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HomeMy WebLinkAboutBuilding Permit #110 - 20 LISA LANE 8/14/2006 TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXAMINATION qti° 3? ob:;'• .. a pL O A F t Date Received Permit NO: "eZraD PpP ,fig ��SSACHt1`'�( Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION cQ� -c> Pnnt PROPERTY OWNER / Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ 5PEMPROVEMENT PROPOSED USE Non- Residential Residential uilding .,;?One family on ❑ Two or more family 11 Industrial ion No.of units: ❑ Assesso Bld ❑ Commercial ,replacement D gition ❑ Others: g(relocation) ❑Other ation only DESCRIPTION OF WOR.WO BEYYEFO,RMED Identification Please Type or Print Clearly) /I y 3-0YfZ OWNER: Name: � S �Z� � 6r Address: �/J CONTRACTOR Name: Phone: + Address: L Supervisor's Construction License: 6�9 l� .3Exp. Date: e°1 Home Improvement License: f � ©S Exp. Date: a ARCHITECT/ENGINEER Name: Phone: Address: Reg.No. FEE SCHEDULE:BULDING PERMIT. S1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost •$ b A 5b FEES—2a�O Check No.: � _Receipt No.: Page I of 4 - - - - - - -T_ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. Electric Meter location to proj ect NOTE: Persons contracting with unregistered contractors do not have access to the guarant fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived El Certified Plot Plan El tamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED I PLANNING & DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ COMMENTS DATE REJECTED DATE APPROVED .r HEALTH ❑ ❑ 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 Temp Dumpster on site yes_no Fire Department signature/date 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) Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT.BPFORMOS Created JMC.Jan1006 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 InteriorV'' -k Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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:BPFORM05 Noe 4 of 4 Location No. y Date ' u i NORTN TOWN OF NORTH ANDOVER O? • OR f 9 a y Certificate of Occupancy $ b� Building/Frame/Frame Permit Fee $ -- Ss,+c"ust 9 Foundation Permit Fee $ ` Other Permit Fee $ r TOTAL $ Check # 35 0 Building Inspector JAORTH -Town of Andover No. kG to r dT over, Mass., 0 'C LAKE A� CC H HEWICK OOK?ATED '? Cl BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D BUILDING INSPECTOR THISCERTIFIES THAT............................. ....#%.17.4n............................................................................................ Foundation has permission to erect........................................ buildings a ......U ......L.#... . ...C......................... Rough to be occupied o ........................................................................................ Chimney provided that the person accepting iTk is permit s every respect conform to the terms of the application on file in Final 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 "75000- PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTTMRRU ARTS Rough .... ............. Service BUILDING CTOR Final Occupancy PL Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. r vj NHOC 15�O 8.3ow-Id 1V'30 { QOOZIZIOI tiollealsi6a21 : , N3W31,O*ddW13WOH : 21O1DyiliNOO i ........... imUC Sli,1•i�1 •__._ ._ �/ze �cyrniaeo�zusea�C� a�.���ae:sacfu�� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR k Number: CS 069120 Birthdate: 04/0311959 {. Expires: 04/03/2007 Tr.no: 10500 Restricted: 00 JOHN W LANZAFAME / 4 30 TEMPLE DR METHUEN, MA 01844 Commissioner INItKNtl IKWHANCt Fax:9786870149 Jul IC ZOUb II►:bU r.uz ------� CIERTWECATE WTa t�•-•�dTYYrI Pi:OD(rtER 07/12/2006 Intemat Insurance A one TW cC�mFt`C M 12 stt�AS A FA TCC 00 Ir�FOWATION 8 Y ONLY XM Cc�"am r* MGM UPON THE CC-nV;gCATa 522 Chlckcrfng Road I{aLD,a4 TWO CL.TITE=9 Ito?AtMIND"Ma-LTXD OR North Andover, MA 01845 AL=TKI _ CSDTk1 c LOQ INSN;=0 AFFO=PtG C.ObZnWE MAIC 0 JOHN LANZAFAME INBatFAk NORFOLK a DEDHAM INSURANSE COMPANY DBA ALL UNDER ONE ROOF' ocu=0` AIM 80 TEMPLE OR c. METHUEN, MA 01844 misu ER m COVERAGES r ,tr-.3a ta: THE POLICE$OF 1 .T R M OR CONDI IONO'F HAVE CZE =UED TO TH7 C,�BUPEO NAMED ABOV[t FOR THE POLICY PERIOD MDIGATEOMAy.t�QT{ytThSTANDINO ANY AIN.TH>:IN$U,ANCE OR CONDITION OF ANY 00"TRACT OR OTHER DOW--ENT WITH QCT TQ WFIICH TN18 C[RTIFICAIC TED N TWFT,D 06i MJ►Y PCRTAIN,iH6 tN$URANCB APPOROL�O BY THE POLICIEit DEacriB D kF3iF:CJ I$t3UDdECT TO ALL TNS POLICIES.AGGREGATE LC'JTt3 BROWN MAY NAVE =N REGUCEO Cy PAM CLAIM. TERM,EXCLUSIOA4$AND t?OkDiTIONJ OF CUCN TR ISDas A OEcarat.LrizanyY-11W_`fidXAa U * tl"'71L3 201550638 613/2003 6/3/2007 WCHOccumm" e c 1ACOA .oD �/ co+M:.�RCtAI Gcr�rtAL LU►DR,TY [�CWM3 MA02 © occult ` = t,00a.trsD oD MED L%P(Any one gcnm) 0 SAW= PUMOMAL D AOv WU:tY ! 1.000.000.00 OEM AGVDQTE WaT AFPLISS 0&R; GENML AWnEQATE 0 200.m.00 POLICY PRO=El LOC PRODUCT&•compR)P AQG i IC00,000.0D AUTO—YLS UJAC%M MY AUTO -nt8VQW LWjT : ALL OWNED AUTOS 50GO LEDAUTos ftaeeWIURY s MRED AUTOS MON•ONM10DAtfiOs �LYtM,tURY 1 ppPpplr 0aea'i pperx� iO��Myy R {Pdy DAMAO@ t tTAGtADE LtA^tt,tlY ANY AUTO pAU�TOROXLY."EA ACCIDENT = EXCCC LJLLA LLtCfUTY AUTti 17N1 " EA C : OCCt6I D CLAIWI M E i EACH OCCURRENCE 0 AOG'�CtATQ ; [*0UCY*I.f s NTgN AWG7QD9484012003 11/1812006 11/9/20116 � $ ANY FROPA�TONPAMWWkQXWWW7NH t R 0mra�EXCLUDW9 61.EACHAt:CIOI3NT 0 100.000.00 RivEctAL ppoYlwmlSdONO below E407fC�4C!•EAQar{,py� d 100,000.00 DTNLryt E.L.tx+BFi�sE•DOLK:Y UW 5 .000.00 c RT7FtCAT(I NDLDER CANCM.LATXOCJ c3tOt"AEM/0:2 Tka A mm p=V:=ppm�•r C .LDD DFFp TNs 61OL.=ATION OA'Tlt37 TIC===U=ML t^tD^.AVW TO tWL 10 DAYS 4IMYVA t:STICQ TO Tie ZL`AT ATtS RDt 05R "" TD TI a Lm,cUr eW Wim'TO 00 CO c"A" r--V=W 0:1. ym On LAC: w Ofi Am KLA wom TILE DIIAME;t.ITS AM=On rreTlvg . CHUM m(a)(DU � iimnm�y� Residential & Commercial Roofing All Types Of Siding CHIMNEYS POINTED-REBUILT-CAPPED Expert Masonry Work T Mass Toll Free Roof Leaks Experts Licensed&Insured 1-800-WAIT-4-US ® r—Ify 0—ed&Operated Si.—J976 jW11 License#034200 (924-848T) IKO �ff 'boss OZ,90/sus S Iiai We Work Year Round n Proposal Submitted To Ph Date "/T S o StreetJob Name City,State&Zip Code 0 Job Location Job Phone /114 We Propose hereby to furnish and labor in accordance with specifications below,for the sum of: a1'.+P� tea J Dollars($(Ey cnLSZ•?JCS ). All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from specifications be- Signage: 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 osal may be or delays beyond our control,Owner to carry fire,tomado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within _days. We hereby submit specifications and estimates for: S � f �t �p qelf Install 3 feet of special"Eave Seal"ice and water barrier protection along all bottom edges of roof and top to bottom in each valley.Cfroofis stripped,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. mor( P,'" )per sheet of plywood. id Install heavy gauge aluminum drip edges along every edge surface of each rooflineq Ud Cover entire roof(s)with IKO 25 year all asphalt,non-fiberglass, premium grade shingles (Color of choice).6i21_L=Trtcj_dYICS 3b W(2 T12o G>f--62 / IQ Replace all pipe boots where possible. /SS eal all flashings with clear Geo-Cel sealant.No black tar unless previously applied. U Remove all work-related debris. Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. fALocal current references and proof of workman's compensation insurance gladly given. Remarks: ,ns c- j- -c -f-�A szspa r! 3 a/CSG ;yko�n s�►rY.�%', Acceptance of Proposal-The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work 7aspecified.Payment Signature: _ will be made as outlined above,/ Date of Acceptance:/� / Signature. 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations . 600 Washington Street CJ Boston, MA 02111 ;M yVev www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Exectricians/Plumbers Applicant Information Please Print Legibly Na[De (Business/Organizationdindividual):�, Address: �'3 D 4M City/State/zip: w-(1 /,-'4�S s Phone #: Aree Y u an employer? Check the-appropriate box: Type of project(required): 1..LJ 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees full and/or art-tune).* have hired the sub-contractors ( p listed on the attached sheet. t �- F-1 Remodeling 2-❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9_ ❑ Building addition o workers'comp.insurance 5. ❑ We are a corporation and its [No � officers have.exercised their 10.❑ Electrical repairs or additions required.] 11. repairs or additions 3- ❑ I am a homeowner doing all work right of exemption per MGL ❑ Plumbing c. 1 , 1(4), and we have no 12. Roof repairs myself. [No workers 52 comp. § ❑ � t employees. [No workers' insurance required.] 13.❑ Other comp.insurance required.] '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. C ontracton that check:this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'.compensation insurance for my employees. Below is the.policy and job site 'nformation. asurance Company Name: -�A ?olicy#or Self-ins.Lic. #: Expiration Date: /1 I9 G lob Site Address: z 'T 2-� /�!s'� City/State/-7ip: d d '4)' 4ttach 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 againsf the.violator:-Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cover�Lg.verification. r do hereby certifj, under the p ins and enalties ofpeijury that the information provided above is true and correct. Date: 6 3r afore: f Phone# '� Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitfLicense# Issuing Authority (circle one): 1_Board of Flealth 2.Building Department 3. City/Towvn 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 6r 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 applicantwho 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 havebeen 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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required..Be advised thatthis 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 pemudlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permithicense 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. Anew 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 (Le. 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