HomeMy WebLinkAboutBuilding Permit #858-12 - 202 MARBLERIDGE ROAD 6/4/2012Permit NO: .76—r-12—
BUILDING PERMIT e7
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
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
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DESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
OWNER: Name: .1wr Ff jeye Phone: fj7T 6 F7 72.1',
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 4106 e 6 6 FEE: $ n .Z),O
Check No.: Zff00a3✓3' y`1, Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature
(if-A"gent/Owner. Signature :of contracto44.
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/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
N OTE: 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
40TE: 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 DEPARTMENTMFORM07
Revised 2.2008
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE APPROVED
Reviewed on * Signature
Reviewed on Siqnature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
' Conservation Decision:
Comments
Comm
Water & Sewer Connection/Siqnature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE:DEPAR 'I Temp Dumpster on site yes ono
Located,at•�124Mam'Street � � =�. j ` fir, � fs'' >; .�"
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Flre DepartmentfSignature- dlte '
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COMMENTS
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
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Locatio" Q,
No. Date 6A�
TOWN OF NORTH ANDOVER
V�t LED -
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
In) TOTAL $
Check �,,v 7
25353
/516ing Inspector
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ILC, MA 01830:
Uudersecretar
Massaxchusetts - Depal tment of Public Safct�
Board of Buildin!- Regulations and. Standards ;-
Construction Supervisor License
License: ,CS 56393 "-'A -
i
i
JAY'J LEBLANC
32 MACON AVE
I iAVERHILL, .MA 01830 ;
I•
Expiration: 10/13/2013 ,
(:anunissipncr Tr#: 6000
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688:9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: '101. M "44,4 -,ire ftd' is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
I OA.
The debris will be disposed of in:
(Location of Facility)
S1 n re of Permit Applicant
Date
his lv �5s-e-
j
642y 4 (-ee-
Masonry • Drywall
Gutters • Carpentry
Replacement Windows
Painting
Jay J. LeBlanc
,Roofing Co.
Interior * Exterior
Phone: (978) 373-5306
Name A7l;,.S F119 of C'.
Street 2 o_ /►gol
City A)c A 3ye r
State /a79
Telephone number
Lic. # CS56393
Lic. # HIC 109311
PROPOSAL
proposal no.
sheet no.
date:
WORK To BE PERFORMED AT
Street 62,f�;. 0,h16 iJ- y
City/V� /9NCtlep State_ !�
Date of Plans
Architect 7 ;? 2
We hereby propose to furnish all the materials and perform all the labor necessary for the completion of...
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All material is guaranteed to be as specified, and the above work to be performed in accordance with the
drawings and specifications submitted for above work and completed n a substatial workman manner for the
sum of
Dollars ($ )
with payments to be made as follows:
Any alternation or deviation from above specifications 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 or delays beyond our control. Owner to carry fire, tornado and other necessary insurance
upon above work. Workmen's Compension and Public Liability insurance on above work to be taken out
by 10A..'e.
A.�C
Respectfully submitted
Per
Note - This proposal may be withdrawn by us if not accepted within days.
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 will be made as outlined above.
Accepted
Date
Signature
Signature
Name
Street
City
State
Telephone number
Masonry o Drywall
Gutters • Carpentry
Replacement Windows
Painting
,lay J. LeBlanc
Roofing Co.
Interior • Exterior
Phone: (978) 373-5306
Lic. # CS56393
Lic. # HIC 109311
PROPOSAL
proposal no.
sheet no.
date:
WORK To BE PERFORMED AT
Street
City
Date of Plans
Architect
State
We hereby propose to furnish all the materials and perform all the labor necessary for the completion of...
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All material is guaranteed to be as specified, and the above work to be performed in accordance with the
drawings and specifications submitted for above work and completed n a substatial workman manner for the
sum of SI'X' l ov„ 7%,e -e. /Yv,vc/re.c' cklfcWS'
% +® Sad ($ 65 lcy with payments to be made as follows:
e►,t 7 W 6
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F
Any alternation or deviation from above specifications involving extra costs, will be executed only uponZ-66
written orders, and will become an extra charge over and above the estimate. All agreements contingent upon,
strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance
upon above work. Workmen's Compension and Public Liability insurance on above work to be taken out
by
Respectfully submitted.
Per
Note - This proposal may be withdrawn by us if not accepted within Lo days.
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 will be made as outlined above.
Accepted
Signature
Date Signature
The Commonwealth ofMassachusetts • -
Department oflndustriglAccidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
www.massgov/d'ra
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual):
Address:_
City/State/Zip: mg o f)'3 o Phone #: 97r 5 7 3 S-:9 a to
Are you an employer? Check the appropriate box:
Type ofproject (required):
1. ❑ I am a employer with a
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/opart-time) *
2. ❑ I am a sole proprietor ro par"Tnler-
have hired the sub -contractors
listed on the attached sheet. x
7. ❑ Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for mein any capacity.
workers' comp. insurance.g,
❑Building addition
[No workers' comp. insurance
5. El We are a corporation and its
10.❑ Electrical repairs or additions
required.]
officers have exercised their
3. ❑ Z am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
I yself. [Noworkers' comp.
c.152, §1(4), and wehave no
12.[�400frepairs
insurance required.] i
employees. [No workers'
1311 Other
comp, insurancerequired.]
'Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensation policy information.
i Homeowners who submit this affidavit indicating they Ste doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:. if / � er(
Policy # or S elf ins, Mc. A: J,) ^ 31 S 3 G Vii 02 Expiration Date:
Job Site Addresses 5LO Z • MAt r6le.r.dse P. City/State/Zip: !v GMoto ic?!'
Attach a copy of the workers' compensation -policy tleclaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
flue 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
of up to $250.00 a day against the violator. Be, advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby cer119 under• the pains andpenalties ofperjury Aat the information provided above is Prue and correct.
41cf l g
Phone #:
Official use only. DO not write in tills area, to elle coinpleted by City OY town Official.
City or Town: PermiMeense #
Issuing Authority (circle one):
1. Board ofl3ealth 2. Building Department 3. CitylTown Clerk 4. EIectrical Inspector 5. Plumbingluspector
6. Other - - -
Contact Person: Phone
Information and -Instruction's
Massachusetts General Laws cha
Pursuant to this statute, an empter 152 requires all employers to provide workers' compensation for their employees.
ployee is defined as "...everyperson in the service of another under any contract ofhire,-
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 shalliiot because of such employment be deemed to bean employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license orpermit 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 `Werther 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 -contractors) name(s), addresses) and phonenumber(s) along with their certificates) 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. Han LLC or LLP does have
employees, a policy is required. De advised that this affidavit maybe 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 thatthe 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 permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
Policy information (ifnecessary) 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 maybe 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license orpermit to burn 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 shquld you have any questions,
Please do not hesitate to give us a call.
• The Department's address, telephone and fax number:
Tho Commonwealth Of M-assa chusotts -
Dopa entof7.ndustxial,A,coldamts
Oflee of Investigations
6.0'Q asbimg w Stxoet
Boston? MA, 021 X x
Tel, # 617-727-.4900 axt 406 or 1-877:UA.SSAFB
Revised 5-26-05 Far, # 617"727-7749