HomeMy WebLinkAboutBuilding Permit #734-14 - 194 RALEIGH TAVERN LANE 4/22/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued:
IMPORTANT: A plican
L' OCATIQN.['1_tt .,g4� L
`PROPERTY OWNER
C�PARCEL: aZONIIVG�
Date Received
t must complete all items on this
P{IntX
Print ; 1O 0, Yea Old gi
D1!STRICTH i,s.tbre ®istr
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TYPE OF IMPROVEMENT.
PROPOSED USE
-
Address: I tj�. nJ
Residential
Non- Residential
❑ New Building
0/0ne family
honCe:
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
$❑ Septicsµ❑Well g
;, Floodpl Wetlands
V11 rshdtDistnct
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a s t
❑'1Nater
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DESCRIPTION OF WORK 1 O tat 1-tM1-uruv1tU:
Identification Please Type or Print Clearly)
OWNER: Name: M 2 S:n�v2 W
-
Address: I tj�. nJ
Lien.
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honCe:
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Supennsor's Construction .License ��-—�
1Exp ,t
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Phone:
7V
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ARCHITECT/ENGINEER Phone:
Address: 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: $ Ing FEE: $
Check No.: ` Receipt No.: l L"
NOTE: Persons con acting with unregistered contractors do not have access to the guaranty fund
r _:Seg�at'ure�of� contractori`�,.c,�;l�u r�.�:;
Plans Submitted L.] Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ PI'ans Waived ❑ .'..,.Certified Plot Plan ❑
Stamped Plans ❑
--TYPE-FOUEWERAGEDiSPDSAL `
Public Sewer ❑
Tanning/Massage/BodyArt ❑ ...
_Swimming Pools ❑
Well ❑
Tobacco.Sales 0
Food Packaging/Sales ❑
Private:(septic tank, etc:. ❑. - - ; .
permanent DUmpster on Site ❑
7HE. FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF U FORM
PLANNING &DE\lELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
k�
-_:-,DATE REJECTED
El
DATE: APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Con nectionlSignature & Date Driveway Permit
DPW To -*d : Engineer: Signature- '.
Located 384 Osgood Street
FIRE DEPART- M; NT Temp Dumpst8r an site yes no
Located at :124£Mair, Street { _ _ ,• �,
Fire D _
epa
rtme►ltsignature/date y '` x4 ,.y: a, w .� x- a#t ��, a r- •' :�
COMMENTS `�` _
-Dimension
i
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
Total land -area; sq. ft.: -
ELECTRICAL: Movement o.f.Meter, location, trust or service drop requires approval of
Electrical Inspector Yes No
DANCER ZONE LITERATURE: Yes No
MGL -Chapter -166. Section 21A =F and G min.$100=$1000 fine
NL)TE5 and DA 1 A — (For department use)
LI Notified for pickup - Date
Doe.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
❑ 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
NOTE: 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/Crossection/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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
E
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers. Comp Affidavit
o 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
❑ Engineering Affidavits for Engineered products
NOTE: 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 apn•-�al period is over. The applicant must then get this recorded at the Registry,of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Pe.rnut Revised 2012
Location
la—
No. Date 114
IF
Cheff
27,476
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee, $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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PROPOSAL
"HERB" ROUSSEAU & SON, INC.
Vinyl & Aluminum Products
i I LR u �-Qv8o*+26,2=-- Lowell, Ma 01853
Free Estimates Tel. (978) 453-8626 or (603) 321-4733
Vinyl & Aluminum Siding - Combination & Replacement Windows & Doors
Proposal Submitted To: Phone: Date:
Mr. Steve Webb 617-909-4260 March 12,2014
194 Raleigh Tavern Lane
North Andover, MA 01845
We hereby submit specifications and estimates for:
Strip off existing siding and haul away all debris.
Certainteed Monogram vinyl siding, color and size to be chosen by homeowner and to be
completely installed.
Install Tyvek paper on entire house.
Repair all rotted wood around windows and doors.
Cover all window and door trim with aluminum.
All soffit and fascia trim to be covered with aluminum and vinyl materials.
Vinyl light blocks, and dryer vent to be installed where needed.
Install approximately160 feet of aluminum gutter.
Yard to be left clean of all debris . ..............................$12,900.00
Optional: Install vinyl shutters..............................................$65.00 per pair
All items on interior walls to be removed or secured.
Lifetime warranty on labor and materials.
We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum
Of: TWELVE THOUSAND NINE HUNDRED DOLLARS AND 00/XX----- ---$12,900.00
Pavment to be as follows: One half down when job is started and remainder upon completion.
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration
or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other
necessary insurance. Price is goa for ninety d s u I th ise agreed upon.
Authorized Signature:
ACCEPTANCE OF PROPOSAL - The above prices, specifications and conditions are satisfactory and are hereby accepted, You are
authorized to do the work as specified. Payment will be made as outlined above.
Signature: Signature:
Date of Acceptance:
YOUR RIGHT TO CANCEL - You are entering into a transaction that will result in a security interest on your home.
You have a legal right under federal law to cancel this transaction, without cost, within three business days from whichever of the following
events occurs last:
1. the date of the transaction, which is the date customer signs retail sales agreement.
2. the date you received your Truth -in -Lending disclosures; or
3. the date you received this notice of your right to cancel.
If you cancel the transaction, the security interest is also canceled. Within 20 calendar days after we receive your
notice, we must take the steps necessary to reflect the fact that the security interest on your home has been canceled, and we must return to you
any money or property you have given to us or to anyone else in connection with this transaction. You may keep any money or property we have
given you until we have done the things mentioned above, but you must then offer to return the money or property. If it is impractical or unfair
for you to return the property, you must offer its reasonable value. You may offer to return the property at your home or at the location of the
property. Money must be returned to the address below. If we do not take possession of the money or property within 20 calendar days of your
offer, you may keep it without further obligation.
HOW TO CANCEL - If you decide to cancel this transaction, you may do so by notifying us in writing at:
914 Maple Street, Lowell, MA 01852
You may use any written statement that is signed and dated by you and states your intention to cancel, and/or you may use this notice by dating
and signing below. Keep one copy of this notice because it contains important information about your rights.
If you cancel by mail or telegram, you must send the notice no later than midnight of the third business day (must
be dated) after you sign the RSA, (or midnight of the third business day following the latest of the three events listed in the section "Your Right
to Cancel'). If you send or deliver your written notice to cancel some other way, it must be delivered to the above address no later than that time.
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ACORL 'XCERTIFICATE
CER TIFI AT.E OF .LIABILITY]� SURANCE
DATE (WAIDDM'Y )
0311713014
THIS CERTIFICATE IS ISSUED ASA. MATTER. OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE' DOES NOT (AFFIRMATIVELY 0R..NEGATIVELY AMEND; EXTEND OR ALTER THE COVERAGE AFFORDED .BY THE POLICIES
9ELOW. THIS CERTIFICATE :OF INBU.RANCE DOES, NOT CONSTITUTE A CONTF.ACT BETV.vIEEN THE ISSUING INS.UFiER{Sl, AUTHORIZED
REPRESEIVT,471VE OR OROD:WG.ER; AMD THIS CERTIFICATE HOLDER., ..
IMPORTANT, .if the certificate holder is an ADDITIONAL INSURED, the pulicy(iesj rr0st be endorsed:. If SUBROGATION IS wAIVED, subject to
the terms and condfir16m of tha pollcy, :ce. rtsln. pollcles may. raqulre an endorsement: A statement: on this, to tlfiute does not confer :rights. to the
certificate holder In lieu of such andorsement s
PRODUCER Phone:978-6N-2266
NAIAE
North Andover .Insurance Agency
WM J. Foster Insurance Services Fax: 9T8-B8Fi-641
M1n St,
North Andover, M.A 01:8A5
MA FOst9r. insurance :Services
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INSURER($) AFFORDING COVERAGE NAIC.#.-
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316 ,Ie n.St ......
Lowell, MA01862
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INSURERS:
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS I.S TO CERTTY :THAT THE POUCI:ES.OF INSURANCE LISTED SELOW HAVE BEEN ISSUED TO THE:INSURED NAMED:ABO'VE FOR. THE POLICY PERIOD
INDICATED. NOTWITHS?ANDING A. NY REQUIREMENT, TERM OR 'CONUTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO JvHICH THIS
CERTIFICATE. (d1GY .BE.1S$UEU :vI'•..MAY PERTAIN. ,THE INSURANCE AFFGRDEC..°Y. THE, POLiCIE$. DESCRIBED. HEREIN IS SUBJECT TO ALL THE TERMS,.
EXCLUSIONS AND CONC TIONS OF SUCH POLIGIE5. LIMITS 5H�34fdiN P^,dY NAME 6 EPa REdUGE ] BY PtiIL� CLAIMS.
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WORKERS CoiAPEIdSATION.
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:DESCRI.pTION be CPERr"To,4910CATIONSI VEHIC E$ :(, 4tath1ACOR.D 9;01, AQd}tlonelR4rilerki S>;P�edule;if'rhora,sa3ae:1erequ!rsd)
RLE: `(EBB r 2.9:4 RiALIEGH TAVERN LANE
TOWN OF NORTH:AN:DOVER
5.600 OSGOOD .ST.
NORTH ANDOVER, .nAA 011845
SHOULD 414Y OF THE MOVE DES,CRISE0.12OLICIES.BE CANCELLED BEFORE:
THE EXPIRATION DATE THEREOF, NOTICE WILL BE _DELIVERED Irl
ACCORDAtiCEWITH THE POLICY PROVISIONS.
kU7HURILEDR5PRE3eNTA-r E
Ci 100-2010 ACORD CORPORATION. All -rights -reserved.
AcbRQ 25 (2010/05) The. ACOAD name and iogo are: registered marks of ACORD
The Commonwealth of Massachusetts -
Department ofIndustrigl Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
UT. www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): J J e ,,, k 'i� q S �j P u"') i N c -
Address: 7D 13 n k 1-2- C,
City/State/Zip: Lo w e t t r fQ 0 t kj', Phone #:
Are you an employer? Check the appropriate box:
1. ❑ 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.
workers' comp. insurance.
5. VK We are a corporation and its
[No workers' comp. insurance
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. 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.EiKother i/r�v4IZ ci�iN t,
I ,
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they ate doing all work and then.hire outside contractors must submit anew affidavit indicating such.
TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Policy # or Self -ins. Lie.
Job Site
Expiration Date:
City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certo under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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 M.
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 hire,
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
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
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 the grounds 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), addresses) 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 for your 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 ofIndustrial Accidents
Office of Investigations
600 Washington Street
Poston} NSA. 0.211,1
Tel, # 617-727-4900 ext 406 or 1-877:MASS.AFE
Revised 5-26-05 Fax ## 617-722.7749
www.x�aass,govfdza