HomeMy WebLinkAboutBuilding Permit #678 - 1659 OSGOOD STREET 5/19/2008TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: sJ
Date Issued: / Olf-
Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION
PROPERTY OWNER i Y1( i� U�'✓ 77"t
Print
MAP NO.: PARCEL: ZONING DISTRICT:
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TYPE OF IMPROVEMENTv� _
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
®`One family
❑ Two or more family
No. of units:
F1 Industrial
B'IFepair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION DI~' W OKK I U >3t PKI --r Utti tIJ
OWNER: N
Address:
CONTRACTOR N
Identification Please Type or Print Clearly)
Le
0 k�, tx)r) Etw
MA 6ijyi'
Address: UO &OAr\ U (--k:- AndUpel
Supervisor's Construction License: Exp. Date:
Home Improvement License: 1 S � Exp. Date: -7 U
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERM/T. $12.00 PER $1000.00 OF THE TOTAL ESTIMA TEJKqST BASED ON $125.00 PER S.F.
Total Project Cost S ?u(N FEES
Check No.: /a3o0 Receipt No.: (�
Page I of 4
TYPE OF SEWERAGE DISPOSAL
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Public Sewer ❑
Well
Tobacco Sales ❑
Food Packaging/Sales [I❑
❑
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 fund
Signature of Agent/Owner
Plans Submitted ❑
Plans Waived ❑
Signature of contractor
Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
4
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJECTED
U
FIRE DEPARTMENT - Temp Dumpster on site yes
Fire Department signature/date
COMMENTS
DATE APPROVED
1-1
K61
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
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required
Provided Required
Provides Required
Provided
/
/
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
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC. Jan.2006
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
❑ 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
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:BPFORM05
Page 4 of 4
Location 16f� 0^4000` 5-i��
f
No. �� Date
MORTM TOWN OF NORTH ANDOVER
L
9
Certificate of Occupancy $
Building/Frame Permit Fee $
wcHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ "
Check # . ` J`�� d •
2 1 6 V Building Inspector
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
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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'�-
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector,
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
pensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): V I Z 0,A& ,,Q co h3 6 Qoo i- i N &- S 1 D i N ti T u C.
Address: = &J MtLI S'CP44.4—T :50 t-rZ-
City/State/Zip: K. lbw b Qye n.. t-tPt Q i zq s Phone #: 9)? 6 U 3 `f d -V
Are you an employer? Check the appropriate box:
1. Rr I am a employer with ?
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.]
5. ❑ We are a corporation and its
3. ❑ I atn a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
insurance required.]
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 #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.
$Contractors 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 an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ��E t.�j(y gg�} _ C.p or S--mn _PA
Policy # or Self -ins. Lic. #: VV C 1 aa), MI. Expiration Date: 9 a3 I o i
Job Site Address: ! (_s n0') a�h e J' City/State/Zip: h. `tad d ,, 6 a d 11 vj`
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: n p Date:
Phone #:
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
DAA CASTRICONE
CAS`I'RICONE ROOFING & SIDING INC.
ROOFING, SIDING & REMODELLING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
In North Andover 978-683-3420 In Boxford 978-887-6147 In HaverhW 978-374-73.14
Vwe the owners) 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 premises belowf described: f
Owner's Name ..................................... ... Tele ne# ................................................
St.
t. .....
1.a ...
Job Address......(r:: ...,....S.c. rJ cr z ..... �•.•.......... City....../..U.G .....�r �..u..� .•�..........
J
Specijicatlons:
....................................................................................:..............................................................................................................
Arip existing shingles. I X ply new drip edge to all edges. J4jV S, Ir
1kpply _feet ice and water shield membraue to bottom ed g es of house. 3 feet ice and water shield membrane
In valleys and bottom edges of any unheated areas of house
tAp P 1Y Pp. felt .,u er
•. P_.
.......,�J..i
--•fieroof usiug
...........................................................................................................................................................................................
�0unterflash chimney. `gew vent pipe flashing. c -legal disposal of all debris. ! /�
Area(s) to be worked on...k• y2 :...�.�....... + .........................� ...: ...... l.Gt.>1✓ f "
.. Ski. I .,,..... , ..... Ca fI�
.....�Gt`Lt........... W /11. L'1Uakr . a .. a...................................................................................
........................................................................................................................................�.t.:.......1.�:�..........,..
.......................................................................................................................................................................
Roof board replacement if neeessary @ 4, .. U /sheet 011`y /foot
Two Year Workmanship Warranty (Not Transferable) N�anufgeturer's Warranty as sp "Fre by manufacturer
The co¢¢��(actor a(�rt es t�erform the work 'sh to materials specified above for the S M of $..... rj (j. �•-�}----- •....
Vaable . on ....Gl.
y,..o.�......... .....
}e ........ ..........:........ on ........... ,---::..........Balance payable on completion of job
Owner or Owncts are not responsible for Property Damage or Liability while job is in operation.
Contractor is not responsible for any dwnagc to the interior of pmperty, including pro -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). Ilcmt in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon
completion of above work all undersigned agree to execute and deliver to conavctor, dreir 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 thin, if permitWd by law, contractor shall be paid by the owner(s) all reasonable costs, anomcy 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 my 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, surccssors or estates of the parties. The undersigned wartam(s) that he is (they tut)
the owners(s) ofda; above mentioned premises and that legal title lhcrclo stands of record in his (tlreir) namcs(s). There arc no rcprosonlatioas, 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 is reference herein shall to 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 heals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A.
Approximate starting date of work ................. Completion date .........................................................
Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and dial no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and utcur no penalty (see notice of cancellation).
IN WITNESS WHEREOF, the parties have hereunto signed their
Accepted:
Signed
Signed
David Castricone, President
dayof ..../.:.f j. .......... 20... .
A
Owner
Owner
ACORQ. CERTIFICATE OF LIABILITY INSURANCE7
DATE (MM/DDIYYYY)
9/?_5/2007
PRODUCER phone: 50E-651-7700 Fax: 50H-553-8089
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC -Commercial Lines
233 West Central Street
Natick MA 01760
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
IIJSURED
David Castricone Roofing & Siding Inc
200 Sutton St
INSURERA:Citation Insurance 40274INSURER
B: The Insurance Co of State PA
INSURER C:
`'quite 226
North Andover MA 01845
INSURER D:
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE 1-1 OCCUR
INSURER E:
hn\JCDA/±GQ
TIE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR. THE POLICY PERIOD INDICATED.
NOTWITHSTANDING 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 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY RAVE BEEN REDUCED BY PAID CLAIMS.
TRSR A
L
POLICYNUMBER
POLICY EFFECTIVE
POLICV EXPIRATION
LIMITS
GENERAL LIABILITY
EACHOCCURRENCE
$
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE 1-1 OCCUR
DAMA
PREMISES Eaoccurerxa)
MED EXP (Anyone. mon)
$
PERS014AL A ADV INJURY
$
GENERAL AGGREGATE
$
GENL AGGREGATE LIMITAPPLIES PER:
-C LOC
POLICY PROEl -
PRODUCTS -COMP/OPAGG
$
A
AUTOMOBILE
LIABILITY
ANYAUTO
07MMBBTNKT
8/1/2007
8/1/2008
COMBINED SINGLE LIMIT
(Eaacdclanl)
$
ALLOWNEDAUTOS
X
SCHEDULEDAUTOS
B.IURY
(PeerrppersNerson)
$250000 L50000
X
HIREDAUTOS
X
NON -OWNED AUTOS
INJURY
(Peso dent)
(Per aocidelr)
$500000
PROPERTY DAMAGE
(PeraocIdenl)
$ 100000
GARAGE LIABILITY
AUTO 014LY-EA ACCIDENT
$
A14YAUTO
OTHERTHA14 EA ACC
$
$
AUTOONLY: AGG
EXCESS/UMBRELLA LIABILITY
OCCUR FICLAIMS MADE
EACHOCCURRENCE
$
AGGREGATE
$
DEDUCTIBLE
RETENTION $
$
B
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WC7222278
9/23/2007
9/23/2008
X WC SI"A7U- OTH-
E.L. EACIIACCIDENT
$ 100000
ANY PROPRIETOR/PAMNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEE
$100000
It yyes describe under
SPEGrIAL PROVISIONS below
OTHER
E.L.DISEASE - POLICY LIMIT $ 500000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES) EXCLUSIONS ADDED BY ENDORSEMENT/ SP ECIA L PROVISIONS
1'FRTIFIf1ATC Llnl MCM
VHI\V GLLH I,IV IV
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REP RESENTATI
ACORD 25 (2001 /08)�
m ACORD CORPORATION 1988