HomeMy WebLinkAboutBuilding Permit #619 - 281 BRENTWOOD CIRCLE 4/6/2006Of MOFTM 1ti
F p TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EYAMINATIUN
�SS�cNuSE�
Permit NO: Date Received:L(l
Date Issued:
IMPORTANT: Applicant must complete all items on this
LOCATION k
--�— Print VPROPERTY OWNER �J S (� ! e
Print
MAP NO.: _PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING
TYPE OF IMPROVEMENT
L New Building
i[i Addition
Alteration
[�4-epair, replacement
I-- Demolition
G Moving (relocation)
Foundation only
DESCRIPTION OF WO
OWNER: Name:
Address:
CONTRACTOR Name:_
HISTORIC DISTRICT YES ❑
PROPOSED USE
Residential Non- Residential
✓One family
C Two or more family 7i Industrial
No. of units:
:j- Assessory Bldg L Commercial
n Other I ❑ Others:
TO BE PREFORTMED
�W �
Identification Please Type or Print Clearly)
d SYo Phone:
Supervisor's Construction License: Exp. Date:
Home Improvement License: // b C� - q Exp. Date:
-kRCHITECT,ENGItNEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE. BGLDING PERMIT: $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$. - � � xI0.00==FEE:S
Check No.: 44 Receipt No.:��
Page Iof4
Locations l'i1'" 'No lo(- No. f Date 41l �,
NORTM
66
OL
0tooR
,ss4<MUSE�
TOWN OR NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee dq $
TOTAL $
Check # f &�3
;840
Building Inspector
TYPE OF SEWARGE DISPOSAL
Tanning/Massage Bodyfit
y °
Swimming Pools
-
Public Sewer i
Well
Tobacco Sales -
Food Packa-ing/Sales —
❑
Permanent Dumpster on Site
Private (septic tank, etc.
Electric l�leter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the girararrty fund
Signature of Agent'O,,vner _ Signature of Contractor\,
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ (1
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
DATE REJECTED
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Nannino Board Decision: Commen
Conservation Decision: Commei
Water & Sewer connection signature Nc date
Temp Dempster on site yes_no_ Fire Dep4gment
Building Permit Approved and Issued by:
Pace 2 of 4
signature.'date
DATE APPROVED
❑
DATE APPROVED
❑
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required
Provided
DUMENS[ON
Number of Stories:
Total land area, sq. ft.:
VU I tJ and UA 1 A — (Y or department use
Page 3 of
Cr-lcd INIC. Lm.'Jiln
Total square feet of Floor area, based on Exterior dimensions.
DEPAR I MEN'r BPFOkN105
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
o 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/Cross Section/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)
o Copy of Contract
❑ Mass check Energy Compliance Report
o 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
Doe: Building Permit Revised 2014
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Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
F JAORTH
a Ss,.f.1 ,
TED
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, sl 50a.
The debris will be disposed of in /at:
A
L + S /m,," NA - Al)), /,,Z9
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.
ti
0C b8 Date...,
.... ...... I ..............
V4r
, . . 4,
fee 0 TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SS CHUS
This certifies that .......... 57 . , . ;/- ... ) . .......... /- 5'1-, , 7 -
.... ... ...... ...................... I ............................
has permission to perform . .............. .-.. . . ................
wiring in the building of ........... ..........................................
at ....41--Z...... .... C.!: k... North Andover, 1,
Fee -10 ........ Lic. . . ........
Check #
.4�
,i
�4
Commonwealths ®f Massachusetts Official Use Only
Department of Fire Services PermitNo._ /�U kf�
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] fieave blank
APPLICATION FOR PI=RiUili iI ®pE11F®RIVI ftUCTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (IvIEC), 527 CMR 12,00
(1'LEASEPRINTMLVKOR TYPEALL INFO T.ION .
Date: 5-
City or Town of:
By this application the undersi ed gives no e of his or her intention perforTo m the electrical wo dctor of lescribed be
Location (Street & Number) a3 ( P�Te^� A ! i low.
Wao C �rG e,.
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? yes
Purpose of Building El No a BLDG PERMIT #
Utility Authorization No._f q 7,5 3 S
Existing Service Eao Amps _Volts Overhead
❑ Undgrd ❑ No. of Meters
New Service 900 Amps )'a,0/
.— it0 Vo Its Overhead❑ Undgrd � No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
fo. of Recessed Luminaires
o. of Luminaire Outlets
o. of Luminaires
D. of Receptacle Outlets
�. of Switches
I. of Ranges
of Waste Disposers
of Dishwashers
No. of Dryers
Heaters KW
Hydromassage Bathtubs
OTHER:
No. of Ceil: Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above I-
grnd ❑ n
grrnd ❑
go. of Oil Burners
vo. of Gas Burners
qo. of Air Cond. Total
Area Heating KW
g Appliances KW
No. of
,us Ballasts
table maybe waived by the
I A dMiturmers KVA
Generators KVA
o.
ALARMS INo. of Zones
Initiating Devices
of Alerting Devices
tion/Alerting Devices
❑I�Iunrctpal
COnnerfinn ❑ Other
Wiring:
of Motors Total HP ' Telecoms
No of
Estimated Value of Electrical Work: o -a p each additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Start: Ins ections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE,E' BOND 0OTHER
❑ (Specify:)
Icert, r�nder the padres and penalties of perjury, that the informatdorc on this appldeatdon is true and complete:
FIRM NAME: S*'T- T 1 ca LL L
Licensee: SeFFLIC' NO.:ji
�� el n Signature
(Ifapplicable, enter exempt" in the ilcYn number line.) LIC. NO•:
Address: g Bus. Tel. No.: ,9,-7 ,C 1zo– p �
*Per M.G17 c.147, s. 57-61, security work requires Department of public a ety S Licen Alt LIC. o.:
OVVNER',S INSURANCE WA_iVER; I am aware that the Licensee does not have the liabili
required g law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ ownety insurance r owner's g nt
Owner/Agent
Signature Telephone No.' PERMIT FEE.
a
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
Flns
sea — I 1+'ailed — [ ) Re -inspection required ($50.00) -ectors' comments:
Passed — [
Inspectors' comments:
'Signature - no
is)
Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.
J The Commonwealth ofMassachusetts
.Department ofXndustrial.Accidents
Office oflnvestigations
600 Washington Street
,t Boston, MA 02111
ivww mass.gov1dia
Workers' Compensation InsuranteAffidavit: Buffde)rs/Contractors[Blectriciansfplumbers
UUlicaxat Information )Please Print Legib
NaMO(B.usiness/Organization/Individual): S fiT E je arr co.J, (, t� c
Address: 1 4 �•���S ,4v f ordo\l." U
City/State/Zip: Lsnj—j Al If v26F 3 Phone #: 4 77 - G 8o - o
Are you an employer? Check the appropriate box:
' 1. K I am a employer with 4. ❑ I am a general contractor and 1
Type of project (required):
employees (full and/or part-time).*
have hired the sub -contractors
6. 0 New construction
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. s
7. ❑ Remodeling .
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
9. ❑ Building addition
required.]
officers have exercised their
10.❑ L'Iecirical repairs or additions
3 • ❑. I am a homeowner doing all work
right of exemption per MGL
11. ❑ PIumbing. repairs or additions
myself [No workers' comp.
c. 152, §1(4), andwehaveno
12.[]Roofrepairs
insurance required.] i
employees. [No workers'
13. ❑ Other
comp. insurance required.]
—Y appucani mar cnecxs ooxin must also till out the section below showing their workers' compensationpolicy information.
7 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.
lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy ancljob site
information.
Insurance Company Name: 1 k.e_
Policy # or Self -ins. Lie. #: n' Expiration Date: 3l J /
rob Site Address: 1 �t ��, o.d@ cL Cl cc \ ,p 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 maybe forwarded to the Office of
investigations of the DIA for insurance coverage verification.
1 d'o hereby certify under thepains andpenaldes ofperjury that the informadonprovided above is true and correct.
0 1r
Phone #• V 'go oft,3--f
Official use only. Do not write in this area, to be complefed by city or town official
City or Town: Permitucense #
Issuing.A,uthority (circle one):
X. Board ofHealth 2. Building Department I City/Town Clerk 4. Electrical Inspector 5.2Iumbinglnspector
6 Other
Contact Person: Phone #:
V
CONTROL # H 0 3.5 3 2 7
IMPORTANT
If this license is or destroyed, notify your ton St.,
Board at the'.
lost
Division of Professional Licensure, 1000 Washing
Suite 710, Boston, MA02118.6100.
If your name or address shown is changed, notify your board
of correct name or address to insure proper mailing of next
to Your license number.
Renewal Application. Always refer
slons of the General Laws
This license is subject to the provisions
and must not be loaned
as amended. It is a personale son. Keep this license on your
or assigned to any other p
person or posted as required by law.
i�
The Commonwealth of Massachusetts
Department of Industrial Accidents
r Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual): �_J/ /A
Address: ad/ cQYel)-Avdor/ r
City/State/Zip: /141 • Ackye" R/i 4 /def Phone #: P r
Are you an employer? Check the appropriate box:
I. ❑ 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
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 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. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 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 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. rn
Insurance Company Name:
Policy # or Self -ins. Lic. #: V VV C w y 4 w I ALJ b T Expiration Date:
Job Site Address: c Pe/ lfl? -Pad aehle Ale 4a1,7,w,' City/State/Zip: /VO AClcii,e 011jr_
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-yearmprisonment, 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 under�te�'ns and penalties of perjury that the information provided above is true and correct:
1rr r /
Phone #: -( 7 r 6 f 5 3 T �- o.
Official 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 M
DAVID CASTRICONE
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569,
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
7 HILLSIDE ROAD, BOXFORD, MA 01921
In North Andover 978-683-3420 In Boxford 978-887-6147
In Haverhill 978-374-7314
I/we 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: e l 2 _g ? n V J—� F
Owner's Name........ �)l...I..YY ...... � /.....�n. d.D..-1k...n.................I.......
..... .........n...JTlephone #.... A.t.l...-'...(...6..n..L,......
Job Address...�A...l...... .1 e.r. dlnl.a»�/.....c-.r.it. ....... City....1..t1�O--/ .a tAza'................. State ..... MA.........
...................... S.............. .......................... ,......................
..........
.......... z,s.�a. ..........D)..
.........1�
........, Le.S..t.�e.1.....,1.� �.t. r.........:...�. e ,-
............. ....., — ,,��.�s.......e,......
Specifications:
..................................�.............
............................... ...................................... I .......................... ......................... I............................................................................................
....................................................................................................................................................................................................................
.......................................... .>-.. 1...8..2-D................................................................................................................
One Year Workmanship Warranty (Not Transferable)
Manufacturer's Warranty as s ec figd by manufacturer
Materials and Labor to cost $....�t�' .1..8.0.......,.,.. Payable ....1 f .Q..Qct........ on .... ...............
Payable ............................. on.................................. Balance payable on completion of job
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-citisting 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, water 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 owner(s) 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 shall 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
One 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 Guarantee Fund.
Approximatestarting date of work..................................................................... Completion date..............................................................
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. Q
IN WITNESS WHEREOF, the parties have hereunto signed their names this ........ %5r., day of..../.� .( t,,.�.......... 20..06...
Accepted: 4
r
Signed... i/I.IA.�it.............Owner
Signed...................................................................................... Owner
Per.......................................................................
Representative