HomeMy WebLinkAboutBuilding Permit #964-15 - 280 SALEM STREET 5/26/2015TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: I V4 A Date Received
Date Issued: 15 I'l k I I )
FMCMATANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT
PROPOSED USE
-44
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Resioential
Non- Residential
El New Building
pKQne family
a ,
0 Addition
0 Two or more family
El Industrial
.'�,,ration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
11 Others:
11 Demolition
0 Other
El
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%t6rshed
DESCRIPTION OF WORK TO BE PERFORMFD:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
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ARCHITECT/ENGI NEER– z� 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.
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Total Project Cost: $ FEE: $
Check No.: Receipt No.: D&kl3z
NOTE: Persons contracting with unregistered contractors do not have access to the gua-rantyfund
Plans Submitted 17J Plans Waived NJ Certified Plot Plan 11 Stamped Plans 11
Plans Submitted -E] PlansWaived-El Certified Plot Plan El Stamped Plans F1
.-T-Y,PE-OF--SF,W-ER-A-GE�DISPOSA-L-
Public Sewer El
Tanning/.N4assage/Body Art El
Swimming Pools 0
well Ell
Tobacco.Sales El
Food Packaging/Sales 0
Private (septic tank, etc.., -E]
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED: DATEAPPROVED
PLAN N I NG'&'DEVELOPM ENt- El
COMMENTS
-CONSERVATION Reviewed on Signature
COMMENTS,
HEALTH Reviewed on Si
-qnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_..
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Qate Driveway Permit
DPW Toiv;: Engineer: Signature:
Located 384 Osgood Street
ART ENT --' Tedip Pump§tef on site
FIRE -DEP YPS no
L ca t, -,l 24 Mel i n Street
F
P. Merl igirfgtUr6lda e',
N
COMMENTS
F-907TI—MR Mel
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 21 A —F and G min.$100-$1000 fine
NOTES and DATA — (For danartmant imAl
Doo.Building Pen -nit Revised 2010
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El Notified for pickup - Date
Doo.Building Pen -nit Revised 2010
I"
Building Department
�.The following ig--a Ast of the required forms to be filled out -for the appropriate. permit tobe obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C.And/OrC.S.L. Licenses
ci Copy of Contract
ci Floor Plan Or Proposed Interior Work
u 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 Affid.avit
• Photo Copy of H'I.C. And as --L. Li8ense's
• Copy Of Contract
• Floor/Crossection/Elevatio. n PIa'n,O'f Propo'sed� W'o' rk With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
• Mass,check En�_r_g_ycdmoliance Report (If Applicable)
• En-ineering Affidavits for Engineered products
9 " . F
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 cast�s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm-tted with the building application
Doc: Doc.Building Permit Revised 2012
Location cto V
No.%q r Date-�S la,�, h
TOWN OF NORTH ANDOVER
Certificate of Occupans.v $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $
Check #
42 2 7 Building Inspector
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ROBERT LANGEVIN
Building& Remodeling, LLC
Homeowner Information Contractor Information
Name
Company Name
49"6–f_ REmVD6,4jkjC,_r
Street Address (do not use a Post Office Box address)
Contractor/ Salesperson/ Owner Name
CiV/Town State Zip Code
Business Address (must include a street address)
A)09–)I+ 1"'ffJDOV�--_� Wyk 01F(A
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Daytime Phone. Evening Phone
City/Town State Zip Code
iqKC-7 I
/,)a A�jj)ow-_Jp, M c / 2-il -�-
Mailing Address (It different from above)
BtA;&7X 36,07 1 Federal Employer ID or S.S. Numbe:4Z C)8�tTg-
Law requires that most home
improvement ontractors have
H e Improvement Contractor Reg. Number
Expiration date
a valid registraction number
0
The Contractor agrees to do the following Work for the Homeowner:
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.)
MR-n7ze-,�j it,) / MC)Viff
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AW -W T -A E-rs , .17AA, Ad U 0 6 -M A--S;,q /Z
Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will
and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of �Date when contractor will begin contracted work.
MGL chapter 142A.)
�r4XFDate when contracted work will be substantially completed.
A, utai tontracii irrice anu rayment bcneauie gt L11
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of. '
7Y
Payments will be made according to the following schedule:
$ uponA7-
,greater)—
y or upon completion of
$ __�by�' / or upon completion of
$ 1�16) 00. upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment must be special to be paid for
ordered before the contracted work begins in order
to meet the completion schedule.(**)
$,��� _bp paid for
NOTES: Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Subcontractors - The contractor agrees to be solely responsible for completion" of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this ap-reement
Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
• Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear.
• Make sure the contractor has a valid Home IWrovernent Contractor Registratigri. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, NIA 02116 or by calling 617-973-8787 or 888-283-3757.
• Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document.
• Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify file
contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not I ater than midnight of the
third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right.
IM -NOTSIGINTHIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two identical copies oftlic contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor.
Homeown r's Signature' Contractor's Signature
Date Date
4AIc-
Zell F
Book No. 51
ITITLE
Witnessed & Understood by me, Date Invented by Date
Recorded by
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Jo Page No._
Witnessed & Understood by me, Date Invented by Date
Recorded by
Project No.
52 Book No. TITLE
17
From Page No.—
To Page No.—
Witnessed & Understood by me, Date Invented by Date
Recorded by I I
I&N_ The Commonwealth ofMassachusetts
Tp.
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
lax 11111�. 1�
JIM
It
U., Bostot4 MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): R-A1F-AVJ')F-1VA36_
Address:__79"S' DA -)-.;F— ::5",r -
A -t -)p Phone #: F' K3 t<O 7
City/State/Zip: NO,
Are you an employer? Check the appropriate box:
I am a employer with
4. F1 I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
1 am a sole proprietor or partner-
K
listed on the attached sheet. t
�2.
hip and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. F1 We are a corporation, and its
required.]
officers have exercised their
3. F1 I am a homeowner doing all work
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.]
Type of project (required):
6. El New construction
_2,-4�� odeling
8. n Demolition
9. F1 Building addition
I0.F1 Electrical repairs or additions
11. n Plumbing repairs or additions
12.F1 Roof repairs
13.n Other
*Any gpplicant t . hat checks box #1 must also fill out the section below showing their workers' compensation policy infbrmation.
I Homeowner"s 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 ofthe sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' conipensadon insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: -
Policy # or Self -ins. Lic. #: Expiration Date;
Job Site Address: City/State/Zip:
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 c i y u rthepai andpenafties ofperjury that the information provided above is true and correct�
SiLmature: ) Ulyu Date:
M
Official use only. Do not write in this area, to be conWleted by city or town offickiL
City or Town:
PermittLicense #
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 M
.........
Office of Consumer Affairs & Business Regulation
,�EW-.=,YOME IMPROVEMENT CONTRACTOR
21fte �1990
j gistration: .j
- Type:
I-, '��LF-'Expi rab o n: LLC
ROBERT LANGEVINSLI
OG & REMOLDING LLC.
ROBERT LANGEVIN--
795 DALE ST
N ANDOVER, MA 01845
Undersecretary
Massachusetts - Department of Public Safety
Board of Building Rlegulations and Stanclaids
Const'ruction Supervisor
License: CS -002685
ROBERT M
LAN6-EVjN,,.,-.,,,
A& A&ZOP-1-1-1
795 DALE ST
N ANDOVER MA 01949
Expiration
Commissioner
0212412016