HomeMy WebLinkAboutBuilding Permit #622 - 26 EASY STREET 3/27/2007TOWN OF NORTH ANDOVER NORTH
APPLICATION FOR PLAN EXAMINATION 0 'T"D #6 q�c
6
Permit NO: Date Received
� o e
0
RA7lD
Date Issued: — �00 �SSAGl"w`��t
IMPORTANT: Applicant must complete all items on this page
, RI LOCATION
PROPERTY OW
MAP NO.: 31
Print ��,, ll
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- Print
PARCEL: l
TVPF. AN -n ITCF. nF RITII,DING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
>eone family
❑ Two or more family
No. of units:
❑ Industrial
/KRepair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
a^d r-tih iriq l f- rQ� (-
Identification Please Type or Print Clearly)
OWNER: Name: ?AQ L Sy ( t_. I V At) Phone: g,3 —5 71 o�
Address: a(, EASY SIR UZ 61 F43'
iJ CONTRACTOR Name: CPfST�2 t c.ON �00 S- I iJ�' Phone: (6 93 `E -a
Address: 00 SU t TF. Z.Z.(y �30. n � av 10
Supervisor's Construction License: Exp. Date:
Home Improvement License: 1 D`i )-(a 9 Exp. Date: 9 �
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ j g j 0• do FEE:$ Me,
Check No.: /A -b Receipt No.: C7,z_J0 71
Page I of 4
•
Locaflon -�4 ,
No. �,�4 Date,--?
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Its Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee
TOTAL
$
'log
Check #
(,2
2 0 O'n
'—Building Inspect.01V
TYPE OF SEWERAGE DISPOSAL
Art ❑
Swimming Pools ❑
g
Public Sewer F1Tanning/Massage/Body
Well F]Tobacco
Sales ❑
Food Packaging/Sales [I
Private ❑
Permanent Dumpster on Site ❑
(septic tank, etc.
Electric Meter location to
project
1N V I1:: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH ' '
r
COMMENTS
DATE REJECTED
DATE REJECTED
❑ ,.
r
FIRE DEPARTMENT 2T6mpDumpsteron site yes
Fire Department signature/date
COMMENTS.
DATE APPROVED
11
DATE APPROVED
❑ • --
no.
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 (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: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 DP.PARTMENTMITORM05
Page 4 of 4
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<< !0l U(,
DAVID CASTRICONE
ROOFING, SIDING &REMODELING REPLACEMENT WIN3��
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
7 HILLSIDE ROAD, BOXFORD, MA 01921 IVUV 1iil�
In North Andover 978-683-3420 In Boxford 978-887-6147
In Haverhill 978-374-7314 B Y.....................
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 premise below described:
Owner's Name......... ,Dow.....SJ111V+V--K1 ..............................W.aa..A.
.......... Tel one #.... ta.�.�l...".t..?....1.�......
JobAddress......r�./. , ..... ..y ...... • L.r.�............................ City.... . .............. State.....,'.......
l
Specifications:
.......................................................................................................................................
Strip existing shingles(v vipply new d'rlp edge to all edges. 8A
.................................................................................................................................................
1 ..........
V9pply ( feet......ice . and ...wa.t.e..r...shield.........m...embrane....to bottom edges of house. 3 feet ice and water shield membrane
In valleys and bottom edges of any unheated areas of house.
.... ...............................................�............... I................. ....................................
Apply felt paper underly nt. Mall ridge vent to T
.................�5' .a.t .................f.J -....1.-...................'/
. ........
...... ....... ....... .
r Raroof using shingles with a_ year warranty. iKd
............................................................... ............... ......................:................... :......................................................
-Eounterflash chimney.
ri.. chimne . nL.Wew vent e flashing.
ashin . 1�el disposal of all debris. .
............................................X}r3'/....
.t.{... ,... .................. .........
Area(s) to be worked on:
.. . . .. ....Gy........ .
.i7.t.'t5*'*r��r•
p I
..el
lA�t► ....R....rrf �t.......r..au,l........... a,.�„ea..�... ......4...;I. ..... .. .............o ..........................
............................. V� ....%�.:R.....4,,...... _. �Retss.. A. . '.....rf� .(rs...................
One Year Workmanship War Transferable
Manufacturer's Warrant s ecifled bxy man Curer IQ
f/
Materials and Labor to co 5...... ll........... .Payable ..........r/.�............. on .......AJ--
Payable
i
....................... on ....................... ! \
.. Balance payable on completion of job i t✓. wl'—
Owner or Owners are not responsible for Property Damage or Liability while Job Is in operation.
Contractor is not responsible for any damage to the interior of property, including pro -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, watcr stains when roofing shingles have not had adequate time to cure).
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 requested
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 owners) all reasonable costs, 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 shell bind and apply to their heirs, successors or estates.
The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title 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
Ono Ashburton Place
Room 1301, Boston, MA 02108 Tel: 617.727-8598
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 shall be excluded from access to the Oueranlce Fund.
Approximate starting date of work............................................................. I....... Completion date .................................................. I...........
Receipt of a copy of this contract 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.
IN WITNESS WHEREOF, the parties have hereunto signed their names this ........................... day of ............................ 20 ..............
Accepted: r�), e
Signed........... (... ^ ...... :...:...\ u.L �,..u, ab. ...... Owner
Signed......................................................................................... Owner
Per.......................................................................
Representative
ff4
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
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:MC
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:
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.
Department of Industrial Accidents
r Office of Investigations
600 Washington Street
Boston, MA 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Si�ino, \ nQ.
Address: 7.00 &4tt r, S+�c_+ - &Ox ZZ(.
City/State/Zip: N D. WOV t HA O I W Phone #: 9-7� 6 S 3 3 YZ o
Are you an employer? Check the appropriate box:
XI 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-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' camp.
insurance required.] t
listed on the attached sheet I
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.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.[ repairs
13.M Other
-tiny appncam rnar cnecxs Dox si must also nil out Inc 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 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:
Policy # or Self -ins. Lie. #: V V V I oW Expiration Date: 91-a 3.- /116
—
Job Site Address: �(� ��%,s y c� % - _; '''–ity/State/Zip:� t:t a/��(�p/
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). c y�
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 under the pains and penalties of perjury that the information provided above is tr a and correct
Signature: Z)� C Date:
Phone #: 1% 0 6 f 5 13
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 S. 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 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 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
applicant who 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 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), 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 not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this 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 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 (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. A new 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
(i.e. a dog license or permit to bur 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-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
