HomeMy WebLinkAboutBuilding Permit #488 - 255 SALEM STREET 1/2/2007Permit NO:
Date Issued: - 0
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
I- A -Mond
_. -. - IMPORTANT: Applicant must complete all items on this page--- , ----
LOCATION a SCRI' e -r1 S4 -6-e e7v
Print
PROPERTY OWN
Print
MAP NO.: PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
Vone family
❑ Two or more'family
No. of units:
❑ Industrial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
0 Other
❑ Others:
0 Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Type or Print Clearly)
OWNER: Name:
Address: d ,�o C5m 1&A;1l
CONTRACTOR Name:
Address: 9%v �•-� /yeo-ze l� �W o i�3S_
Supervisor's Construction License: O 5 oILI Z.4 Z Exp. Date: ? o
f
Home Improvement License: /'S�J`^1v7/ Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED C T BASED ON $125.00 PER S.F.
Total Project Cost :$ FEE:$
Check No.: ZY Receipt No.:
Page I of 4
TYPE OF SEWERAGE DISPOSAL
Tanning/Massage/Body Art ❑
Swimming Pools ❑
g
Public Sewer ❑
Well ElTobacco
Sales ❑
Food Packaging/Sales El❑
F]
Permanent
Permanent Dumpster on Site
Private (septic tank, etc.
Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner ' §7 nature -of cont
Plans Submitted. . ❑ Plans Waived ❑ - Certified Plot�Plari* ' '❑ Stamped PI a s ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED
En
DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJECTED DATE APPROVED
HEALTH ; ❑ ; . _ ,
COMMENTS
FIRE DEPARTMENT -Temp Dumpster on site yes- no
Fire Departmen6ignature/date , � - i,. - 4_L
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
Building Setback(
Front Yard Side Yard Rear Yard
Re uired Provided Required
Provides Re uired 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:BPFORM05
Created JMC. Jan.2006
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
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:BPFORMOS
Page 4 of 4
Location
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No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
cHus `� Building/Frame Permit Fee $ /
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TOTAL $
Check #
'19908
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The Commonwealth of Massachusetts
Department of Industrial Accidents
W Office of Investigations
m
' d 600 Washington Street
W Boston, MA 02111
M www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_ ya a a, 's � �,� ,7 g_ � � ��G[1�/c's�%r'�l � Lz,�_-
Address: 9 �7 kA,.m,—e % � �✓ Lr,�� 124 f20,5-
City/State/Zip: /A✓ 'L..r ,
Phone M v �Z/ 7e,',Fl
Type of project (required):.
6. ❑ New construction
7. 04 Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
"Any applicant that checks box #1 must also fill out the section below showing their 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: t&)L 1 4131' i j — �6 Expiration Date: IF/C
Joh Site Address: .ZS 5i. lnn 51 City/State/Zip: `Q,,o,Y,/' M q
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thgain�nd penalties of perjury that the information provided above is true and correct.
Official use only. Do not write in this area, to
City or Town:
or town official
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
i //o
Contact Person:
Phone #:
Are you an employer? Check the appropriate box:
1.
I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):.
6. ❑ New construction
7. 04 Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
"Any applicant that checks box #1 must also fill out the section below showing their 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: t&)L 1 4131' i j — �6 Expiration Date: IF/C
Joh Site Address: .ZS 5i. lnn 51 City/State/Zip: `Q,,o,Y,/' M q
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 thgain�nd penalties of perjury that the information provided above is true and correct.
Official use only. Do not write in this area, to
City or Town:
or town official
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
i //o
Contact Person:
Phone #:
MARQUIS
SidingHome Improvement L.L.G.
97 Laurel Ave
Haverhill, MA 01835
Bill To: (978) 521-7681
Ann & Jerrold Beeney
255 Salem St
North Andover, MA 01845-3014
Page: 1
gjkma&
Number: E266
Date: December 08, 2006
Description Amount
27 Square @ 300 8,100.00
302 Facie/Rake/Soffit @ 3.5 1,057.00
15 pair shutters @ 45 675.00
Assorted mounting blocks 100.00
Nails 50.00
Permits 250.00
9(cttStantt of PTOP081- The above primo, spcifrcaWm and'coctditiae are saMdactcxy and are herby
ac OWed. NRs*S Siding 8 Home Irnpraverrrerd is arritwrrzed to do the vnxk as specified. Payment wiN be o fined as
above. Fwthernore, I Wdenitand that Oft Is only an estkrmfie and may not refied the Final cost should momner molds
arty changes.11M estimate Is VAR rWOft VM for 30 days from the date prem. AS work to to pwfwnwd In a
profeselwal mariner axarding to standard prachom. Any alteration of deviation from the specifications over and above
the estimate invOMM extra oost will be executed only upon ctrstcmer approval and viff become an additional charge.
Marquis Siding and Horne Improvement does nal assume fiabFity forwomk not provided by b employees. If the customer
fails to con" with the terms of the AWeernent arnt this matter Is placed for colieedon, the undersigned agrees to pay ail
reasonable charges mduding attarmys tees and casts.
Signature D
y RWidf4
0� ►MAaQ� R`calulens
r� a N7G �d�
+�_ ft7*r _ _ + da
�:. 1$51x] � .",�rQR
14�QUIS SIC) 71 '?/l4j2'OO8
9 4A 1NG home DOA
E'1'�FN7
• _' 01835
sc
1-ice.0OF-
145 8Ut1 D1iyG
Number; R UI-A71a
se. CS TRUC7rON SU ERVISORS
09
8irt4dats: oaO24/14242
.- _ 08/24n008
{'ARK A y Restrl�yed: 00 7r, no: 0.0
97 LAUREL AVE
HAVEF 1"ttL MA 8]835
�_� Y Cotnfilas7oner
NQ'FD 4973
Date ...
... .. ... .... .....
TOWN OF NORTH ANDOVER
RECEIPT
This certifies that ./�l.c. `.,c.�. ...c�../d-a?f..t✓.
haspaid .....:,SD .... . ............................................................................
for.....................................
Receivedby ....... ...... .. .. .... .. ......................
Department........... . ............................. ............ ; ..................
WHITE: Applicant CANARY: Department PINK: Treasurer
The Commonwealth of Massachuse6tts
Department of Fire Services
196 ..Office of the State Fire Marsha!
P.O.Box I025StateRoad
Stow, A 01775
RMIM
PE
RMI
Date:
North Andover'ermit No
I .. I I . Dig Safe -Num er
(Cityof Town) (if Applicable)
In accordance with the provisions of Nt G.L.1 4 8 chapter
as provided in section 5 � 7 C H 34
Start Date
This Pennit is granted
to:.
Full name ofperso,;Firm or Corporation
locate d u . mpSter for rpor�
Permission to construction/renovation/demolition renovation/demoli
tion of building.
Comments: dUmpster must be.,251 from structure if unable to place with required
clearance dumpster must be covered with plywood or tarp end of work -day
at
Give location by street and no., or desc6be iu such manner as to proyk� adequate identification of location
F . ce Paid s 50..00 Fire Chief
lx
This Permit will cxpire. 0
( Signature of offical granting permit) Offical granting permit Title
t
tZrl-Oftla di
it. 021
08
Not
butsi
Bill To:
Ann & Jerrold Beeney
255 Salem St
MARQUIS
Siding & Home Improvement L.L.C.
97 Laurel Ave
Haverhill, MA 01835
(978)521-7681
North Andover, MA 01645-3014
Page: 2
Number. 5266
Date: December 08, 2006
Description
1.) We will remove existing sWftg.uivalent.
2.) install with siding to be t ertainteed Main Street (double clapboard d) or eq
3.) Replace damaged sections Prior � covering with Tyvek houeewrap.
5.) Use "J" trim and "p" trim as req
5.) Cover soffit area under tae's and rake sections with vinyl soffit.
7.) Custom bend rakes and fascia with aluminum.
.) Custom bend door bend aluminum over lower frieze board In front.
ti
a .) Cur and window trim with aluminum. l shutters.
1t).) Replace 15 pair existing shutters with maintalnence free viny
11.) Remove and replace existing gutters*
12.) obtain any required petmits-
13.) Clean and rake areas in a professional manner.
14.) We will give a one year warranty on all workmanship.
Marquis Tiding & Home Improvement is covered by full liability and workers cornp+E;nsation Insurance
to protect your expensive investment and to keep your mind at ease.
Payment shall be made 113 at the start of work 113 at half_vmy point in jolt, with the remainder to be pard upon
completion.
Total
0(treptSnte d V1r O'PD%St - The above prices, specifications and dna are satin o and are herby
accepted. Margrf& Siding &'loins Iwpo mm t is authored to do the work as specified. Papnent will be outlined as
above. Furthermore, I understaid that this Is only an estimate and my not reflect the rural cost should customer make
any dmVw. TMs estimate m WK remain valid for 30 days from the date presented. AS work to be performed in a
professiora) manner according to standard practices. Any afteratiat of deviation from the speciftabons over and above
the estimate involving extra cost W be executed only upon castomer approval and will become an additional charge.
Marquis Siding and Home irnpiovwnent does nal assume liabillty for work not provided by its empkye". If the customer
faits to c mM with the terms of the Agreement and this matter is placed for collection, the undersigrted agrees to pay all
reasonable d arget mfeand assts.
Signature Date I'R -07-,06
Amount
$10.232.00