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HomeMy WebLinkAboutBuilding Permit #680 - 237 CARLTON LANE 4/24/2007TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issuedzr_ IMPORTANT: Appli LOCATION o1 J 7 a, /- PROPERTY OWNER Pati / Date Received must complete all items on this �11 kaAc Print a cJ 44 Nor-Fti Andwe, MAP NO.: PARCEL: Print do 2& 216 ZONING DISTRICT: –------ ---- TYPE A-ND-USE-OF-BUIL-DWG TYPE OF IMPROVEMENT 0 PROPOSED USE _ - - ❑New Building –------ ---- TYPE A-ND-USE-OF-BUIL-DWG TYPE OF IMPROVEMENT —HISTORIC DISTRICT_ -YES _ _❑ ._.__. _____ - _ _ PROPOSED USE _ - - ❑New Building Residential ire family No Residential ❑Addition ❑ Alteration ❑ Two or more family No. of units: ❑ Industrial epair, replacement 7EDDernolition ❑ Assessory Bldg ❑Commercial ovin (relocation) ❑ Other ❑ Others: ❑ Foundation onl DESCRIPTION OF WORK TO BE PREFORMED Sf�ii° and 141, //'7 A. a.// ajr w al-, ii.or c Identification Please Type or Print Clearly) OWNER: Name: C G Uhf Phone:1. 79y $1l Address:_ ac37 Q.r��/1 iiG�rlc. A/O /%/too✓e. _ --- ------ CONTRACTOR Name: . �Q l�h�nno �' ' cJ/l„r Phone %f Address: A/ -e i rrii6 224 /t/o, /ilei 0 /yT Supervisor's Construction License: Exp. Date: Home Improvement License:_ /il) 9 Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATEDST BASED ON $115.00 PER S.F. Total Project Cost :$ IM10. a0 FEE:$ Check No.:� Receipt No.: 3 Page I of 4 TOTAL $ ;. Check # J �� 2136 Building Inspector ... r' ..-..� .. v. IT ' F � TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer ❑ ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ Permanent Dumpster on Site ❑ Private (septic tank, etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i nature of Agent/Owner Signature of contraeV2 CO '"`� Signature Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ / i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS TE -REJECTED-__- DAT'E--APPROVED"----.._.-. a DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Shznature & Date Driveway Permit Building Setback( 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.: 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 ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses a Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit t,..... ❑ 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 Page 4 of 4 Commonwealth o Mass chiet s I u City/Town of (%Ae System Pumping Record h04 Form 4 .o Hca DEP has provided this form for use by local Boards of Health. Other form- may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. Systematl on the computer, use only the tab � + ca y key to move your A juo cursor- not ( , use the return key. Ci !Town 2. System Owner: ,� Name or ietwn Address (if different from location) City/Town B. Pumping Record k[H State State Telephone Number Zip Code Zip Code ft 1. Date of Pumping Date /Lo -/1' 1 2. Quantity Pumped: Gallonsgelo 3. Type of system: ❑ Cesspool(s) ( Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: M 6. System Pumped By Name v \ Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 m x m m y m EP v, y O CA C) 10 0 CD St Z H CLO =� O 0. as H nto 0 d 00 CD CL � O Q alo C� O y a v c° �. O CIM C I S v CO) O CDCD Z oCD C O 19 w FA cn w n O z C 0 0 Z 0 m 0 m 0 1 S. m CD US 0 N CLCA0 N C?�O m -4 QN C N y to m n =ro h .�► O � m N '71 -lOmN o y dam? m = o loo �0 0 O N c) . CD a � :c � ��: - m d, mom *4 ate• N � N am c •CA °° it m m N yz e N 0 CD o 0, N � m •� �'� % Fm I n a3 N �. "' �^ co m 0. - VV o � =r :S : I m dd amca A r 0 r1 � o 0. z ccn 'y►�y c '^17 O /� O y Oo O O H g � z 41 103 3/),.2-,l0? p MC M97 DAVID CASTRICONEAPR 1 �. �aGj D CASTRICONE ROOFING & SIDING INC. ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS ................ HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 978-374-7314 Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on premises below described: Owner's Name......(�,...�9L-"j ......1--.1 C....1. a%, wrri.�c t..�...............I a:SJob Address.... r7...f..... h ....L -.I.-.1. ................ a....2.�.:.2.4Y. -...?.... Specifications: ................................................. ..................................................................................g.......... ..r ti trip existing shingles(Ij ✓J�pply new drip edge to all edges. Wk, e- 8' State.... M ......... .................................................................................................................................................................................................. tply _feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane � in valleys and bottom edges of any unheated areas of house. ............................................................................................. ✓Apply felt paper under4yment. ✓install ridge vent to -Reroof using ...................... ................................................... shingles with a - ,7o year warranty. . Eounterflash chimney. ..New vent pipe flashing. -final disposal of all debris. ............................................. It.................................. ............................................................................................... Area(s) to be worked on: ............................................�.r ll.../�Cta.(.. CI I`�.� ........6.1.........L,.t.4 S rz..r....;.............. ..I.....,.�........L................................... .................................................................. ........ Roof board replacement if necessary @ 40 /sheet or —/foot. ................................................................................................................................................................... ........................ Two Year Workmanship Warranty (Not Transferable) Wanufacturer's Warranty as speci byrm�anufacture The c tractor agees to perform the work �Q sh the materials specified above for the S of $.... (..i..�v i'�.................. (VPayable ... Y.L1.�I-0.......... on .... ......... Payable ............................. on.................................� alance payable on completion of job Owner or Owners arc not responsible for Property Damage or Liability wh is in operation. Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as re4uested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable casts, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrants) that he is (they are) the owners(s) of the above mentioned premises and that legal tide thereto stands of record in his (their) names(s). There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108 Tel: 617-727-8598 )k Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction - related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL e. 142A. Approximate starting date of work ................................................ Completion date......................................................... Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice eoof cancellation). ,r IN WITNESS WHEREOF, the parties have hereunto signed their n �L..../..Y...Jday of f-�.., 20 Q Accepted: .........................................................»........ David Castricone, President Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 , www mass.gov/dia Workers' Compensation Insurance Affidavit: Build ers/Contraetors/Elect ricians/Plumbers Applicant Information _ Please Print Legibly Name (Business/Organization/hidividual): Address: o©Ai nG ' ZZ(. City/State/Zip: � 6. Ntr1&Jef M A 0 I B qS Phone #: 9-1 � G 8 3 3 Y10 Are you an employer? Check the appropriate box: 1.)z I am a employer with __%_— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ 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. ❑ Building addition 10. El Electrical repairs or additions 11. ❑ Plumi-bDina.Lwairs or additions 12.21 o f repairs 13.❑ Other �•, rr••r• •• •••• • �••��•� wn R, "lual 01- u„ uut clic secuon oelow snowing their workers' compensation policy infomnation: t Homeowners who submit this affidavit indicating they are 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 and job site information. Insurance Company Name: • -1- _/ ' [ Policy # or Self -ins. Lic. #: V V V C 4 OO 5 4 0 DO l oW V T Expiration Date: Job Site Address: 243 7 &.4 hn kAAe- City/State/Zip: No . Aod o ver. AJA e IF t% 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 tine up to $1,500.00 and/or one-yearimprisonment, 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. Ido hereby certify underthe pain�s andpenalties of perjury that the information provided above is true and correct: C tl ;O„nlrP• (;7-) ; he\(L i - ' % 1 t- iT- - .. /_ r 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 #: Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978)688-9545 Fax(978)688-9542 DEBRIS DISPOSAL FORM p1ARTb{ y y�� e COCMICryj WNk 1 In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: � Z- INC - Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 104569 Expiration; 7/14/2008 Type: Private Corporation DAVID CASTRICONE ROOFING, SIDING & David Castricone . 200 SUTTON ST SUITE_226 NORTH ANDOVER, MA 01845 Deputy Administrator