HomeMy WebLinkAboutBuilding Permit #839 - 30 WENTWORTH AVENUE 6/28/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 4 - Date Received
Date Issued: y� t�
IMPORTANT: Applicant must complete all items on this page
LOCATION
PROPERTY OWNER
Print _
MAP NO: PARCEL:_ZONING DISTRICT: Historic District yes no
!Machine Shop Villaqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
--One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
-"'Repair, replacement
Assessory Bldg
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
OWNER: Name:
UcOk.Mir 11UN Ur VVUKK I U tit PERFORMED:
Please Type or Print Clearly) d yJ
t //"A./ Phone: 97f 91�J
Address:
CONTRACTOR Name: / /4/ zJ?�kaxe
HA oi9.)_i
Address:
Supervisor's Construction License:__ qg-"6 Exp. Date: /01 / f49 40
Home improvement License: 1S Exna Date- 7`f
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ . dU FEE: $ y
Check No.: o? .3 f Iq Receipt No.: 2 e dam!/
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
_ .....-..___ . _.._. c.:..�
Signature of Agent/Owner Signature of contractor
J
a
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning. Decision/receipt submitted yes
Planning Board Decision:
t.
Comments
r
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locatea 6564 uS ooa street
FIRE DEPARTMENT = Temp_Dimpster on site yes no
Located at 124 Main Street
Fire Department signatureflate
COMMENTS
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 No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
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
Ll 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)
o 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
Li 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: Doc.Building Permit Revised 2008
Location -?,o
No. 00,Ti
o,6
Ia. eh 4
-4
Date
Check #asf�
230-54
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ e�w
Foundation Permit Fee
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I"`ol G J - C'DAVID CASTRICONE l j
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 Noah 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 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 d scribed: n �1
Owner's Name...... M. j..r 5 .......................................... Tel hone #..YF �.-.`�L.-. .�.a'�
Job Address ...t2 C �...... +t,C.y(%.i:..... ... L1 vr..... City .....
o..'1,1 .............. State.../.:.1A/�
Specifications:
. r......................................................................................................................................................................I.......................
✓Strip existing shingle!I'W .Afply new drip edge to all edges.
...................
„Apply .ice .a..n...d...w...a..t.e..r..s..h..i.e..l.d...m....e.m....b..r.a...n..e...t.o...b..o..t.t..o..m...e..d..g..e.s...o..f...h..o..u..s.e.....3...f.e..e..t..i.c..e...a..n..d...w...a..t.e..r...s..h..i.e..l.d...m...e..m...b..r..a..n..e..
in valleys and bottom edges of any unheated areas of house.
Zply felt paper underlayment. tall ridge vent to
.;; .....................
+,Aeroof using %.{(i, /yet t r% .oma, a IV, F� shingles with a _P4) year warranty.
X.....................................................................................................................................................
'Eountertlash chimney. w vent pipe flashing. Legal disposal of all debris.
..................................................................`! ..............................
/Area(s) to be worked on:
................................................✓.....tr0........ &L`.�.Cc.�...... itF
.........i?l5 �..1s.......................................................................
.........................................................................................................................
..................................... J .........
............................i4 y./"... ....E•d�s,1 •,Etal...................................................................................................................
............................................................... ...................... ..................................................................................................
Roof board replacement if necessary @ 40 /sheet or /foot.
.................................................................................................................................................................... ...... ...........................
Two Year Workmanship Warranty (Not Transferable) N anufacturer's Warranty as speci by manufacturer
Theco tractor agrees to perform the work�a h e materials specified above for the SU of $..... 4.�Q. jj..........
1Payable ..... t?zi......... on ....
.............
Payable ............................. on ............. ...........(��
..=alance payable on completion of job_
Owner or Owners are not responsible for Property Damage or Liability wh. orb s n operation.
Contractor is not responsible for any damage to the interior of property, including pre-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). Items in attic may need to be covered 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 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 maybe assigned by
contractor, and also that the obligations hereof 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 tide 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 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 CONTRACT 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 parties have hereunto signed their names ay of .. ✓�. ,� ......, 20.�f !.
Accepted: `
Signed.................................................................."..........,.Owner
Signed............................................................................. Owner
David Castricone, President_
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
pensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): e AMTR l CO N&. R O) FSC d S iD 1 N (, 1 N L
Address: 2cbc:) S(j-t-rniJ S—v Su V't-E-_ -Z2tA
City/State/Zip: h - MbQ 46l< MA 0 1 & 4S Phone 4. 9-) 9 (p 6 3 3 41-0
Are you an employer? Check the appropriate box:
1. ® I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
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. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.t
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. ® 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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
0- -b
Policy # or Self -ins." Linc. #: yN C q 7 S, /a `,j y (o Expiration Date:
Job Site Address:_J d 16-14GtlOi c A &v2 City/State/Zip: /I/,,. All(lo lam.- •
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 certify un r the ains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: /.2l o _
�m.lawflo
use only. uo not write to ants area,
City or Town:
or town official
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 #:
Town. of .North Aiadover
]Uklildiilg Dcpj j-t:a-Jc11t
21 Chaxles Street
North Audove:r, Massachusetts OI845
(978) 688-9545 Fax (978) 688-9512
DEDR1S :DISPOSAL FO121.VI
In accordance with elle provisions of MCrL e 40 s 54, and a condition of.
Building permit:. the debris re .,.,ILi.ng from the work stuill be disposed
of in a properly licensed solid waste disposal facilit.', :is defined by MCT1, cI l s150a.
The debris will be disposed of in lar.
Sig,iarure of Applicomt
Date
NOTE A demolition permit Dorn the Town of North Andover must be obtained for this
project iluougli the 01-1.1ce of the Building Inspector.