HomeMy WebLinkAboutBuilding Permit #736-15 - 17 GRAY STREET 2/16/20151S BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No# :-�J
1
IMPORTANT: A
Date Issued:
LOCATION
must
Print
Date Received
PROPERTY OWNER
Print
MAPID-?4 PARCEL:ZONING DISTRICT
all items on this
100 Year Structure
Historic District
Machine Shop Village
NORTl1
O��q LED 16 1HQ
y0
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7.0 4A En
yes
yes no
yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
o'bne family
El Addition
El Two or more family
El Industrial
"Iteration
No. of units:
El Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑Septic ❑Well
Floodplain 0,Wetlands
❑ Watershed District
Water/Sewer
DE5GKI1-' I IVN VI- VYVKM I v OC rcr�rvr�inw.
Identification - Please Type or Print Clearly
OWNER: Name: ?,, eryl- �1°&1�- Phone'It
Address:
Contractor Name:
Email: fie -
Address: _4/
Supervisor's Construction License: e s - 4 yGo2 7Y Exp. Date: C —/ l� ��
Home Improvement License: / 7/ �" Ag Exp. Date: -3 r�
ARCH ITECT/ENGINEE
Address:
Phone:
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: $ /0, 420&1 FEE: $r�—
Check No.: Receipt No.:
NOTE: Persons with unregistered contractors do not have access to the guaranty fund
-/Z,c <
Location1 ( Ale= =
No. Date
Check #� i O
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $r
Foundation Permit Fee $
Other Permit Fee $
TOTAL .$
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Ari ❑ Swimming Pools ❑
well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑ Pennaneut Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On Signature
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
V
Water & Sewer Connection/Signature ®ate Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPART Located 384 Osgood Street
�MENT ,Tei�np#Dumpster ontisite...,yesu�. + �., �_no��
4Located_ati12�'4rMM-Street
FireDepartment si'gnatui•eldate
* qZ'. - �r q;-'mz-t ea .. ate... A .zt 1.. ♦«y tt„_
COMMENTS. ' _ ,
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of dieter location, mast or service drop requires approval of
Electrical Inspector lies No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA -- (For department use)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
M
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
4� 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
Engineering Affidavits for Engineered products
OTE: 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
Copy Of Contract
Floor/Cross Section/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
TE: 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
Workers Comp Affidavit
4. Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: 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: Building Permit Revised 2014
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INC
CONSTRUCTION CONTRACT
Cheryl Reade, the property owner, desires to contract with, Head Above Builders LLC, the contractor, to
perform certain work on property located at 17 Gray Street, North Andover, Ma.
1. Job Description
The work to be performed under this agreement consists of and is limited to the following:
Demolition of second story bathroom, installing new stand up shower, toilet, vanity, medicine
cabinet, insulation R-21, vent, sheetrock, paint, new subfloor, linoleum, and trim door, window
and baseboard.
II. Payment Terms
In exchange for the specified work, Cheryl Reade agrees to pay Head Above Builders LLC as follows:
$10,200.00 payable one half at the beginning of the specified work, and one half at the completion of the
specified work by cash or check.
III. Time of Performance
The work specified in this contract shall begin upon signature of contract and be completed by the 181h of
January 2016.
IV. Liability Waiver
If the contractor is injured in the course of performing the specific work, Cheryl Reade shall be exempt from
liability for those injuries to the fullest extent allowed by law.
V. Additional Agreements and Amendments
a. All agreements between Cheryl Reade and Head Above Builders LLC, related to the specified work are
incorporated in this contract. Any modification to the contract shall be in writing.
Homeowner
Contractor:
Dated:
Dated: ! �S
The Commonwealth ofMassmchusetts
Department of IndustrialAccidents
_ X Congress Street, Suite 100
- Boston, MA 021.4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/li lectricians/Plumbers.
TO BE TILED WITH THE PERMITTING AUTHORITY.
NaMe (Business/Organizationlindividual): 2Z&
Address:—, -,t:, �/ 7
City/State/Zip:
Phone #: % a
Are you an employer? Check the appropriate box:
1.[g -;a employer with employees (full and/or part-time).''
2. ❑ lam a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. [] lam a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
r-
proprizretorstitID16 emp oyeesm---•—
5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors -fide employees and have workers' comp. insurance.1
6.❑ We are a corporation and its offigers have exercised their right of exemption per MGL c.
152, §1(4), and we have not oyees. [No workers' comp, insurance required.]
Type of project (fequired):
7. 0 New construction
8. ! ,' einodel]rig
9. ❑ Demolition
10 [] Building addition
11.❑ Electrical repairs or additions
Q-Plwnbing-repairs-or_additions
13. [] Roofrepairs
14. [] Other
*Any applicant that checks box#1 must also till out the section below showing their workers' compensation policy information.
I Homeowners who sulinnf this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such.
l'Contraotors 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 fiave employees, they must provide their workers' comp. policy number.
I am an employer that is pi'ovidirzg workers' compensation insurance for my employees.' Below is the policy and joh site
information.
insurance Company
Policy # or Self -ins, Lic. #: Expiration Date:
City/State/Zip
rob Site Address:
,
Attach a copy of the workers' cbApepsation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as xequired under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as well as civil p
be forwarded to the Office of investigations of the DIA for insurance
day against the violator. A copy of this statement may
coverage verification.
Ido hereby certify under the pains and penalties ofpedur",) that the information provided above is true and correct
�Srin� � ��� Date:
ature
IF� z
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 I City/Town Clerk 4. Electrical. Inspector 5. Plumbing Inspector
6. Other
Contact Person
Phone
i —'Office or Consumer Affairs & Business Regulation
DOME IMPROVEMENT CONTRACTOR
egistration: 171422
j Expiration:3/16F2016 Type:
DBA
I' MFCO
j • I
I BARRY. MURPHY
22 SALEM STREET
r BRADFORD; MA 01835
• F
Llndersecretary
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sac
i Ooard cifBuiidln t of Pub,dti 4fe2y :A \
#+►n#ti Reg�ations
and
' ltciion �Pt'�iwr
Standards
1 license: Cs -040278
BARRY T MIJRPIjV
�vERSTREET rir ��
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. Commiss_ionneer'
Expi ratipn
06/14/2016