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HomeMy WebLinkAboutBuilding Permit #529 - 20 JOHNSON CIRCLE 4/9/2009BUILDING PERMIT'` TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:� Date Received 0 M i `* 0 cu.w�w�Y..cw i. , 4, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: 11 Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �ptrc ��1�� I 4 a n etl� r rDi � n 1 7� a r DESCRIPTION OF WORK TO BE PREFORMED: OWNER: Name: L Please Type or Print Clearly) Aririraec• R o U c��V,, e,,P o -CL -s- /U/4 Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 5 )'1 O 1 © FEE: $ Check No.: atq,l Receipt No.: NOTE: Personcontracting with unregistered contractors do not have access to the fuaranAo fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF 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 DATE REJECTED DATE APPROVED PLANNING. &_DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED 9 0 DATE REJECTED DATE APPROVED 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 Located at 384 Osgood Street 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 2 1 A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2007 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) a 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 2.2007 Location 9) `tC knj 0 eN CIA No. a� Date NORTIy TOWN OF NORTH ANDOVER 16. s Certificate Occupancy + ; • of "^•e° .'<�' Building/Frame /Frame Permit Fee �Ss�cMusa 9 $ $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # V Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ohe�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers j Applicant Information Please Print Legibly Name (Business/Organization/Individual): AU- U ^x 6 -'rA Address: 3 ' 1 -c -N^ Ptt 12t( City/State/Zip: tA-��--'" +� ►'�->; Phone M ?'V - '"5_ -9573 I ►re you an employer? Check the- appropriate box: ❑ I am a employer with `14- 4. ❑ I am a general contractor and I employees (full and/or part-time). ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] ❑ I im a homeowner doing all work myself. [No workers' comp. insurance required.] t have hued the sub -contractors listed on the attached sheet. 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. EJ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.2 -Roof repairs 13.❑ Other ny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information' omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such rntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. )m an employer that is providing workers' compensation insurance for my employees. Below is the.policy and job site °ormation. ;urance Company Name: Aft /-N Ecy # or Self -ins. Lic. #: % �- J 64 ° 2 °O Expiration Date: Site Address: �' J `'� S , C ,.a 0-A i0 City/State/Zip: tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a .e 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 up to $250.00 a day against the violator:- Be advised that a copy of this statement may be forwarded to the Office of restigations of the DIA for insurance coverage..verification. 'o hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct ck(-,j,.,,I 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 #: z s•. 9 ui om o 0 O ` 0 O y c O CCD C.3 •dam `� CL = W o o w a v cn W G .°U ro G o w o a: v Uw" G a o u: ro w" W �o o cz v cn G w" o w co u". w v o z cn v Q cn ui om E Moa ce 0 N C O a co m cm m 0 CD c N m t O Z O J CD F. CO z 0 U -e ZA .3 O of v .3 W P4 a� 0 ai ■ L c V Z CD CL O h � C I Com_ H Q C CO2 'g m m CD CD t �3 CD CD0 M o a o- CM< ev Q 'v .CL. O°r CA Z CD CL V y C� . C _c C. CO2 C LLI 0 N U) 19 W LLI 19 LLI UA o O ` O y c O CCD C.3 •dam CL = O Cc E f S a h • O m .ow CJs mcm CD c CD m O ?-- w y O 3 C! � m 3 c H W ca0 m mo p aw LZ go m scoo y C Z OCL m Q CC33 'y Z O co O H m y m C = m;awo y � W �0+ m �0.. = O -Us O 'r C .. �C.t O C W M o ... .E 'O Q Q, C3 CD CH a m� O� H _ .0 O 0 - a 4 -m E Moa ce 0 N C O a co m cm m 0 CD c N m t O Z O J CD F. CO z 0 U -e ZA .3 O of v .3 W P4 a� 0 ai ■ L c V Z CD CL O h � C I Com_ H Q C CO2 'g m m CD CD t �3 CD CD0 M o a o- CM< ev Q 'v .CL. O°r CA Z CD CL V y C� . C _c C. CO2 C LLI 0 N U) 19 W LLI 19 LLI UA rim PEARY i NSURAW AGENCY 9788871149 Nwryinsurance Agency i22 Chickering Road 'I Andover, MA 01845 c CERTIFICATE OF LIABILITY INSU NCSD11rd ��osY, JOHN IANZAFAME DBA ALL UNDER ONE ROOF 30 TEMPLE DR METHUEN, MA 01844 THIS CERTII~ICATE IS ISSUES} AS A MATTER OF INFORMATION OMLY AM COf*:ERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE ;POLIC4ES BELOW. INSUREERS AFFORDING COVERAGE NAIL $ INSURER A NORFC)LI( 3 nFnm M INSURANCE COMPANY ^ tcISURER t AIM I,ySM�2ER C. MN3iMiER D- _ -- +aus THE POLICY PERIOD WDICATED. NOTWITHSTANDING BELOW dTHE14d, ROLIICIES OF WtNSURA♦A Oil STED ON OF A{ YV HAVE int WEN ISSUED TUTjjER DOCUNI NT 1flt" RESPEC AMED ABOVE TTo WiiICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLK3ES DESCRIBED uwRITTEiCI A£m1S CTTt3 ALL THE TERMS,i JtCiU5iQN5 AND CONDITIONS OF SUCH POLICIES L't j l ACaGFi�EiA i t LwYn � .� arsvr�a...r... TYPE OF NiBURAHCP. .._ �.- . --- - roucy Lit Rti401433A 06!031200$ (1610312009 LIIAITs 1.000.000 00 EACH OCCUR"€NCE s A i GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE LTJ XCUR t,OD0.000 00 ES ETO s oeFaaence $ t 5.000 �.�.— MED EXP (Any one Pemm) PERSONAL 6 ADV INJURY $ I •DO0-f#40 00 „— GENERAL AGGRPGATE S 2,000,000 00 PRODUCTS - COMPIOP AGG S 2-0OQ 000 00 GEN1 AGGREGATE LIMIT APPLIES PER. POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL MNlVNEA AUTOS SCHEDULED AUTOS HIRED AUTOS NO*4)WNED AUTOS COMBINED SINGLE LIMIT ; fEa attideM) BODILY INJURY S (Per person) BODILY WURY S (per acddant) PROPERTY DAMAGE $ {Pet aCct; GARAGE LIABILITY ANY AUTO AVIO ONLY • EA ACCIDENT S DTHER THAN EA ACG S AUTU ONiY AGG $ £XCL'cSSA3SIBR£t1A LlALgUTC OCCUR ❑ CLAJAS MADE DEOUCIIIWE RETENTION f EACH OCCURRENCE $ ' AGGREGATE S S i 8 wpmmTmAND EMPLo�RSC iN►> ANY PROPRIETORIPARTNER&XECUTIVE100,00000 OFFICERI MMSER EXCLUDED? YA as, desoibe under ECIAL PROVISIONS below AWC70094UO12007 1110912008 1110912009 J TLtRY L1MtTS FR E.L EACH ACCIDENT ; 100.000.(Ht EL DISEASE EA EMKOYEE S E 1. INSEASE - POLICY LIMIT S 500.000 00 OTHER SHOULD OF yHE ABOVE DESCMED POLICIES SE CANCELUP BEFORE THE EXPIRATI00 DATE T14ERE F, THE ISSUM OWRER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER RASED TD THE LEFT, MY FAILURE 10 00 SO SMALL gXe 40dMoMfB0uiW1di4ng Regul a ons and tan One Ashburton Place - Room 1301 Boston. Mas! jg tts 02108 Home Improvement Contractor Registration Repistration: 137057 Type: DBA f Expiration: 10/212010 ALL UNDER ONE ROOF k JOHN LANZAFAME ,. 166 A MERRIMACK ST. METHEUN, MA 01844 Al .3 5oM-051f)&PG9490 .7kL r�rntt�utxx o�'.:�U:ostac�tude t N Board of Building Reguladofia and Standards HOME IMPROVEMENT CONTRACTOR Reg"atioh: 137057 Dn. .101212{110 Trfl 275510 T> lA 4LL UNDER ONE ROOF SOHN LANZAFAME Ift A MERRIMAt'K ST. VETMEUN, MA 01844 t TO 275510 Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card License or registration valid for individul use only before the espiratiat date. U found return to: Board of Building Rsgulations and Standards One Ashburton Place Ron 1301 Boston, Ma. 42106 "\` 'C, Not valid without re vlassachusetts - Department'If Public >afetl Board of Building Re;�ulations and Standards Construction Supervisor License License: CS 69120 Restricted to: 00 JOHN W LANZAFAME 3` ` 30 TEMPLE DR METHUEN, MA 01844 Expiration: 4/3/2011 Q, l OM 794-3M o 14,WWAIT-4US tA aco 3pronagal 14- LLQ gnlunitted lis 1 Y 7' 7 3 '311 k A(A GA e .v2� Job lob CftSw&23pCode 00-tA Wa and � � bow: four the mem Of'- we Proper b /./rpt ivm -CjT J �'i e ``' ►� l �`ti� - �_ n br s ADtwo elf �odcn6a ram � a nmerY�# �� uc�+irtoa aenard lie aaa db a�w ndmu~ at�rrIsom ow am Avdxdnd Mftwbw �- "Oe VIO fmSJr AU L md coodWwm are OWNSMmy and an Left mabeM& asa