HomeMy WebLinkAboutBuilding Permit #65-11 - 33 PILGRIM STREET 7/15/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: S 0— ( ( Date Received
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TYPE OF IMPROVEMENT
New Building
Addition
Alteration
Repair, replacement
Demolition
OWNER: Name:
PROPOSED USE
Residential
-One family
Two or more family
No. of units:
Assessory Bldg _
Other
Non- Residential
DESCRIPTION OF YVORK TO BE PREFORMED:
Please Type or Print Clearly)
Industrial
Commercial
Others:
ne:
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: $ 1-26 ��
FEE:
Check No.: 3 eZ(� Receipt No.: 03 1 b
NOTE..Persons contracting with unregistered contractors do not have access to the guaranty 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
o 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)
o 'Copy of Contract
❑ Mass check Energy. Compliance Report
o 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
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 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010 '
No
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
_
Public Sewer
Tanning/Massage/Body Art
Swimming Pools, ;j
Well
Tobacco Sales
Ir
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
PLANNING & DEVELOPMENT
COMMENTS
DATE APPROVED
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:
Conservation Decision:
Comm
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tnwn Rngineer: Signature:
Location RIA 6z2-7 S
No. Date /-7 —1 r—lo
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # 13 ;2-6)
231 U6 Building Inspector
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DAVID CASTRICONE
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 North Andover 978-683-3420 In Boxford 978-887-6147 In HaverhU1978-374-7314
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 described-
Owner's
escribed
Owner's Name..... ...t1 ' ...... .t.K xi 5 ........................................................... Te hone # ..................................................
l ... city..
ty..Job Address.... .....d• r.......................... \ f (....... :..... State.....
...
Specifications:
...t,
r...ip...ex..i....sti..........shin..............................pl....y...new..........drip ...... e............
dgeto.all.......e......es.........................S**?......................................................................................
Sng gles( �►pdgZrr 1~ �
......................................................................................................................................................................................................................
--,apply _feet ice and water shield membrane to bottom edges of house. 3 feet ice and water spiel embrane
in valleys and bottom edges of any unheated areas of house.
F "Zi:vl y�"r
ply f It pa derlayment. Install ridge vent to
...........�.Pa..4.......,............................................. ...........:..........................................................................
..........
Reroof using shingles with a ?0 year warranty.
......................................................................................................................................................................................................................
--Counterflash chimney. ,-(Yew vent pipe flashing. -Legal disposal of all debris.
.......................................................... J ....... .�..................................... ........
Area(s) to be worked on: J %
..................�1:�•..Lz'�..tcl`e :.....?C:cam ....pc...1..a.................................
........ ..r? C�tia 4� ...........i...K �,......... J.yl,. rr, w.......................................................................................................................
............................................ I ....................... e .................... %f.................
Roof board replacement if necessary @ 66 /sheet or YS-54o0t.
..................................................................................................................................................... ....... `...
...........
Two Year Workmanship Warranty (Not Transferable) 11')anufacturer's Warran...as..sp.:ed by........manu.facturer
The c actor agrSes to perform the work d ish the materials specified above for the S of s..L.C.T ,'.D ............ . ...
ayable1;1?.L7.LZ G?....... on ...,�T...........
Payable......:.. ............. on ........ ..'—.�. _...... Balance` payable on completion of job
Owner or (Tuners are not responsible for Property Damage or Liability while job rs m 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 fuller agreed that this contract may be 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 title 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 staled. 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).
? l N
IN WITNESS WHEREOF, the parties have hereunto signed their names this ......9........ day of ... `..". /........... 20... ..
Accepted:
r
..... . . ......... .. . ......
David Castricone, President
Signed.......................................................... Owner
Signed............................................................................. Owner
IZuS6 c B 'l aL k
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www. mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name (Business/organization/lndividual): C AS16 { C O NE R Ott F V NC, 1 S lD 1 N (, 1 N L
Address: ZpCp Su-r-rntJ ST Sy <-t-e- Z2b
City/State/Zip: N.. AcNbo JE iC NA O 1 & c1S Phone #: °I-) 9 (P � 3 3 4 20
Are ,you an employer? Check the appropriate box:
1. ® I am a employer with 4. ❑ 1 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-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I atm a homeowner doing all work
myself. 1No workers' comp.
insurance required.] .r
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.1
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, 51(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
I L ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.n Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
I
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 die 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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 7" CC-te L.n
O MD o -ti k, Aocb 'M
Policy # or Self -ins. Lic. #: yN C q qI5 y
A I to
Job Site Address: ,33 �I ICjr7t/l+
Expiration Date: 9- a 3- .2-0 l a
City /State/Zip:dy3 kjiyf" Ho al p
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 rine
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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: E)2 . C Date:
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 #:
Town. of North Andover
]Utuldiiag Dcp;,rt.wcnC
27 Charles Street
NcWh Andover, Massachusetts 0.1 S4.5
(978) 688-9545 lax (978) 688-9542
DEBRIS :DISPOSAL FORM
a I o O
►° Awa ,Nl � �)��'l'`�„�1,� �� '
o'��ra
I LJ
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Buitding permit # _ the debris re:t.!lting from the work slull be disposed
of in a properly licensed solid waste disposal facili'1., as defined by MGL cl 1, s150a.
The debris will be disposed of in /at'
1�aGili'ty .Ii:�,;�i11011 ^.
Slgillature of Applic,art
Date
NOTE: A demolition pern-lit fl-onl the Town ofNort.h Andover must be obtaMcd :for this
project 1:11 otigl► the Office of the Building Inspector,
N
r veer nO. WWWWW'eaAM r` ,. -Gl is cr c l W teal
Office. oI'Conswuer Affairs & 13usutess Rcgulaliuu
h HOME IMPROVEMENT CONTRACTOR
- "Registration: 104569 Type:
f
? Expiration: 7!14!2012 Private Corporatio ` ..
DAVID CASTRICONE ROOFING, SIDING &
David Castricone
200 SUTTON ST SUITE 226
NORTH ANDOVER, MA 01845 lI„ �L1•Sec,•el;,,•y
ll;u�achu.x•ft. - Urlr,u-Irnrnt of Puhli� 1;tFrt�
VBoiwd of Builtlin:; f:c ulations and Slan lartis
Construction Supervisor Specialty SP Y License
License: CS SL 99358
Restricted to: RF,WSit.
f
DAVID CASTRICONE
31 COURT STREET 'T
NORTH ANDOVER, MA 01845
Expiration: 1 211 61201 1
( nwiis.iuurr
T rg: 99358
n
L-•-••w•-1w',., %.#L -F% I I wr R-.. w4 L- In-►a.eNL-I i e IIm..n%J?R-kl-'LITa'vA— 09/28/2001
PRODUCER (508)651-7700 FAX 508-653-8089
Eastern Insurance Group LLC - Commercial
233 west Central Street
Natick, MA 01760
Select 0(t.53389
THIS CERTIFICATE IS ISSUED AS A MATTER OF INrORMATION�
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THI$ CERTIFICATE= DOG=S NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED 13Y THF POLICIES pELOVV.
— �-
INSURERS AFFORDING COVERAGE NAIL #
INI5UREP 0avid Castricone Roo ing & Siding Inc
200 Sutton St
Suite 226
North Andover, MA 01645
INSURERA: The Insurance Co of State: PA
INSURER 13:
INSURER C;
INSURER D:
INSURER E.
rnvr. n wrr_c
THE POLIGIE5 OF INSI IRANGE LISTE=D BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE_ FOR TI1� POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY QF-OUIQEMENT, TE47M OR CONDI-PION Or ANY CONTRACT OR OTHER 0OCUMErif WITH RESPECT To WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONL)ITION$ OF'3UCH
POLIGILS, AGCRFGATE LIMITS SHOWN MAY HAVL DELN REDUCED DY PAID CLAIMS.
INSR
DD'
TYPE OF INSURANCE
POLICY NUMBER
DATEPC)LICtMrdlUp T'IVF
POLICYw m(Jy N
LIMITS
GENERAL LIAUILIIY
SACH OCCItRRFN('I;
COMMERCIAL GENERAL(-�LIIASILITY
CLAIMS MADE I I OCCUR
DAMAGE TO RLNTF_U
' SAny one p,3 IG nj
h1CD CXr (Any one paruonl
$
S
PCRSONAL N ADV INJURY
$i
C'LNF-NAI AGC3QEGArc
$
,.
CtN'L A0011fUATL LIMIT APPLIES PCR.
r'VODUC Ib, - CUMVICI V A00
$
P0LICYF—j PRU LOC
JECT
-
AUTOMOBILE
LIAbILIYV
ANY AUTO
CO A4BIhICD SINGLE LIMIT
11-a pCudvnQ
$
ALL OWNI_q AU'IO.S
SCHEDULED AUT05
BODILY INJUNv
(I,ei pelFOD)
HIRED AUTOS
NON -OWNED AUTOS
nornLv INJURY
(Pur :act irivnll
$
PRprl'.R'IV 0AMAI V
Epee eer,Iden11
R
_
GARAGE LIADILITY
AUTO ONLY, ISA ACCIDENT
$
rA ACC
071 -AER THAN
$
ANY AUTO
AUTO ONLY. AGO
S
EXCE991UMBRFLLA LIABILITY
CACI I OCCURP NCE
$
OCCUR CLAIM$ MADE
AGGNLGAT[
$
$
OLUV01,113m
RETENTION E
WDRNFR9 COMPENSATION AND
EMPLOYERS' LIABILITY
WC9752746
09/23/2009
09/23/26 �a)
WC S'rATL;- I OTH
ny-UMGM FR
F.L. EACH ACCILiFNT
$ 100, QQQ
A
ANY PROPRIF„-roP/PAR-tmvRIE,KECUTIvE
OFFICERIMEMBF11(,xCLUDr_D”
If yyoo5, dvsGnbC UndCr
&PEGIAl. PROVISIONS belml
---
E.L. UISfJISF. -1 1 EMPLOYE
$ 100,000
P.L. DI$FASF - POI -ICY LIMIT
$ 5QQ )QQ
OTHER
--
— - —
tW9CRIPYION OF OPERA'rI0N6 I LOCATIONS I VEHICL[9 1 EXCLlIS10N9 ADOFD BV ENDORSEMENT I SPECIAL PROVISION£
David Castricone
200 Sutton Street
Suite 226
North Andover, MA
SHOULD ANY OI' YH5 ADOV[ l'S;RIBED I.OLICfE$ 3C CANCEL1.0 WORE YHE
Roofing & Siding EXPIRATION DATE THEREOF 'i -IE 159UIN0 INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOT.h:T"_ TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT rAIWR.E TO MAIL SUCH !'2i fICE 9 TALL IMPOSE NO OALIGAYION OR LIABILITY
01-845 Or ANY KIN11 UPON YHE tN$L.7 (- Bi IY$ ArVNY5 Oil rIEPRESENYA71V$5.
AUTHORIZED REPRESENTATIVE q
Stacey_ 13rice/PKG�eJ1;y�-
ACORD 25 (2001100) �ACORD CORPORATION 1988