HomeMy WebLinkAboutBuilding Permit #845 - 31 GRAY STREET 6/27/2006Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received "2l,
IMPORTANT: Applicant must complete all items on this page I
LOCATION I ( Cr,
PROPERTY
MAP NO
Print
Print
PARCEL: ZONING DISTRICT:
-- .,.T.. YTC7 . ter, T]TTTT nTXTn AiCT(IRTC DISTRICT YES ❑
DESCf TION OF WORK O BE PREFORMU)
/', kl, 4
Identification Please Type or Print Clearly)
OWNER: Name: KvSG^ r��� �� 1-«% �'v Phone i?8 ' 2"' 1
Address: 1/ 6--171
CONTRACTOR Name: • C�
Address: J (/, � >Ol
7,f/ — 9, ?-7 - ZS o, -f-
�/
Supervisor's Construction License: Exp. Date: /
Home Improvement License: 11 l Exp. Date:
ARCHITECT/ENGINEER Name: Phone: 97z�5 -7 �y
Address: Reg. No
FEE SCHEDULE: BULDINC PERMIT: $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ 1-7b e,-�o x10.00=FEE:$ /�? 6, mea o
Check No.: a-O� Receipt No.: `1 -,
Page I of 4
0
0
Location 67- 6b Dy'd-1 r—
No. Date _6 - 2:�-d
AORT#1 TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
MU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
7
q3uildin'g Inspector
TYPE OF SEWARGE DISPOSAL
Public Sewer F1Tanning/Massage/Body
Art ❑
Swimming Pools
Well ❑
Tobacco Sales ❑
Food Packaging/Sa
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
Electric Meter h
project
1�T/1TT. r
- -- _ �• _ ,curia Lurstrucuug wnn unregisterea contractors ao not have access to the
Signature of Agent/Own Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
N
CONSERVATION
i
COMMENTS
z
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
DATE REJECTED DATE �
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
DATE REJECTED
❑■
Comments
Comments
❑■
DATE APPROVED
DATE APPROVED
Water & Sewer connection/Si2nature & Date Driveway Permit
Temp Dumpster on site yes_noX— Fire Department signature/date 6 J
E"-
Building Setback (ft.)
Front Yard Side Yard
Rear Yard
Required
Provided Required
Provides
Required
P4-rovided
/
/1
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
INv 1 tN and DA1 A — (For de , ent use)
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC. Jan.2006
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
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
❑ Mass check Energy Compliance Report
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Pane 4 of 4
REScheck Compliance Certificate
Massachusetts Energy Code
RES checkSoftware Version 3.5 Release 1
Data filename: Untitled.rck
TITLE: JENKINS ADDITION
CITY: Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 12/28/05
DATE OF PLANS: 12-28-2005
PROJECT INFORMATION:
JENINS ADDITION
31 Grey Street
North Andover, MA 01845
COMPANY INFORMATION:
Andover Renovation Solutions, Inc.
110 Winn Street
Woburn, MA 01801
COMPLIANCE: Passes
Maximum UA = 301
Your Home UA = 268
11.0% Better Than Code (UA)
Permit Number
Checked By/Date
COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications,
and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts
Energy Code requirements in RES checkVersion 3.5 Release 1 (formerly MECchec4 and to comply with the mandatory
requirements listed in the RES checkInspection Checklist.
Gross
Glazing
Area or
Cavity
Cont.
or Door
Perimeter
R -Value
R -Value
U -Factor
UA
Ceiling 1: Flat Ceiling or Scissor Truss
894
30.0
0.0
31
Wall 1: Wood Frame, 16" o.c.
1938
19.0
0.0
95
Window 1: Wood Frame:Double Pane with Low -E
259
0.310
80
Door 1: Solid
21
0.280
6
Door 2: Solid
35
0.370
13
Door 3: Glass
42
0.310
13
Floor 1: All -Wood Joist/Truss:Over Unconditioned Space
894
30.0
0.0
30
COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications,
and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts
Energy Code requirements in RES checkVersion 3.5 Release 1 (formerly MECchec4 and to comply with the mandatory
requirements listed in the RES checkInspection Checklist.
The heating load for this building,
Conditions found in the Code. The
design load as specifi/d in Sections
Builder/Designer
the cooling load if appropriate, has been determined using the applicable Standard Design
TAC equipment selected to heat or cool the building shall be no greater than 125% of the
QCMR 1310 and J4.4.
Date )I. Zf-,Or
"l Air f! BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 079181
Birthdate: 11/06/1953
Expires: 11/06/2006 Tr. no: 3762.0
Restricted: 00
WILLIAM C PENNY -
2 COPLEY DRIVE
ANDOVER, MA 01810
Commissioner
* Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 128016
Expiration: 2/11/2007
Type:. Private Corporation
ANDOVER RENOVATION SOLUTIONS, INC
WILLIAM PENNY
110 WINN STS
WOBURN, MA 01801 Administrator
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9.545 Fax. (978) 688-9542
DEBRIS DISPOSAL FORM
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 ell, sl 56a.
The debris- will he disposed of in /at:
s �o ., (Kc
Facility location ,
Signature OfApplicant
11 • 'L8�• o �'
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
& §•raa '^ Y�. � fV7+.xN � � $ .' rgq�pk^Sr'a `xW°
'RIM Fad
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
S,77..CTION 1- SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
o
Nom, 1 _ J\�p�� /A 'Map Numbir Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
VP51- I. S • IF. 4J _ 1 S'0.0 1
Zoning District Proposed Use Lot Are& (sf) Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required I Provide Required I Provided Required Provided
o I ta. Cc' 0 31.3 30 1 1 r o. 3
1.7 Water Supply M.G.L.C.40. § 54) 1.5. Flood Zone Information: 1 1.8 Sewerage Disposal System:
Public ❑ Private A I
Zone Outside Flood Zone Municipal ❑ On Site Disposal System
SECTION 2 - PROP RTY RSIIIP/AUTHORIZED AGENT
2.1 Owner of Record
06a✓ld%s � k t,hs c - ► 3� r�> sk �tJo, A�v.�ayo�uA
P1a t) Address for Service
` 9 Ug S
tgnature Telephone '
2.2 Owner of Record:
�vsa� l. -ori I V% — J t �� �s S.wv�c t>ArC tAro.i�
Name P ' _ Address for Service:
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
wi kl Q ✓►n C. loP_yl vhf
Licensed Construction Supervisor:
Z60V ICA, Die-. cW'v,L A �j!'t' D I CJ a( O License Number
j
':,idress . ) i i'
.1 �J1 a b O �� EXpi tion Date
Signature Telephone
3.2 Registered Home Improvement Contractor
A,Accyr, Arm wa'k1 a%q Gc;,1.DhwKs . 1 vi c .
Company Name
L\0 W 1 vNA �3�- W p is J✓1/l _ "A O t b o k
Not Applicable ❑
12�011o
Registration Number
Expiration Dl 0
e
0.
i
} � 117e UUMMURWeutirl UJ IY1u33Ul.I11.lJGLW
k Department of Industrial Accidents
jOffice of Investigations .
_? d 600 Washington Street
Boston, MA 02111
^ 5•y' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Orgaruzation/Individual): AYtIJ�e' l ifti+ �� RWIS _ Iy)G..
Address: IID W i vt v► _C*.
City/State/Zip: A D (b Phone #: 1 g I 9 3-7 R9 0S_
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).*
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. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 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.] f
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:
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
lContractors 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: 3� C Gt.t CJ�'Yc�Uf City/State/Zip:A-A9#, 9't/+ MA
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 e. 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 againit ihe. violator:- Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA•foi insuzance coverage. verification.
I do hereby cli-lify under
C
and penalties of peljuty 11.at the information provided above is true and correct:
Phone #: -)S1 0151 ggoC
Oficial 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 #:
i .T_ormation anu jutst,rucuuns ) it
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 other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legalentity, 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 be deemed to be an 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 commonwealtk 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 of public 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 boxes that apply to your situation and, if
necessary, supply sub-contractor(s) 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 carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Re advised that this affidavit may be submitted to the Department of. Industrial
Accidents for confirmation of insurance coverage. Also 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 if you 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 permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license 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 burn 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
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Zevised 5-26-05 www.mass.gov/dia
N
Andover Renovation Solutions, Inc. 110 Winn Street, Woburn, MA 01801
Subcontractor Insurance Information
December 28, 2005
MacKenzie Forms, Inc.
8 Allston Ave, Wilmington, MA 01887
Granite State Insurance Company C Group 0264497 05-10-2006
Turco Plumbing and Heating, Inc.
10 Princess Ave., Chelmsford, MA 01824
A.I.M. Insurance Co. 70133449012003 09-28-2006
Gracia Backhoe
Michael J. Gracia
2 State St., Wilmington, MA 01887
Hartford Underwriters Ins. Co. 6S60UB-0223B59-7-03 11-10-2005
O'Keefe Construction
21 Francis St., North Reading, MA 01864
Zurich American Insurance Co. 6ZZUB934X60803 08-31-2006
T & M Construction
P.O. Box 157, Hampton Falls, NH 03844
Granite State Insurance Co. WC 680-71-48 10-05-2006
Brett Belisle
262 Hackett Hill Road, Hooksett, NH 03106
Cental Insurance Co. WC7983201 07-29-06
Cooling Unlimited
565A Main St. Reading, MA 01867
Liberty Mutual WC5-3125-227239-044 06-22-2006
Country Home Custom Builders, Inc.
3 Owens Ct, Unit 2, Hampstead, NH 03819
American Home Assurance Co. AIG WC769-03-96 06-06-2006
r7
FORM U.- LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT ��Q�/C�n/ ��iy�t?�/aCTN cv' a� PHONE��(7
i��v►�n dplbery. 1vlc .
LOCA IT ON Assessors umeto-7$ PARCEL 57 -
SUBDIVISION LOT (S)
STREET 3\ d✓e-tA cl-11r. ST. NUMBER
*****************************************OFFICIAL USE
ONLY**********************************
DATE REJECTED.
ff-mmallammilm I I
TOWN PLANNER
COMMENTS
'
SEPTI
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C6MI
R�HEAL
/1/
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED_
VOTE APPROVED.' ' -.9- 7 L v
DATE REJECTED ! o
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7
1✓i // wo It 1W'— f 117./40), &2,
PUBLIC WORKS - SEWER/WATER CONNE TION
'W J e C7 t/),RIVEWAY LSLU PERMIT
FIRE DEPARTMENT r k
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9\97 jm
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