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HomeMy WebLinkAboutBuilding Permit #854 - 300 RALEIGH TAVERN LANE 6/14/2011Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 0"i Check# r3 24�bI6 Building Inspector Permit NO: r�5 Date Issued: 19 A TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION IMPORTANT: Date Received � 1 -r4l 2m must complete all items on this LOCATION -2 © n L IE7'Z-- Cr- �4 '71P)AJ1.1 �A Q C Print PROPERTY OWNER 12`� `�� 9 M )n a 7J 2 Print MAP NO: _ qa A PARCEL: ©� 2 ONING DISTRICT: Historic District yes io Machine Shop Village yes x o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial k2 -Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other -. �"^-�� ®Septic Well GSE ! .TM'!^ �}' ` ' F �; IFlood lain -, . D Wetlands p ®iWatershe D strict, t - 1Water/Sewer •e..:.�..-...T- DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: �%`ii'y DE Z Phone: Address: 3 c►� C3� �� z�g v� eel -^r1 /� c.� r� n1-i�►� /�^��1 e� '1„��1 CONTRACTOR Name: o �\ A L � . Phone: & il- I' f�q t) % Address: rQ 'N, [ 6 0 6 '>5 ( O kk f Me IVAMt:1 f n -d IVL-A- - 40,3r/7 Supervisor's Construction License: r <` Exp. Date: Home Improvement License: 1J� Exp. Date: 5 a/ ARCHITECT/ENGINEER Phone: e e Address: Reg. No FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COS B SED ON $125.00 PER S.F. Total Project Cost: $ FEE: $� Check No.: x"'73 Receipt No.: (qaa� NOTE: Persons contracting with unregistered contractors do not have access the guaranty fund 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 COMMENTS DATE REJECTED III DATE APPROVED El Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Commen Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fixe Department signature/date 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 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. f. 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 p Fw. ❑ 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/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 ❑ 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 {f ❑ Mass check Energy Compliance Report I ❑ 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 t 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 2008mi Massachusetts - Department of Public SafetN Board of Buildine, Regulations and Standards Construction Supervisor License License: CS 63173 Restricted to: 00 FREDERICK A PAPPALARDO PO BOX 606 HAMPSTEAD, NH 03841 - Expiration: 1/21/2012 (' nunis,iuner Tr#: 17398 _ Oftice fon erairs HOME I MPROVEMENTCONT usi 1 eg° 1 Registration: ati°n RACTOR. x-1,51124 Expiration 17 012 Type:. R " LA CORP 1 C�� Private Corporation TTE D'f2 HAMPSTEAD, "NF 03848 Undersecretary 0 z O; as u w° cn p F A o w° a�' , U Cd x O t rn a�' w v U w I, cn w o cG w H w w 92 o cn q o cn , . c o m c :cCD c v o � C h O C C.3 C-3 CL A :m= :z o o m h � Ea m C . m � m CL. h ciC m us a cmc E ca • m m d o ; 3 z COD C 93 m ._ _O y C C H e0 O CD cm .+ a:.i S.: m N m > cm , 'oa �. ate= m mor- 3Qyo. c > Z `o o a c a Q m ��mc •o = m :mea N :a CO) $ M m$ o m s W C .O •a atLcc O c Z ca a s. = A :.m i h CDF- z aim z O U k: III UP U O O v CL' a 2 i O L O w Z CD a. O CO) 0 C cm CO) O CD 0 m m O O O CL = O � 3� O O i cc L.. a CL Qi Q COD c Q = CcC .� C) CD s zh O C C _c d CO2 D LLI Y/ cn 19 W W 19 W U) The Commonwealth of Massachusetts Department of Industrial. Accidents Office of Investigations 600 Washington Street Boston, MA 02111 �,4 s• • www.mass.gov/clic Workers' Compensation Insurance Affidavit: Builders/Contractors/JElectricians/Plumber8 Applicant Information Please Print Legibly Name (Business/Organization/Individual):Ro�ZP 1 I'A- Cyd t2 A Address: '� '� 0, n 1 t P 7T P k-�)v? PO 2.6 (0 6 City/State/Zip:IIAMP5Bei MA 6 3 &Ll ( Phone #: (, o 3 - 7S-9 `",lyD % Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4• ❑ I am a general contractor and I employees (fall and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity.,, -,workers' comp. insurance. 5. w e are a corporation and its Lel [No workers' comp. insurance 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.] i 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. F1 Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other 'Any applicant that checks box #I must also fill out the section below showing their worke rs' compensation policy 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:. Job Site Address: Expiration Date:, 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 ce under thepa ins d penalties of perjury that the information provided above is true and correct. 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 Persoin: Phone #: The Commonwealth of Massachusetts Department of Industrial. Accidents Off of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):` \G� w 4V Address:L% City/State/Zip: WV,*0WA14703 4 Phone #: Are you an employer? Check the appropriate box: 1. ❑I a a employer with 4. ❑ I am a general contractor and I ployees (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. 5. ❑ We are a corporation and its [No workers' comp. insurance refgliire.d.] officers have exercised their 3. ElI 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.] 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 1 . Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. i Homeotiyners 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: 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 obi e b,IA for insurance coverage verification. I do hereby iffy u er the pain�dpenalties ofperjury that the information provided abov� is true and correct. /. I MUM 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 l Nalne (Business/Organization/Individual):—1'Jtq•U Address: `� 7 0 , A" IAV o —r r-1 `I City/State/Zip: ZV-` kl 0 a,.;, I q Z_ MOANS Phone##:_ Go !2, �t2 0. Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6• New construction 2. I aIn a sole proprietor or partner- listed on the attached sheet. t 7. EJ Remodeling Khip and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g• ❑ Building addition NO workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1011 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right ofexemption per MGL - I l•❑ Plumbing repairs or additions inyself. [No workers' comp, c. 1,52, § 1(4), and we have no 12.[] Roofrepairs " insurance required.] T employees. [No workers' ' comp. insurance required.] 13 Other 51— 'Any applicant that checks box #I must also .fill out the section below showingtheir workers' compensation policy information. t ffomeownets who submit this affidavit indicating they aie doing all work and thep hire outside contractors must submit anew affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. n 0 Insurance Company Nar 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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance'coverage verification. 1 do hereby c(at+t;g�'under the p "(1penalties ofperjury that the information provided above is true and correct 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 #• TIte Commonwealth of Massachusetts ` Department of IndustrialAccidenfs gut % j" Office of Invesfigations 600 Washington Street Eau�ii .Boston, MA 02111 www.mass gov1d a Workers' Compensation __.li• ♦ Y n •• Insurance Affidavit:]BuiiderslContractors/Eiectricians/d lumbers Nalne (Business/Organization/Individual):—1'Jtq•U Address: `� 7 0 , A" IAV o —r r-1 `I City/State/Zip: ZV-` kl 0 a,.;, I q Z_ MOANS Phone##:_ Go !2, �t2 0. Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6• New construction 2. I aIn a sole proprietor or partner- listed on the attached sheet. t 7. EJ Remodeling Khip and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g• ❑ Building addition NO workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1011 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right ofexemption per MGL - I l•❑ Plumbing repairs or additions inyself. [No workers' comp, c. 1,52, § 1(4), and we have no 12.[] Roofrepairs " insurance required.] T employees. [No workers' ' comp. insurance required.] 13 Other 51— 'Any applicant that checks box #I must also .fill out the section below showingtheir workers' compensation policy information. t ffomeownets who submit this affidavit indicating they aie doing all work and thep hire outside contractors must submit anew affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. n 0 Insurance Company Nar 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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance'coverage verification. 1 do hereby c(at+t;g�'under the p "(1penalties ofperjury that the information provided above is true and correct 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 #• Inf®rniafl®n and Instruefi®ns . Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as `:..every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or ocher legal entify, or any two or more of the foregoing engaged in aloint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and, who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or -on the grounds or building appurtenant thereto shall not because of such employment bedeemed to bean employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation .affidavit completely, by checking the bokes that apply to your situation an , dif necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cant' workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any, questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/license number which will be used as a reference number. In addition, an applicant that must submit multiplepermitllicense applications in -any given year, need only submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Dq,partmcnt of Industrial Accidents Office of Investigations 600 Washington Street Keston, MA 02111 Tel. ## 617=727-4900 ext 406 or 1-877-MAsSAFE Revised 5-26-05 Fax ## 617-727 7749 - www mass.govfdia �M MM s Rdus[Mod 27 Walnut Hill Road DATE: June 07, 2011 Derry, NH 03038 603-490-4673 Customer: Ramani Arvind CONTRACT FOR 300 Raligh Tavern Lane QUOTE # 000323 N. Andover, MA 603-233-1426 DATE DESCRIPTION MATERIALS LABOR TOTAL 06/0711 As discussed with Jason on 6/6/11, we will install siding and metal for the entire back of house at 300 Raliegh Taver Lane, N. Andover, MA. This will include foam backing, white or (color) vinyl siding, and sof- fits. The windows trims, doors trims and trim boards will be wrapped in aluminum. Customer, (Ramani Arvind) will supply all materials needed to accomplish job. This contract is for labor only and includes a $300.00 discount by Jason. Payment as follows: Depositat start of job................................................................................. Onday job is completed............................................................................. Total........................................................................................................... Please sign below to accept contract as stated above and confirm of job on Tuesday June 7th, 2011. r Juan M. Diaz Advanced Handyman Services Ra rvind 300 Raligh Tavern Lane " kt, N. Andover, MA 603-233-1426 Thank You for the opportunity to quote this job. $1750.00I $1750.00 $1750.00 $1750.00 $3500.00