HomeMy WebLinkAboutBuilding Permit #476 - 34 EAST WATER STREET 12/21/2006L
TOWN OF NORTH ANDOVER
NORTH
APPLICATION FOR PLAN EXAMINATION of �.�•o �ti
,c
Permit NO: Date Received
....tea:. ;.
4T D
Date Issued: s,�cMus�
IMPORTANT: Applicant must complete all items on this page
LOCATION `/� 1/ z/ - !,r �� I`% �► l
PROPERTY OWN
MAP NO.: (e / PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
1111/ lbt t5,1iJ
7-z,,i ?4i 9l J
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
❑ One family
C-Tw`o or more'family
No. of units:
❑ Industrial
DAdfia-ir, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving relocation
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Il r 1 ac) L�-
Identification Please Type or Print Clearly)
OWNER: Name: ki (.I,, A,1 k± 2 Phone:
Address: S6-0) Cli
r S'Tt,,,v7
1111/ lbt t5,1iJ
7-z,,i ?4i 9l J
CONTRACTOR Name:
rJ sC
Phone: A -? G 3 3 a/ 7
Address: _'���--� �%_l��l .r �✓� /� �� d d l
Supervisor's Construction License: (5 7/ d Exp. Date: /4za �—
Home Improvement License: /1 ? )e- 60 Exp. Date: 4� 6 "7
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COS ASED ON $125.00 PER S. F.
Total Project Cost FEES
Check No.: Receipt No.: ��
Page 1 of 4
Locationti- S�7 /� 1�R r-j—
No. Date ^ v
NORTH TOWN OF NORTH ANDOVER
of'"•o ,•,h•C
3:' 0
AL
Certificate of Occupancy $
s''s�cNus ••"EBuilding/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
19893
Building Inspector
TYPE OF SEWERAGE DISPOSAL
Art E]Public
Swimming Pools El
Sewer 11Tannmg/Massage/Body
❑
❑
Tobacco Sales�---
Food Packaging/Sales ❑
Well
Perm��.
Site ❑
Private (septic tank, etc. ❑
rrt'�umpster on
j
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner 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
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
El
DATE
Stamped Plans ❑
DATE APPROVED
11
DATE APPROVED
El
DATE REJECTED DATE APPROVED
❑ ❑
FIRE DEPARTMENT - Temp Dumpster on site
Fire Department signature/date
COMMENTS f
/' 4,—no
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Sienature & Date Driveway Permit
Building Setback (ft.)
Front Yard Side Yard Rear Yard
e uired Provided Required Provides Required Provided
J
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
Page 4 of 4
rvyvsal Page No. of Pages
Tom DeFusco
23 Dutton Road
Home Improvement Reg. # 117756 Pelham, NH 03076 Tel 603-635-3017
Constr. Lic. #071037 Fax 603-635-3751
PROPOSAL SUBMITTED TrO�, r PHONE DATE
\ r �1 1
S REET JOB NAME
.NIJ� /t L % r/ t� t' i✓� / r
CITY, STATE AND ZIP CODE JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for
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At 140POSP hereby to furnish material and labor — complete in acccoor.-dance with the above specifications, for the sum of:
dollars ($ I r ).
Payment to be made as follows:
� � r
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized y� J
manner according to standard practices. Any alteration or deviation from above Signature
specifications involving extra costs will be executed only upon written orders, and will become
an extra charge over and above the estimate. All agreements contingent upon strikes, Note: This proposal may be
accidents or delays beyond our control. Owner to carry fire, tornado and other necessary withdrawn by us if not accepted within days.
insurance. Our workers are fully covered by Workmen's Compensation Insurance.
,�Myb= of F1rOPOSA-The above prices, specifications Signature
and conditions are satisfactory and hereby accepted. You are authorized to do the
work as specified. Payment will be made as outlined above. C .
Date of Acceptance: Signature
SEP.28.2006 09:33 19784590888 WILSONINH #3228 P.002 1002
.ACORN,, CERTIFICATE MJF LIABILITY INSURANCE 09/ , '
PRCDucele (978)459-7744 FAX (978)459-0488 NKk1kUED AS UONCITIFCATE�p
OYAN0 COFEM OPJG THE ERTII
Wilson inSulrance AQ"CY InC- HOLDER. THM CERTIFICATE. DOES NOT AMEND, EXTEND OR
6 CourthMSO Lama Snit* 14 ALTER THE COVERAGE AFFORDEDYTHEP SEL
Chelmsford 14A 01824
INSURERS AFFORDING COVERAGE KAIC 8
mmum:D Tom Oefusco dba Tam OeFusw Ceneral INSLMM- A: Scottsdale insurance
contracting INSIwRe: Liberty Mutual Insurance
7 Austin Street INssJRfttc: _.
Methuen NIA 01844
e1S11KtH t:
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THE POUCIES OF NSURANCE LISTED BELOW FUNS SEEN ISSUED TO THE 1NSUREt NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVYITHSTANDWG
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DEBOMBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
pMICIES. AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUGID BY PAID CLAIMS_
Nit IYPEOrWS11RMICE POUGYNLBil19t POI "aLLCYarFECIIVE pOUCYEXPMATION Luffm
GENERAL LMBILRY
CLS1299326
08/03 j2006
08/03/2007
LFACH OCCURRLMCC s 1 a 000; 00
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DAMAGETORENTED ' SO 00
FRO CX(M
MED CXP (Any atn pvmgn) S S
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GFIC4W AGGREGAIt t 2, 8,000
PRODUCTS-COMP/DPAGCi S 11000,00
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Sample
ACORD 25 (2001MB)
SHOULD ANY OF THE ABOVE DEBCRIBED POLW." BE CANCELLED BEFORE THE
IMMA"X DATE TINMOF, THE SWING IMSURM MLL EWFAVOR TO MAIL i
10 DAYS WRITTEN WOMC Tri TM CEIMMAT6 HOLDER NAMED TO TME LEFT.
BUT FAILURE TO MAIL SUCH NOTICE SMALL IMP03RIMOODLIGAMONOR
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The Coninionwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
,^N www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): SC v
Address: 'r) --Z. 3) rr
City/State/Zip: ��� (A!2 Phone #: -2
Are you an employer? Check the appropriate box:
I. ❑ I am demployer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ Iam a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
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
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
'Any applicant that checks box # 1 must also 611 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
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 workerscompensation insurance for my employees. Below is the policy and job site
information. �
Insurance Company Name:
v
Policy # or Self -ins. Lic. M ULL 37,E 3 :3 fr U L G O/G Expiration Date: �� 4
Job Site Address: /,/,1j`r S-1 cue -i.— City/State/Zip: OA 1�-, r,
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 fate
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 tire information provided above is true and correct.
/�
Phone #: G d3 G 5 (<- 3 01,
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 ✓/:e 7�omwmo�zurea� 0�.,1�aa-,ta�a.,�aet7a
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 071037
Birthdate: 06/18/1950
Expires: 06/18/2007 Tr. no: 11773
Restricted: 00
THOMAS A DEFUSCO
23 DUTTON ROAD
PELHAM, NH 03076 45�
Commissioner
A. ol, //a-uarl
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 117756
Expiration: 11/15/2008 Tr# 124836
Type: DBA
TOM DEFUSCO GENERAL CONTRACTING
THOMAS DEFUSCO
23 DUTTON RD,,,Q a .`
PELHAM, NH 03076 Administrator