HomeMy WebLinkAboutBuilding Permit #049-15 - 20 CAMPBELL ROAD 7/15/2014 BUILDING PERMIT of "ORT" qti
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: ® l J Date Received
7.9��H.aTeo I.FP�.(5
... � SSACHUSfa
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION -
PROPERTY OWNER
nn . �r100 Year Structure yes nq
EMAP . ARGEL--: �Z-,NING DISTRICT _ �Histonc'Drstrict ye� ,r o
aching Shop Village ye-a no .
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
D��Se tic` ❑�1%1/I - - `"`; ,�. � -�-�_� �- �,
p .� .❑IFloodplam: ❑`Wetlands t, ❑ Watershed�Distnct j
'Water/_Sewer k - _ 7
_- ..
DESCRIPTION OF WORK TO BE PERFORMED:
l � l` i
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address: C.1/�
; .r -J'.�f/�'' .. ..• �' -a"�'q� ...� �� � '� �: ;" ,..,:;--tis- ;M Tom' -r'_ -
Coritractor�IVame
VQddress
��Sup`erv�sor;s'C�onstruction iLicense t _ �� _ p �D to.,��,��� ` �^
w
Home Improvern_entr�License: . - %�€Expo:
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: $ C U
i
Check No.: Receipt No.:
NOTE: Persons contracting with gist red contractors do not have access to the guaranty fund
Signature of AgentlOwner Signature of-contractor�. �` r r
. S
Location r—t p PP
No. 7 "3 _ , -- # Date !
• ' TOWN OF NORTH ANDOVER
.,x �•
• . • Certificate of Occupancy $
Tf Building/Frame Permit Fee $ L ta�
.' Foundation Permit Fee $�
`y. Other Permit Fee $
TOTAL $
Check#Ji 7
c'""� �
t}
Building Inspector
Plans Submitted El Plans Waived.El Certified Plot Plan El Stamped Plans ❑
TypF 6F SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION -Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
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:
Located 384 Osgood Street
-."'�'�-,��.''..~^ fi 't � ..�: �,.�.IFRE!0EPARTRMENT< Temp ®umpste_r onVisite ye - 4 -_ J-p-
(Locatec3rat124Main.Street "" 'II
fife�Departme�r t signatur%date,
000"MMRN,
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 No
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 Pennit Revised 2014
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/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.
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
'
L, 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:Building Permit Revised 2014
777
EIN#51-050-3313 Haverhill MA 978.374.9224
. MA Reg,HIC#149221 mbe . Lawrence MA 978.687.7339
MALic.UCS#78130 ' Hampton NH 603.929.9224
BBB. Single-Ply License#1711 F&ftn9 Hampstead NH 603.329.8200
'SCwu=4ei1932 CO- Toll Free 1.888.SOS.ROOF
._•265 Winter Street
Haverhill MA 01830
I 1 n *Li ed *Insured *Factory Trained *Factory Certified
Name: (� Date:
- r7/7
Telepho 7 a '5?3 L4(ZI,Alt. ephone: _Email: _
pp �� �
Billing Address: v� City: /V� �? �((1XI State: U _
-Job Address: ~� _ - - . City: State:
Scope of Work XStrip and Re-roof ❑Re-roof Approximate Roof Area:
❑ Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected.
❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site.
❑ Inspect wood deck,if we'discover any rotted wood,replacement will will performed at*$ 3 ,93 per LF for roof deck boards. If
substantial deck rot is discovered,re-sheathing of roof deck can be performed at*$ l Za . per SR If individual sheets are found to be
rotted/or de-laminated,removal,disposal and replacement will be performed at*$ 50= per sheet.If any trim boards are rotted,
replacement will be performed at*$-12 ' per LF for new pre-primed pine.Inspect siding at roof line and all flashing behind siding,if
we discover any damaged flashing or siding at the roof line,replacement will be performed at*$ .If wood deck,siding,and
flashing is sound,we will re-nail any loose wood to rafters,sweep deck,and prepare for roofing.
❑ Install 8"drip edge to all rakes and eaves.Color / rr
❑ Apply ice&water shield(UNDERLAYMENT)as per manufacturers'specifications and/or d
❑ Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck.
❑ Re-flash all plumbing stack pipes,and any roof pgetrations as required and dictated by good roof practice toe u t tightness.
❑ If upon inspection,we discover chimney lead to bcd worn or deteriorated,replacement will be performed at*$ _.
❑ Install a new: �Year ❑ Traditional X�Architectural O Designer Color
❑ Furnish and Install a new shingle over style ridge vent system ❑Soffit vent system*$
❑ All debris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the job site in a legal fashion.Under no
circumstances will the watertight integrity of the buil ding b compromised.
Special Notes J�' S
Ar I hsou 0 vU
t r
s U
UPON COMPLETION AND PAVMENT IN FULL,R OF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF
YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND/ S YFAfZS HONORED AND ISSUED B TH
SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ 1'i^"k� ��Ut~
*Denotes potential additional costs above the total estimated price. SdG�
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the materials and labor specified above for the total sum of: $
(Dollars)
Payment will be made according to the following work schedule: ,� f
$ deposit upon signing contract j �/G �S 1 g 35a.' 5b6
$ by_/_/_or upon completion 6f
$ upon completion of contract.
(Law forbids demanding full payment until contract is completed to both party's satisfaction)
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram or by delivery,not later than midnight of the
third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
Acceptance of the Contract Proposal
Home Owners)Signature(s): Date: 7 bn 1 L!!L..
IT
contractor's Signature: Date:
_lamhPrtrnnfino_rnm /Di—,
NORTfi
Town of 2 : 1, ndover
O - 0
No. i� y
h ver, Mass S 114
Y o >
COCHICMt WICK �1'
GATED
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
...................c:. ........... :�L........ ..................................................
. ... . . ... .. ..
has permission to erect buildings on � G.4:!! 4.f4?.�i.t.�C rr.....��...... Foundation
.......................... ........ .... ...
T � Rough
to be occupied as .......... ...!.... :..........:t.. ............................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application
Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
I f PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
` !o • UNLESS CONSTRUCTIO T TS Rough
Service
.................... .. ....................,................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
The Commonwealth of.M'assachasetts -
Departm ntoflndifstrigl,4ccidents
Office oflnvestigations
644 Washington.Street
Boston,MA 42111
www:masss govIdia
workexs'Compensation Insurance Afidadt:Builder,-IContractorsIRlectr cians/Pliiiiabers
At Cheant Information Please 'rzn Ite�ibXv
Name(Business orgadzation&(R-viduat): Z"h
Address:
City/Stade/Zsp: t/L D Phone#:
Are your an employer?Check the appropriate box: Type of project(required):
4. El I am a generacontractor and I
Al am a employer with� l t
� 6. E]New construction
employees(fall and/or pail time)* have likedthe sub-contractors 7. [1 Remodeling
2.C] I am a sole proprietor or partner listed on the attached sheet..
ship and'havena.employees These sub-contractors have 8. [lDemolifon
working forme in.any capacity. workers'comp.insurance. 9, []Building addition
[NO workers'comp.Insurance 5, ❑We axe a corporajion and its 10.[]Electrical repairs or additions
required.] officers have exercised.their
3.[] I am a homeowner doing all work right of exemption per MOL 11.[]Plumbingrepairs or additions
myself.[No workers'comp. c.152,§1(4),andwehaveno 12•[]Roofrepairs
insura-acerequired.]i employees.[No workers' 13.[]other
comp.insurance required.]
MW applicant that checks boxil must also flt out the section be-16w showingtheir wbrkere eompensadonpoHcy Momation.
'Homeowners vrlio sabmitthis affidavit indicatingthey 94 doing allworlc and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis box must attached an additional sheet showingthe name of the sub-contractors andtheir workers'camp.policy information.
lam an employer thatisproviding workers'compensation insuranceformy ernproyees Below isthepolicy anctjoh site
information. `
Insurance Company Name:_
Policy#or Selz ks.UG.#": 4 o9���C���� ExpirationDate: d '_
rob Site A ddxess: � � S� City/State/Zip:
Attach,a copy of Me workers'compensation-policy declaration page(showing-the policy number and expirations date).
Failure to secure coverage as required.under Section 25.A.ofMGL o.152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year impasq ent,as well.as civil penalties in the form of a STOP WORD ORDER..and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statementmay be forwarded to the Office of
Investigations of the DSA.for insurance coverage verifcation.
ided above is true and correct. -
X do 71ereby cert f der ine pains and penalties of penury that the information pro v n Y�^
Sinat�zre Dat •
e
Phone#•
official use ortly. .Do not write in this area,to he completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle(ne):
1.Board of Health 2.BuildingDepartment 3.City/Town Clerk: 4.Electrical inspector 5.Numbing Inspector
6.Other - -
ior,
Information and Instructxol.s
Massachusetts General Laws chapter 152 requires
all employers to provide workers'compensation for their employees.
Pursuant to this statute,an ev ployee is defined as"...every person tfii the service of another under any contract o hire,
express oximplied,oral or written."
An erloye is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo ormore
of the Foregoing engaged in a joint enterprise,and includingthe legal representatives ofa deceased employer,.or the
receiver ortnistee of an individual,partnership,association or other legal entity,employing employees. SSowever the
owner of a dwelling house having notmore than three apartments and who resides therein,or the occupant ofthe
dwelling house of another who employs persons to do maintenance,construction ox 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"
MOL chapter 152,§25C(6)also states that"every state or local Xicensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth fox any
applicant who has not produced-acceptable evidence of compliance with,the insurancecoverage required:'
Additionally,MGL chapter 152,§25C(7)states"Neitherfhe commonwealthnor any of
its political subdivrsions shall
enter into any contract for the performance ofpublic workuntil acceptable evidence of compliance with the insurance
requirements of this chaptexhave beenpresented fa the contracting authority.."
Applicants
Please jilt out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)nam.e(s),address(es)andphonenumber(s)alongwiththeircertiricafe(s)of
insurance. LimitedUability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees otlierthan the
members or partners,are notrequired to carry workers'compensation,insurance. If an LLC ox LLP does have
employees,apolicyisxequired. De advised thattbisaffidavit maybe submitted tothe Department of 1ndustrial.
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 fox the permit or license is being requested,pot the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required fo obtain,a workers'
compensationpolicy,please call the Department atthe 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 andprinted legibly. The Department has provided a space at the bottom
of the affidavit for you to fin out in the event the Office of Investigations has to contact you regarding the applicant.
Please be-sure to fill in the pen if/license number whichwill be used as a reference number, In addition,an applicant
thatmust submitmultiple.permit/license applications in any givenyear,need only submit one affidavit indicating current
Policy information(ifnecessary)and under"Job Site Address"the applicant should-write"all locations is (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 proofthat a valid affidavit-lion fide for future p ennits or licenses. Anew affidavit must be filled out each
year.Where a.home owner or citizen is obtaining a license oxbermit not related to any business or commercial venture
(i.e.a dog license orpermit to burn leaves eta.)said person is NOTmquired 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:
Tho.Can oxtwea th orM 4MSac „ e
DepartMAt QXIAJUaxial A cc deztt
Of oe 0:0*1*1000-Ag
49.
Revised 5-26-05 Fayfi ��
www-Mawago-V1414