HomeMy WebLinkAboutBuilding Permit #725-2011 - 286 RALEIGH TAVERN LANE 4/29/2011TYPE OF IMPROVEMENT
New Building
Addition
Alteration
Repair, replacemenf-
Demolition
OWNER: Name:
BUILDING -PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
PROPOSED USE
Residential
✓One family
Two or more _family
No. of units:
Assessory Bldg
Other
L
Date Received
OF WORK TO BE P
Type or Print CI.early)
Non- Residential
Industrial
Commercial
Others:
L�
avd-e on 4,
µoRfH
O�t.�LED '6i
C: Lis
3 166 0
ARCHITECT/ENGINEER 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: FEE: $__
Check No.: L'� Receipt No.-
NOTE: Persons con acting with unregistered conh-actors do not have access to the guaranty fund
Plans Submitted Pians Waived Certified Plot Plan Stamped Pians
TYPE OF SEWERAGE DISPOSAL
Public Sewer F7'
sage/BodyArt Swimming Pools
Well sFood Packaging/Sales
Private (septic tank, etc. umpster on Site
THE FOLLOWING SECTIONS_FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM '
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Si nature :
'C0 1hVA1 1hVA1 E N T S
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals 'Variance, Petition No:
. Zoning Decision/receipt submitted yes
Planniri.r,. Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/signature & Date
• Driveway Permit
DPW Town Engineer: Signature:_
Dimension
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
Electrical Inspector Yesapproval of
.. No
DANGER ZONE LITERATURE: Yes
MGL chapfer. 966 section 21A -F and G min.$100_$1000 fine No
N I rvr-r- -
`oc.rsuitamg Permit Revised 2010
r
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 N.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ 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
L3 Workers Comp Affidavit
❑ Photo Copy of H.I.G. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossecfion/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable) `
13Mass 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
. n
❑ _el.Uc•ri:• ed Proposed Plot
i lI
a
❑ 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 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: Building Permit Revised 2008
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The Commonwealth of Massachusetts
c I Department of Industrial Accidents
1 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): .DAV i I CAS'1741( oNt I?" F i N6- " Sl INL,
Address:_ ZO n Su TTo 3 SfrzE ET So i to Z 2.t0
City/State/Zip: N o. A N ayiEe—, (JA 61 VS Phone #: 9) % (% 3,3'12 Q
Are you an employer? Check the appropriate box:
1. ® I am a employer with a
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. [1 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.❑ 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.
#Contractors 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: A 2T1 A
Policy # or Self -ins. Lie. #: id f (M q QS U 3 Expiration Date:_ q
2q t Ana e� 114
Job Site Address: �� C l U � �e,.,y E'l11 G�/lSL 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 fonn 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 the pains andpenalties ofpeijury that the information provided above is true and correct.
Signature: Date:
Phone #: q r] U 3 J 4 ;L®
Official use only. Do not write in this area, to be completed by city or town offrciaL
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 #:
Y
il;l\1:llllll.\l'Il.\ I)l'II1l lllll'Ill nl ["Uhlic 1a111'll
B oiwtl uI I')Illlllin.. I\l,-,Illallllll\ .(II(t lldnlla l•ll\
Construction
�., /
011lcc of Consumer Affairs & Buincss ltcgulafion
Supervisor Specialty License
License: CS SL 99358
= -`
yHOME IMPROVEMENT CONTRACTOR
Type.
Restricted to: R1 ,WS ,ai
_ 1 Registration: 104569
v Expiration: 7114/2012 Private Corporatio `
DAVID CASTRICONE Ii`�' ^"'7.',r
DAV'10 CASTRICONE ROOFING,` SIDING &
f
31 COURT STREET
NORTH ANDOVER, MA 01845
David Castricone
200 SUTTON ST SUITE 226
`y 'F
NORTH ANDOVER, MA 01845 llndersecretary
Expiration: 12/16/2011
( unuui.�iunrr TM: 99358
•
a I
Y
ACORDT. CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY)
11/3/2010
PRODUCER Phone: 508-651-7700 Fax: 508-653-8089
Eastern Insurance Group LLC -Commercial Lines
233 West Central Street
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick NIA 01760
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A! Citation Insurance 0274
David Castricone Roofing & Siding Inc
200 Sutton St
INSURER B: CHART IS
Suite 226
INSURER C:
INSURER D:
North Andover MA 01845
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR. THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS
TR
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
POLICY NUMBER
POLICYEFFECTIVE
POLICYEXPIRATION
LIMITS
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
GENE RAL LIABILITY
EACHOCCURRENCE $
COMMERCIAL GENERAL LIABILITY
PREMISES Eaoecur . $
CLAIMS MADE FIOCCUR
MED EXP (Anyone person) $
PERSONAL BADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMITAPPLIES PER:
PRODUCTS -COMP/OPAGG $
POLICY jEP'CDT- LOC
A
AUTOMOBILE
LIABILITY
ANYAUTO
BCNGCV
8/1/2010
8/1/2011
COMBINED SINGLE LIMIT $1,000,000 1 000, 000
(Ea accident),
BODILY INJURY
(Per person) $
X
ALLOWNEDAUTOS
SCHEDULEDAUTOS
BODILY INJURY
(Peraocidare) $
X
X
HIREDAUTOS
NON40WNEDAUTOS
PROPERTYDAMAGE $
(Per aocldenl)
GARAGE LIABILITY
AUTOONLY-EAACCIDENT $
OTHERTHAN EAACC $
ANYAUTO
AUTOONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACHOCCURRENCE $
AGGREGATE $
OCCUR CLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
B
WORKERS COMPENSATION AND
WC003989723
9/23/2010
9/23/2011
}{ WCSTATU- OTH-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L.EACHACCIDENT $ 100 000
E.L. DISEASE - EA EMPLOYEE $100,000
OFFICEW/MEMBER EXCLUDED?
It yes, describe under
SPECIAL PROVISIONS below
E.L DISEASE - POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT! SP ECIAL PROVISIONS
CERTIFICATE HOLDER CANCFI 1_ATION
ACURD 25 (2001 /08) m ACORD CORPORATION 1988
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
Town of North Andover
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
1600 Osgood Street
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
North Andover MA 01845
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACURD 25 (2001 /08) m ACORD CORPORATION 1988
a DAVID CASTRICONE
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 famish all necessary -
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, tern and
conditions, on premises below described: / ��� ��3 ,vz 66 eAotrt 2>
Owner's Name...... ! "`C �Y✓c�lrl................................ =�39 - CL1l S= Cotl �Lcu/R
.............................................................. Telephone #..................................................
G/Chh...:.h! ...... City.../4.GV��T.................... State./ef,Job Address......5m,.I:J......
Specifications:
Str xisting shingles. Apply new drip edge to all edges. /
................................................................................../........................................................................................
Apply b 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 fe paper d rlayment. Install ridge vent to Re _ u� PXiSrl7rc�
............ Yt?t? 4....................�_ .:....................................................................................................
Reroof using Z3lD 3 5/7 �r# 1� a2 -r-,-34 shingles with a 30 year warranty.
......................................................................................................................................................................................................................
Countertlash chimney. New vent pipe flashing. Legal disposal of all debr'
..................................... .............................................................. `............................................................................
Area(s) to be worked on:
....................................................../.................................................................................................................................................................
t l
PCrltrvrjl 1Ci'.,,— -y?G1oty.L'-rj
..................................................................................................................................................................................................
......................................................................................................................................................................................................................
Roof board replacement if necessary @ �® /sheet or �q /foot.
......................................................................................................................................................................................................................
Two Year Workmanship Warranty (Not Transferable) lWanufacturer's Warranty as specified by manufacturer
The contractor ages to orform the work and fur►�ish the materials specified above for the SUM of $.....�3.�.................
Payable .1..... ........ on ....?....'..t..
.................
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 :o the interior of property, including preexisting conditions (i.e. water stains, crumbling plaster, exposed nails) or
conditions resulting from application of mate Mals 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 covereo 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 ag-ee 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 :nay 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 sl A 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 : nditions 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 here_f shall bind and apply to their heirs, successors or estates of the parties. 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 ina rporated, 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 r�-ierence 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 is excluded from the Guaranty Fund provisions of MGL c. 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 CC `ITRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation).
IN WITNESS WHEREOF, the parti,:s have hereunto signed their names this ... 2� .... day of.. .... A... ..... 20./.../.....
Accepted: Signed J�/ .�......
....... Owner
(� Signed........6.!!!r .:1!i. .:?..U��.:.y.......
Owner
David Castricone, President
Location
< r
No. _�2a Date
MORTM TOWN OF NORTH ANDOVER
so
l 9
i •
�e Certificate of Occupancy $ r
Us <� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # U cv
L`ti�1
Building Inspector