HomeMy WebLinkAboutBuilding Permit #505 - 322 TURNPIKE STREET 3/26/2009Permit NO:C;,.3�
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
qty `� 16
t1
ry t. s C
3
TYPE OF IMPROVEMENT
New Building
eplacement
Demolition
OWNER: Name:
PROPOSED USE
Residential
One family
Two or more family
No. of units:
Assessory Bldg
Other
Non- Residential
DESCRIPTION OF WORK TO BE PREFORMED:
Industrial
Commercial
Others:
Identification Please Type or Print Clearly)
n -rcm Phone: CC 79-
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: T $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ ee
U c%00
FEE: $
Check No.: 6 j Receipt No.: i�
NOTE: Pers cont acting with unregistered contractors do not have access to the g uaran
•
g ty fund
�gntur :..9en O
n�=con
Sigtur� oftract
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
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
I
COMMENTS
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
Located at 384 Osgood Street
FiRf DEPARTMENT TeTu;pster.o� s#e des rio r�
r
,Located ate4 �9ain xStreet , r„3
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COMIIENT� t� _
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Dimension
I
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
i
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of C
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21 A —F and.G min.$10041000 fine,
I
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
I
I
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
❑ 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
❑ 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Location ��-. �� n ^` ► i '�
No. u Date
TOWN OF NORTH ANDOVER
• ; , Certificate of Occupancy $
sACMus �� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
G TOTAL $
Check # t o 1
21891 �!
U Building Inspector
.�� The Commonwealth of Massachusetts
r Department lo Ind .f ustrial Accidents .
,i - Off ce of 1-nvestigations
600 Was6zine ton
Street
Bostopz
02111
t wwx7.mass.gov/dia
Workers' Compensation Insurance Affidavlt: guilders/Contractors/EleetriccanslPiumbers
A . heant Information
Please Print Leaibi
Name(Businessss/drganization/individaal): V a -J
Address:
City/State/Zip:
Armee yon _employer? Check the appr
1am a employer with (�
employees (frill and/or part-time).*
2. ❑ 1 an a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
No workers' comp. insurance
required.]
3. ❑ I an a homeowner doing all work
myself. [No. workers' comp.
insurance required_] t
Phone #: C1 -y G cld S.S
-irate box:
4. ❑ I am a general contractor and I
have hired the sub -contractors
listed On the attached sheet. $
These sub -contractors have
workers' comp. insurance.
�..
El We are .a corporation and its
officers have exercised -their
right of exemption per MGL
c. IS2, § 1(4), and. we have no
employees. [No .workers'
comp. insurance r
TYpe of project (required):
•6.. ❑ New construction
7. Remodeling .
8. ❑ Demolition
9. ❑ Building addition
10:❑ Mectri.cal repairs or additions
11.0 Plumbing repairs or additions
12. oof repairs
equtred) I 1317 Other
*Any appficant.fhar cheeks box # 1 .must also fill out the section below showing t{�ir. „„.. compensation Policy tnmrmation.
t Homeowners whe submit .flus ai.�davtt indicating they arc duigl ir` "tit; ;toil filen hire outside con
truciurs ghost su'omii x new affidavit indicating s
YConnactors that ch=k this box must attached an additional sheet showing the na_*ne of the sus ccnnzetors and their workerr' affi avit_. __ a g such.
r __
cnrfnvyor Inaz is provufine workers' compensation
information insurance for '+9' employees. Below LS the oft
P c3 and job site
Insurance Company Name:
Policy # or Self .ins. Lic. #: -% d T 0 Ji 0 a 3 0 A c71 cf U C
T� Expiration Date: /0
Job Site Address:
Attach a copy of the workers' compensation policy deelartion Q City/State/Zip: "Vo
Failure to secure coverage as required under Section 25A of pa (showia; the policy number and expiration date).
MGL c. 1 S2 can lead to the
fine up to 51,500.00 and/or one-year imprisonment, as well imposition of criminal penalties of a
of up to 5250.00 a day as civil penalties in the forth of a STOP WORK ORDER and a fine
. against the violator. Be advised that a copy of this statement may be forwarded to the
investigations of -the DIA for insurance coverage verification. Office of
-I .:- L --- L_. _
- .- ," w1J- "nuer nee paths and penalties of perjurf' that the information provided above is true and correct
#:
ass
Official use onlp. Do not write h7 this area, to be completed by city or town
City or Town:
Per -.;+ft
.i
Issuing Authority (circle one): cense #
1. Board of Health 2. Building Department 3. City/Tow. perk 4. Electrical inspector S. Plumbing
6. Other b Inspector
Contact Person:
Phone #
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined. as ".. ever -y 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 includi-ng the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house.having not more than .three ag artments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maim--nance, 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 o r local licensing aeenc}l small with.hoid 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 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 comppZ-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub -cont mctor(s) name(s), address(es) grad 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. Be. advised. that this afliciavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. 'Also be sure to sign and date the. affidavit. The affidavitshouid
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 reg*asdirg the lava or if you are required to obtain a workers'
compensation policy; please call the Department at the nganber:Iisted below. Self-insured companies should enter their
self-insurance license number on the appropriate ime.
City or Town Officials
Please be sure that the affidavit .is complete and printed le vsz ly. 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 permitllicense number which will be used as a reference number. in addition, an applicant
that must submit multiple permit/license applications in arty 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 affiidavit 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 burnleaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like t6 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
Dtparlment of Lidustr-ial Accidents.
Office of Investigations
600 wash ngton Street
Boston; MA (12111
Tel. # 617-727-4900 vert 406 or 1-8.77-MASSAFE
Revised 5-26.45 Fax 4 617-727-7749
v^wmass.gov/dia
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NOTICE
TO
EMPLOYEES
NOTICE
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-7274900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(7PJUB-0230N91-9-09)03-11-09 TO 03-11-10
POLICY NUMBER EFFECTIVE DATES
GILBERT INS AGCY 137 MAIN ST
READING MA 01867
NAME OF INSURANCE AGENT ADDRESS PHONE #
DUVAL ROOFING LLC 184 PARK STREET
FORTH READING
MA 01864
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
wzoP,cas TO BE POSTED BY EMPLOYER
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 58443
ExpiratFon 1- /10/2(19 Tr# 9949
KENNETH P DUV�I�Lr
I PO BOX 190/72 NOITwH ST �- �J
N READING, MA 01864 Commissioner
✓ste V� a��nw�wrea�iz a�._/�aaaac/zuaelia
Board of Building Regulations and Standards
HOME, IMPROVEMENT CONTRACTOR
Registration: 109288
Exptratton ;9/9/2010 Tr# 273490
S
I }
Type DBA
DUVAL ROOFING`
Kenneth Duval
72 NORTH ST
N. READING, MA 01864 Administrator
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, Ma. 02108
Not valid without signature
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Page No. of Pages
Builders License # 58443
Home Construction Reg. # 109288
yeaflz��
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(781) 944-1994 (978) 664-2557
"The Areas Oldest Roofing Company"
P.O. Box 637, North Reading, MA 01864
op. MyTfED T olt4ui
o� / � V
v!
DATE
STREET 1„
3c) .� rA (kx ��
JOB NAME
CITY, STATE AN P CODE
Ac bUer
JOB LOCATION
We hereby submit specifications and estimates for: Recommended
J ! / rr R &C4 ( (Included in price)
Optional
(Not included in price)
/
b' Rip & Remove all shingle debris from roof & jab site: 1 layer 4 U/2 layers ❑ 3 layers or more
e
Repair/or Replace any roof decki 0g;�not to exceed 50sq(ft. (additional at $1.70 per ft.)
I✓ Install 8" aluminum drip-edge/and rake-.edgealong entire perimeter. Choice of mill, r brown
Install ICE & WATER underlayment along hoizbntal Bayes, valleys, sidewalls, sky -lights and chimneys
1p/ Install premium base sheet underlayment between roof deck and roofing shingles
Install 30yr CertainTeed/GAF/Tamko or IKO architectural roof shingles
❑ 40 year ❑ 50 year M kms , r a)A Q 5
�
Ll60 year ❑ Lifetime -�- V
" See manufacturer warranty policy for more details
/
V1 Install new aluminum vent -pipe flange (s)
el Chimney (s) -counter-flash and re -step existing flashing
❑ Cut & Install new lead flashing
Ridge-vent/exhaust vent with low profile design, hidden by shingle caps
❑ Soffit -ventilation ❑ Roof louver -vents
Seamless style aluminum gutters - custom fabricated at job site by our own gutter machine
,❑ Downspouts Leaf gutter guards
Other & f� /120 `" J r 00
�^❑
1AS te: f l 1, f I!1 /cc,
rc �,tlbPlfJl c� 1L �,lq t� p
color e4erm14r1ld
lRre , r�IIr►n IV 0r c�a M, a a'r� 4 i 0 �ltll�jl
*Please Note: All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear -off
Price includes all items above that are checked only / others may be priced separately upon request.
Pe Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
Soo 1 Total price not including options. dollars ($
Payment to be made as follows: l o o
30% deposit required before ordering materials. Balance due in full upon day of completion.
Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864
Late charges of $50 per week for all outstanding bills due upon day of Authorized
completion. lei Signature X4 �Crt.t�
- Accepting proposal means areeing to the terms of the enclosed binder Note: This proposal may be 1 `
rnntrart Phaco Ginn rnntract R roti vn tnn cnnv (white) with denosit. withdrawn by us if not accepted within 3 i / days