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Home My WebLink AboutBuilding Permit #721 - 222 MAIN STREET 5/7/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ",),;L Date Issued: – 7-- o �— Date Received / p-�t�eo �a•6~ O o i 4 TYPE OF IMPROVEMENT PROPOSED USE Re ' ential Non- Residential ❑ New Building V One family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑ Well [ Floodpl I etlancts. Watershedistr%t { C War/ Sher, DESCRIPTION OF WORK,TO BE PREFORMED: OWNER: Name: Address: CONTRACTOR Nan Supervisor's Construction Li Home Improvement LicenSE Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $122.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ I1 3Sy FEE: $ 100 Check No.: y Receipt No.: 2-o I (D NOTE: Persons contracting with unregistered contractors do not have access to the uara ty fun Signature of Agent/Owner Signature of con ac r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑Swimming Art ❑ Pools El 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 `4 HEALTH COMMENTS 70 ❑■ DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED U DATE APPROVED IN Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street' FIRE DEPARTMENT -- Temp Durrlpster on site yet 116'1 Located at 124 Main Street Fire Department tignatureidate y v cbm NTS tri, 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 - Date .................................. ............................................ ..................._.................................................................... ................. _.................. ............................................. ................................ ................ ....... ... ...... ...... ....... ..... ...................................... 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 ❑ 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 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 2.2007 LocationC93C No. 1a I Date MORTM TOWN OF NORTH ANDOVER 0�•..•° ,�,4, Certificate of Occupancy $ s'•••°' Eta AC MUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 7 20i 0 Building Inspector CO) m m 4 X CO) EP m v y C � 'O O CD n Z y 06 n� 1. [7 C CL CO) a� �o d Co o p CDCL o c " d Co CD C CD y� ap y -• CD cv CCD H O CD CD Z O CD O CD cn cn n O cn cn o cn 0 Ip ?-Ro m S O —may O Q p� H .0 N3 S O0 m �m 0 t7 d2 o m Z N ?-O a N Oy. at m y T �. a- �-► =rma►�d m y N m N O O ?m p m = >� O w_ o Z L• 0 : \� O y • n 11`� m w: a C, m m S o ^' 7d :� E • OH CD m cis c am N O A N C d Q CA Ao N �r co 0 1 mom: ate: r Sr N moo: CD H R �C dm: a's r 0 c� o o =' gym: o cn 0 cn o �. O Crf r � �E' r S-��., w �' w tz n n E3 �. a- yto 7d 7d y 0 9 W Q 0 2 0- R �! 1 CD V Ct) CP VanQ%V),<1N1!, 0000cp N cp � Uj 4st i�� pc00 Q f'•. z0 yCt '4 ;.�1 l97 LP lit t...! 1.0 Lr ±l! rot. v1- K.t }-i CID W W ■ Ire, W Q a z U H 1 CD V Ct) CP VanQ%V),<1N1!, 0000cp N cp � ycA x Mn pc00 o ami C7 CID W W ■ Ire, W Q a z U H MWG C0WX1r1&1TCTI0W ROOFIWG COMI AWY Haverhill, MA / Plaistow, NH VR/esidential . &ew4ecd, 9r4*'d, .State ,fie WOWd ❑ Commercial Dater -Jz( -oEstimate For : ,+ "V�' ,r.5= Telephone 1: • 1- Q/ FS_ Telephone 2: Address: Job Location:: City/Town:&>� ,fk,e�-g ALA_State: City/Town: Quotation /Proposal to furnish and install the following: l"Approximate roof area: _ 76U,, O'New Roof ❑ Re -roof ❑ Gutter 0 Repair ❑ Ventilation ❑ Re -sheathing of roof deck using plywood State: Vrepare for re -roofing by ensuring all safety measures are taken in accordance to OSHA standard regulation. Remove existing layers of roof materials down to the roof deck and inspect wood. IF upon inspection we discover any rotted wood, replacement will be performed at $ -��— per square foot. If wood is sound we will re -nail any loose wood to the rafters, sweepdeck, and prepare for installation. R''Install 8" drip edge ❑ Install 5" drip edge ❑ Install hug edge ( re -roofs only) dolor e.4_,4r'¢ ®!Apply ice and water (underlayment) per manufacturers specifications and or �3 Apply felt paper (underlaymentj to the balance of the exposed wood deck. VRe-flash all stack pipes, tie-ins, chimneys and/or roof penetrations as required to ensure water tightness. ❑ Re -seat chimney base using cement and fabric 0"'( Re -lead aFAMMnt=h=aey ❑ Re -build chimney $ Install new I 6-� yr Elle traditional rr7 Architectural style shingle roof system p color ,i ft /Manufacturer,�1G? CfH�'to!„2;;k g ❑ Furnish and install a new shingle over ridge style vent system ❑ Solfit vent system $_ VA' ll debris generated by MWG Construction will be cleaned and disposed of from the job site in a legal manner. In no circumstance will the water tight integrity of the building be compromised. Special Notes: ON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF TEN YEARS HONORED AND ISSUED BY MWG CONSTRUCTION AND YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. Total Estimated Price: $ Payments to be made as followed: Date of Acceptance: (2, ., r (Home/Business Owner): / � (signature) (MWG):Zi ' _I a Business # 603-382-5929 Fax # 603-382-7955 Cell # 508-783-0511 077-2, iv The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lembly ..I Name (Business/Organization/Individual): Address: �,�;�r City/State/Zip: Are y an employer? Check the appropriate box: th 1. I am a employer with ' 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 have hired the sub -contractors am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any applicant that checks box # I must also FII out the section below show' 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.❑ Roof repairs 13.❑ Other mg err workers compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors 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 and job site information. Insurance Company Name: -my��C Policy # or Self -ins. Lic. #: �4 �, y� ,� ------� Expiration Date:_ Job Site Address: a�a�.,�i � _ �G{� /,,�, , �, City/State/Zip: &?A5 Attach a copy of the workers' compensation policy declaration page (showing the policy 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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. i/ienature: 'f� a �P Oficial 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 #: CERTIFICATE OF INSURANCE IISSUE DATE (MM/DD/YY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Byfield Insurance Agency Inc DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE P O Box 400 POLICIES BELOW. Byfield, MA 01922 COMPANIES AFFORDING COVERAGE INSURED Michael Gosselin COMPANY A.I.M. Mutual Insurance Co dba M W G Construction LETTER A 38 Forrest Street Plaistow, NH 03865 COVERAGES _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIO LIMITS DATE(MM/DD/YY) DATE(MM/DD/YY) LIABILITY NMERCIAL GENERAL LIABILITY 'S & CONTRACTOR'S PROT. LE LIABILITY AUTO OWNED AUTOS 3DULED AUTOS ID AUTOS -OWNED AUTOS AGE LIABILITY :RAL AGGREGATE $ IUCTS-COMP/OP AGG. $ ONAL & ADV. INJURY $ [OCCURRENCE $ DAMAGE (Any one fire) $ EXPENSE (Any one person) $ 3INED SINGLE I $ BODILY INJURY $ (Per person) BODILY INJURY (Per accident) $ DAMAGE I $ 7EAN Y EACH OCCURRENCE $ A FORM AGGREGATE $ UMBRELLA FORM WORKER'S COMPENSATION ANDX WSTATU- OTH- EMPLOYERS' LIABILITY TOR Y LIMITS ER 7013481012006 A THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE OFFICERS ARE: RX rxri OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS 08/12/2006 108/12/2007 $ :)UU,UUU $ 500.000 $ 500.000 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE