congress Street, Suite 100
Boston, MA 02114-2017
y ' www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): MD1 INCORPORATED
Address: 16 WOODLAND ST
LAWRENCE MA 01841
Phone #:978-685-5691 / 978-804-7588
Are you an employer? Check the appropriate boa:
1. ❑✓ I am a employer with 3
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.:
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
coma insurance reauired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. [] Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #I 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.
3Contractors 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 are employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: CONTINENTAL CASUALTY COMPANY
Policy # or Self -ins. Lic. #: UB5B759670
Expiration Date: 11/20/2013
Job Site Address: /,�* t / \ ,oya smoy %r City/State/Zip: Y, Agj poyot ,
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
Phone #:978-804-7588
that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
ZS /1-3
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 #•
Demorla Design & Build
63 WEBSTER ST HAVERHILL MA 01830 (978) 9945497
Building Repair Proposal
4/28/2013
Owner: Fabio Franco Job Site: 162 Kingston St. North Andover MA
Address: 162 Kingston St Use: dwelling
North Andover, MA Construction Type: Wood -framed
Job Breakdown and Cost:
Materials Labor Subtotal
& Equipment
I. Exterior:
a. Replace 7 windows $1,300.00 $700.00 $2,000.00
Totals $1,300.00 $700.00 $2,000.00
Total Amount to be paid for the work to be performed under the contract is $2,000.00
The Job will be completed within 30 business days.
Beginning within 5 business days after the closing date and completed within 30 business days thereafter.
The homeowner is entitled to his/her three-day cancellation period under MGL c 93 s48, MGL c140D or 255D sl4 as may be applicable.
The owner has all warranties on the owner's rights under the provisions of and MGL a 142A,
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
The contractor and the owner hereby mutually agree in advance that in the event
that the contractor has a dispute concerning this contract, the contractor
may submit such dispute to a private arbitration service which has been
approved by the Office of Consumer affairs and Business Regulation and the
consumer shall be required to submit to such arbitration as provided in MGL c. 142A
Owners:
Fabio Franco
Owners who secure their own construction -
related permits or deal with unregistered
contractors shall be excluded from access to the
Guarantee Fund.
All home improvement contractors and
subcontractors shall be registered and any
inquaries about a contractor or subcontractor
relating to a registration should be directed to:
Office of Consumer Affairs and Business
Regulation
Ten Park Plaza, Suite 5170
Boston, MA 012116
Phone: (617)913-8700
Date: Z�( 613
Contra Date:
�Szo13
Demorla Design & Build
Ila.,.achu%ett` - Department of Public SafetA
0 Board of Builtlim, Ke,2ulalionr and 1tantlard%
Construction Supervisor License
License: CS 47056
MARCOS A DEVERS
16 WOODLAND ST
LAWRENCE, MA 01841
Expiration: 10/25/2013
t .tnuui•�ittru r Tru: 5685
r"'%�r• inierr��riirivri�Il r•/r'J���,:.:sn�ri�r/!
Office oiCoosnmer Affairs & Buaibeaa Regulation
NOME IMPROVEMENT CONTRACTOR
e9Istr8ti0n: 106698 Type:
expiration: 7/24/2014 Private Corporatic
MDJ INC.
Marcos Devers
61 WOOD LAND STREET
LAWRENCE, MA 01841 Undersecretary
COMMONWEALTH OF MASSACH
ENGINEERING
REG/PROF CIVIL ENGINEER
ISSUES THE ABOVE LICENSE TO:
If!
MARCOS A DEVERS
16 WOODLAND ST
LAWRENCE MA 01841-2315
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33848 06/30/14 183409
EXPIRATIONLICENSE NO. DATE SERIAL NO.
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International Safety Education Institute (ISEI)
moi'UCSan Diego Extension American
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30 -Hour OSHA Hazard Recognition Training for the Consh icW tndusUy Course
on 8/8/2012
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