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HomeMy WebLinkAboutBuilding Permit #623 - 196 SOUTH BRADFORD STREET 4/7/2006NORTH Of t.ic �1N0 3a Ot p TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION '9SS.1CHl15Et Permit NO: Date Received: �0 Date Issued: J111b IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWN ER Lj &0J <<4 (J 6✓L T (-4- Print MAP NO.: PARCEL: TYPE AND USE OF BUILDING ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Exp. Date: '1 Residential Non- Residential C New Building 0 Addition ❑ Alteration 'One family ❑ Two or more family No. of units: ❑ Industrial vV, Repair, replacement D. Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED en? �- 96 Qr% Identification Please Type or Print Clearly) OWNER: Name: e,�SCNrtIt�,.1o�, Phone:4`��-�Y3-3��� Signature Address: C C S- d1ZA1-9t,-6r?-0 S CONTRACTOR Name:76\" a,l�h2✓fiG/ '"�f Phone: Address: TD 1e- iZ t 0/1 M -r'V l v L -k) X.Zia ) Supervisor's Construction License: 06? /2-0 Exp. Date: '1 Home Improvement License: 13 1 d 5- q Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. N FEE SCHEDULE: BULDING PERMIT. $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S. F. Total Project Cost :$ 1006) -- x10.00=FEE:$ '70 Check No.:(/AO c���"'o / Receipt No.: I TYPE OF SEWARGE DISPOSAL Tanning/Massage/Body Art 171Swimming Pools ❑ Public Sewer Well Tobacco Sales Food Packaging/Sales Private Permanent Dumpster on Site 11.1 (septic tank, etc. NOTE: Persons contracting with unregistered contractors du nut have access to the guaranty fu Signature of Agent/Owner Signature of Contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Elt sped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH11 COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED DATE REJECTED Ir Zoning Board of Appeals: Variance, Petition No: s Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer connection signature & date Temp Dumpster on site yes—no— Fire Department signature/date Building Permit Approved and Issued by: 0 DATE APPROVED DATE APPROVED 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) Doc: INSPFC'I LONA I. SNKVIt TS I)I:PAIZ'I'MI N'I' IAPf•nRMni OcatedJA1C 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 ❑ Debris Removal Form ❑ 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 ❑ Form U ❑ Surveyed Plot Plan ❑ Debris Removal Form ❑ 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 ❑ Form U ❑ 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 111 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 cops' and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORAIOS Location 1?6 S lfw,4-�W - -71 N o. tla 2 - - 74 Date �/ 61�' TOWN OF NORTH ANDOVER Certificate of Occupancy $ -too Building/Frame Permit Fee $ C", Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 U7 Building Inspector or The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wrvw.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/E'ectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t Address: 3 o Teeit City/State/Zip:/A - rePL/'Jyw� Phone #: ynj)- / Are yo an employer? Check the, appropriate box: 1.. I am. a employer with 4- ❑ 1 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 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 These sub -contractors have workers' comp. insurance. ❑ 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' 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 12.21oof repairs 13.❑ Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: 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 their workers' comp. policy information. ' .,an employer that is provtaing warners- UUrrtPe«3u«v14 w -0---j— -,, 'nformatiom assurance Company Name: /41 Nl h V1q--1 ?olicy # or Self -ins. Lic. #: AW e— Expiration Date: / 1 / °! b fob Site Address: / �� ���� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure 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 )f 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 ins.uragce coverag..e verification. r do hereby certify ur er the pains and penalties of perjury that the information provided above is true and correct - 3i store: Date: Y 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 #: 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 dr 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-contractor(s) 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 hould-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 permidlicense number which will be used as a reference number. In addition, an applicant that must submit multiple pernit/lieen.se 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-N ASSAFE Fax # 617-727-7749 revised 5-26-05 www.mass.gov/dia y m m m m m v m y C � � d � O CD C7 Z y CD o F. ? 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O O moo: co o moo: o0 n3 ;w co) co 0CD Im d CL C7 o y O O O O m 3 R z M ~ 'r1 p O p O O O C" to w d cn O 7C to 7d 0 c Residential & Commercial Roofing Chimneys All Types Of CHIMNEYS POINTED -REBUILT -CAPPED Siding Expert Masonry Work Mass Toll Free Roof Leaks Experts Licensed & Insured Locally Owned i!c'OAO& fed Since 1976 ""'-� License #034200 1 -800 -WAIT -4 -US ® (924-8487) IKO �e WveAw oe O©An mas We Work Year Round 978-794-3883 • -975.7531 70 Jefferson St., North Andover, MA 01845 / Temple 1 A 01844 Proposal Submitted To q Phone % Date Street „r�� .-- --'” %r% /f Job Name City, State & Zip Code r �? d tI C /1`1✓ C3 t 5� 3 Job Location Job Phone We Propose hereby to furnish and labor in accordance with specifications below, for the sum of: -7 f i bll a.>,wl � Did Dollars All material is guaranteed to be as specified. All work to be completed in a workmanlike AutholiZed manner according to standard practices. Any alteration or deviation from specifications be- Signature: low 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 NOTE: This pro sal may be or delays beyond our control, Owner to eery fire, tornado and other necessary insurance. w Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not aae ted within days. i L� We hereby submit specifications and estimates for: stall' '3 -feet. of special "Eeve,Seal" ice and water barrier protection along all bottom edges of roof and top to bottom in each valley. if roof is stn poed `we will -apply conventional -ice and water, shield ft. high in the same locations previously described and tar paper will cover the _ remaining bare wood. Any rotted or damaged boards will be replaced at ( .-..-. ) per linear ft. Or( S'o,o-) per sheet of plywood. �nstall heavy gauge aluminum drip edges along every edge surface of each roofline. Cover entire roof (s) with i&_ fiberglass, premium grade shingles (Color of choice). _pi e.L v o,�F S � / ►�' a cl�4~ 6Ri o6c; _, 7_ 4d Replace all pipe boots where possible. L114eal all flashings with clear Geo -Cel sealant. No black tar unless previously applied. Remove all work-related debris. UdContractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. z U-1rocal current references and proof of workman's compensation insurance gladly given. remarks t -- 7 Cl 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 Signature: Awill . be made as outlined ab7., Date of Acceptance; i Signature: \ _ m §§ o § �/\�\. ~� ~ »� � , §� o § y•.. aa $ ƒ 5 A2 a / 222.2 E C�z-. i 0 k ?ƒco .2. 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