HomeMy WebLinkAboutBuilding Permit #67-11 - 29 ROCK ROAD 7/27/2011BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued: �'
IMPORTANT: Applicant must
LOCATION actZ
Date Received
,mplete all items on this
runt
MAP 210 PARCEL:ZONING DISTRICT: ;Historic District yes
Machine Shop Villaae . ves
16' ryO
0,4
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well.
Floodplain Wetlands
Watershed District
Water/Sewer �_..
t . : .
utsc:rur i wN Ur VVVRK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone �1'1D'�681-4t2o
Address: 'a9 2J c.iZ %?
e
RI
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: $ D�
Check No.: lig Receipt No.: a q b �
NOTE: Persons contracting with unregistered contractors do not have access to the gugranty fund
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
❑ 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
Li 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)
❑ 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
o 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
o 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
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
el�
COMMENTS
tl
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
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
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 approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21 A —F and G min.$100-$1000 fine
No
NOTES and DATA - For department use
❑ Notified for pickup - Date
- ....... ........... ................... -.... --............ _.... --....... ---...................... _.......... ...... ......... - ........ ...._........- - - _ ...—.._........-----.......................................................... __.._..- ------------.................................................. _-- --
Doc.Building Permit Revised 2010
Location
No. 6 Date
LORTN TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
244uS
Building Inspector
I . Protect house exterior and landscaping as hest as
possible. (tarps etc.)
2. Strip all shingles from entire train roof.
3. Inspect and re— nail any loose or lifted plywood.
4. Any compromised plywood will be replaced at an
additional cost of $50.00 per sheet of 1/2" cdx fir.
5. Install heavy gauge 8" aluminum drip edge to all
eaves and rakes.
6. Install 6' of IKO Armourguard ice and water
shield along all eaves, wall connections and top to
bottom in all valleys.
7. Install all new pipe boots.
8. Above the ice and water shield, install IKO syn-
thetic underlayent to the remaining sheathing up
to the ridge.
9. Install IKO Leading Edge starter shingles
10. Install IKO Limited Lifetime Cambridge AR ar-
chitectural shingles to entire main roof
11. Install new GAF Cobra ridge vents.
12. Counter flash chimney and skylights with ice and
water shield, tie into new roof and seal with clear
sealant.
13. Building permit included.
14. Removal of all work related debris.
15. Contractor workmanship warranty =10 years un-
der normal wind and rain conditions.
Balance due upon caaaapletion
Referrals available wort request
Hi&hly rated member of the accredited. BBB and
An&ies' List
Acceptance of Proposal --The above prices, specifieg tions and conditions are satisfactory and are herby ac-
cepted. You are authorized to do the work as specified Payment will be arcade as o fined hove.
Date of Acceptance: j / IY6I rt Signature: —
The Cornnionrvealth of Massachusetts
Del) artnrenI of Industrial Accidents
Office of Investigations
600 0ashington Street
Boston, MA 02111
;vn,iv.mass.gov/dia
Workers' Compensation Insurance Affidavit: Build ers/Contractor-s/1✓lectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): mitt ll,l ,QG:%j O% c -s- go 6i
'
Address:
City/State/Zip: LTHy (-'22 OwA -0 Phone #:
Are you an employer? Check the appropriate box:
1. I am demployer with _
4. El 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.
workers' comp. insurance.
[No workers' comp. insurance
5. 0 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. [:1 repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.ErOther go! /
.Any applicant that checks box?7 I must also fill out the section below showing their workers' compensation policy inronnation:
t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck
=Contractors that check this box must attached an additional sheet showing the name orthe 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: .,1A MJTuat
Policy # or Self -his. Lic. #: (S o Expiration Dale: i((R la -t1
Job Site Address: [?"4< R /J4 City/State/Zip: /JA M4S_S
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 ofcriniinal 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 ander the pains and penalties of peijury that the information provided above is true and correct
OJJIFcial use only. Do not.wriie in this area, to be completed by city or towit official.
City or Town:
Perrnit/Liceuse #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5.:Pluittbing Inspector
6. Other
Contact Person:
Phone #:
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Andover, MA 01645
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30 TEMPLE OR
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rs and Flusiness Regulation
Dffice of Consumer Affair
10 Park Plaza - Suite 5 170
Boston, Massachusetts 02116
Home Improvement C9 tor Registraiion
Registration. 13701 7
Type: DBA
clxpiration : 10f2:2 012
ALL UNDER ONE ROOF
JOHN LANZr-k.FAME
166 A MERRUACK ST.
METHF-UN, KIA 01844
Omcc .(Coaxamer Vff;:Be" "M Ruby;
tHOME IMPROVEMENT CONTRACTOR
Registration: 13705? Type:
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before the exomtkn date- If found return to:
Office of Consunter Affairs and Eltniness Regutnimn
10 Park PWA - Suite 5170
Boston. MA 02116
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