HomeMy WebLinkAboutBuilding Permit #672 - 199 STONECLEAVE ROAD 5/22/2008-�
BUILDING PERMIT
TOWN OF NORTH ANDOVER c?
APPLICATION FOR PLAN EXAMINATIO
Permit NO: Date Received ��Z�a"
�.9 q0RArap PPP,�'�(i
' D� SSACHUSE
Date Issued:
IMPORTANT: Applicant imust complete all items on this page
LOCATION ®ld-IK's—
Print ,._._.
PROPERTY OWNER�/t�i" c/'
Print
MAP NO: 0�,d PARCEL:01-3/ ZONING DISTRICT: Historic District yes no
Machine Shop Village yes F
TYPE OF IMPROVEMENT
PROPOSED USE -
Residential -
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septi WeN
Floodplain Wetlands
Watershed District
iter/Sewer
_ DESCRIPTION OF WORK TO BE PREFO"ED''
Identification Plea Type or Print Clearly)
OWNER: Name: Phone:
Phone:
Address. f 9 g sy��1-G'y /" �• J s-�C— , �t
CONTRACTOR Name:/��77fS?'��!%a S Phone:
Address: 2 t1&-)�7TN2 Ale
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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: $ FEE: $ 4�'�
Check No.: l Receipt No.:
NOTE: Persons contracting ;i[h unregistered contractors do not have access to the guaranty fund
re
re of
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public SewerSwimming
Tanning/MassageBody Art
Pools'
Well
Tobacco Sales
` ' • ,:i ~''_�
gl'Sales`
Food PackaginSal
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 Reviewed on L���� Signature
COMMENTS
Pbb c��ccr� co c� �S Gam- o jc,5�
HEALTH Reviewed on D Si nature
l/
-`-COMMENTS
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
DPW Town Engineer: Signature:
FIRE DEPARTME-NTS•- Temp Dumpster on site
Located at 924 Main Sireet - f'—
Fire Department signature/date
COMMENTS
Locateo 364 USQ00C1 Street
a
yes `*_ no, = ��
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
❑ 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
�f
❑ 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)
❑ 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
❑ 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 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:BPFORM07
Revised 2.2008
Location
No. Date
*O*Tpl TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
14us
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 1 1 55)
U Building Inpector
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The Commonwealth of Massachusetts
Department of IndustrW Accidents
Office of Investigations
600 Washington Street
Boston, AL4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electric"'
ans/Plumbers
D icant Infnrmafinn
Name (Business/orpmization/Individual):
Address: .
City/State/Zip: TS944 r�
Are,you an employer? Cheek the appy
1. am a employer with
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working forme in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
J ti'
/4 J e
r►/i �i • C(X 3_�Phone.#: 3 / 59
date box:
4. 0 I am a general contractor and 1
have hired the sub -contractors
listed on the attached sheet
These sub -contractors have
employees and have workers'
comp. insurance.#
S. ❑ 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
10.0 -Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑� Roo�epairs
13.0,6
er 4 &Je GAoj,,j
*Any applicant that checks box #1 must also fill out the section below showing their w I—
t Aon owners who sub :dt this da�tit also
fill out e••e doing g ori compensation policy information.
b ^i a all work and then hire outside contrz�•tors must submit a new r�rdavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub conuacto s and staff wit�tt ,r o� not those entities have
employees. If the sub-contractors.have employees, they must provide their wor
kers' comp: policy number.
I am. an employer that is providing workers' compensation insu
information. rance for my employees Below is the poticy.and job site
Insurance Company Name:_
Policy # or Self -ins. Lic. (00 f 1 j9, D I oZOO �q
j +?� Expiration Date: 02 'I
Job Site Address:_ / 9 (S-r✓� C%�q �/C %
City/State/Zip:Aj, 4AJdO ,/t--
Attach a copy of the workers' compensation policy declaration page (showing the poiic}, 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 imof position
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 D DE a
Investigations of the DIA for' coverage verification.
Ido hereby Zceder the pains •and penalties of pe 'ury that the information provided above is true and correct
Si store:��✓
Date:
Phone 0..:
Flssuin',,
only. Do not write in this area, to be completed by coy or town official
Town:'Permit/License #
hority (circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. plumbing Inspector
soa•
Phone #:
AA�Vw of
PSP
BBB NSPB Inc Installation Contract �ME e R a,='
21 Tiverton Ave Bradford MA 01835 Phone. 978-235-4959 Fax 866-470-0944 www.pool2u.com
This contract/ is entered into on y 'Jam" 0 t? , by and between North Shore Pool Builders, and:
dv/J .Xe C -If --Irl i' -s-5 , Hereafter " Owner".
For valuable consideration the parties do hereby agree as follows:
Scope of work: North Shore Pool Builders shall provide all labor and materials, and will construct pools for owners at the residence as
described by the plans and specifications (hereafter "The Project") selected by owners and more particularly described as "Pool
Construction". Copies of said plans and specifications have been executed by North Shore Pool Builders and owner on the date hereof
and hereby made part of this contract.
Work Site: The project will be constructed on property of the owner located at
M9 6Y-01JeCJe-1Vf- � 11)60KY-I, ✓er- 1-0d6: G l svp
And more particularly described as `residence" (hereafter "The Work Site"). Owner hereby authorizes North Shore Pool Builders to
commence and complete the usual and customary excavation and grading on the work site as may be required in the judgment of the
excavating contractor to complete the project. Unless called for in the specifications no landscaping, finish grading, filling or
excavation is to be performed at the work site by North Shore Pool Builders except if required.
Permits: Owner shall apply for and obtain permits and regulatory approvals that may he required_ by the local municipal/county
government, the cost thereof shall be an expense of the owner.
Not Responsible for underground utilities or use of nonconforming utilities: North Shore Pool Builders shall have no
responsibility for the condition of the soils at the work site. Any excavation, filling or other work required by the owner other than the
usual and customary excavation and grading shall be an additional expense of the owner. Owner shall determine before construction
begins if additional site work is required because of soil conditions at the work site and shall provide North Shore Pool Builders
specifications as to such additional site work. North Shore Pool Builders shall not be responsible for any damages suffered by owner as
such result of soil conditions at the work site.
Excavation Service: When excavation is performed owner must be present. Any charges other than normal customary charges will be
responsibility of the owner and will be determined by excavator at the time of excavation. Since different landscapes may require extra
charges if any. These charges will be invoiced in addition to the NSPB Inc Fee below at completion of Installation.
Sand delivery: Proper access should be made for delivery of sand. North Shore Pool Builders is not responsible for moving sand from
driveways and places other than excavation site. We will charge for moving sand from driveways and other places as deemed
necessary for pool construction. Furthermore we reserve the right to reschedule installation due to actions resulting from improper
access of sand delivery.
Insurance: North Shore Pool Builders maintains workers compensation to insure against risks covered by insurance. North Shore Pool
Builders is responsible for any worker's compensation coverage or payments required and will indemnify and hold owner harmless for
the payment of claims against owner.
Changes to scope of work: Owner may make changes to the scope of the work. However, any such change or modification must be
made by written "Change Order", in the form of a letter to North Shore Pool Builders specifying the changes. Owner agrees to pay any
increase in the cost of the project as a result of change orders. In the event the cost of the change order is not known at the time the
change order is executed, North Shore Pool Builders will estimate the cost and the owner agrees to pay the actual cost whether or not it
is in excess of the estimated cost. I
North Shore Pool Builders fee: Owner agrees to pay North Shore Pool Builders the sum of {S /�-( , } for
performing the services set forth in the scope of the work. Including Installation mileage up charges for your town. North Shore Pool
Builders will be paid as follows: In Full on completion.
Late Payment/default: Owner agrees to pay a late charge of 5% of all late payments which are more than ten (10) days late plus all
costs of collection including reasonable attorneys fees in the event payment is not made in accordance with the terns of this contract.
Water Charges: If it becomes necessary to have your pool drained to have a repair issue fixed, North Shore Pool Builders is not
responsible for water charges resulting from water tankers.
Warranty: North Shore Pool Builders warranty shall be limited to defects in workmanship within one (1) year from the date hereof.
North Shore Pool Builders does not warrant defects arising after one (1) year and defects in material. North Shore Pool Builders hereby
assigns to owner all warranties on materials as provided by the manufacturer thereof.
Insect/rodent damage or any acts of nature: North Shore Pool Builders is not responsible for insect and or rodent damage or any
acts of nature that may result in damage to installed pool.
Witness the siYng atures of the parties hereto on the date first written above.
North Shore Pool Builders: / °-✓ �/ �t�?�!' �/� U�
Owner: ✓
Q -1
OFFICE OF
41 BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
Ce North Andover, Massachusetts 01845
CC
C
Gerald A. Brown Telephone (978) 689-9545
Inspector of Buildings Fax '(978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please pk
DATE:
JOB LOCATION: —.
Number Street Address
e--
HOMEOWNER ld A
,eL,
Name
PRESENT MAILING ADDRESS -
LV -I-Own
Home Phone
p
Stec
Work Phone
Zip Code
The ctuz ent exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to enpge an individual for hire who does not pan= a license, provided that the
Owner nM as supervisor). State Building (Code $ection. 108.3.5.1) ,
DEFINMON OF HOMEOWNER
Person(s) who owns a parcel of land on which helshe resides or intends to reside, On which there is, or is intended
to be, a one or two family stzmctures. A person who cmshmcts more that one home m a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" as== m9mmWity for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned -homeowner- certifies that he/she understands the Town of North Andover Building Department
mqxction procedu= and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNA
I
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
To= Homwwams Examption
BOARD OF \.PPEALS 699-9541 CONSERN.V11ON698-9530 TTE-UMI 6X8-9540
PL.VN-NrNG 68N-9535