HomeMy WebLinkAboutBuilding Permit #786 - 34 LIBERTY STREET 6/12/2006Of NORTH
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Permit NO:
Date Issued: o' /Z- 401r,
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received:
6�/Z '6�,
IMPORTANT: Applicant must complete all items on this paare
LOCATION � ���r� ' J
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PROPERTY OWNER
Print
MAP NO.: PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES 0
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
�.7 One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
D Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Please Type or Print Clearly)
OWNER: Name: 0/ CL �`���� Phone:
T z o' 6—WcJ-1 Signayr�
C �
Address: .
- -� � ✓ f
CONTRACTOR Name: -)�n �'✓�n'���' / Phone:1`%�'•
Address:
Supervisor's Construction License: GC� �Z L Exp. Date: I 13 U
Home Improvement License: �% e �� Exp. Date: lale- C
ARCHITECT/ENGINEER Name: Phone:
Address:
g. No.
FEE SCHEDULE: BULDING PERMIT. $10.00 PER $1000.00 OF THE TOTAL ESTLVATED COST BASUD ON $125.00 PER S. F.
Total Project Cost :$ /Z 900 ` U L x10.00=FEE:$
Check No.:-�� Receipt No.: a 6
Page I of 4
TYPE OF SEWARGE DISPOSAL
Tanning/Massage/Body Art ElPublic
Swimming Pools J
Sewer ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales V
❑
F-1Permanent Dumpster on Site
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund
Signature of Agent/Owner Signature of Contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ amped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
4
1
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition N
Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
DATE REJECTED
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJECTED
U
Comments
Comments
❑E
DATE APPROVED
Water & Sewer connection signature & date
Temp Dumpster on site yes_no',X Fire Department signature/date (,J� (` O -z L vqw e--)
Building Permit Approved and Issued by: 6x^ P�-\-
Pag
2 of 4
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required
Provided
DIMENSION
Number of Stories:
Total land area, sq. ft.:
NUIEJ and DAIA—(For
Pave 3 of 4
Created JMC. Jan2006
Total square feet of floor area, based on Exterior dimensions.
SERVICES DEPARTMENT BPFORM05
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 DEPARTMENTAIFORMII5
Page 4 of 4
Location r �r
No. 7i�</ Date
�ORTh
TOWN OF NORTH ANDOVER
"
Certificate of Occupancy
$
s'••'° E<�'
Building/Frame Permit Fee
$ .69
CHUS
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Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
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The Commonwealth of Massachusetts
Department of Industrial Accidents
u� Office of Investigations .
a d 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ALL tf,1 DGn en -- "Tc 0'
Address: �3 o, T -r-- -,PC i' 0/7
City/State/Zip: /Li (--,r/-/ Ll el-) M A SS Phone #: 9 7�>- 9 %:-` /-
Are you an employer? Check the appropriate box:
1.jP1 am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2.17 I am a sole Dronlietor or partner- listed on the attached sheet. I
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
❑ 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.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #I must also fill 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
(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. #: /�`'`-�-� J o����a�Zd Expiration Date:
Job Site Address:
Li7City/State/Zip: %kdf
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!he violator:- Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA -for insuzanep coverage verification.
Ido hereby certify u►tder tlne pins and pjnalties of perjurythat tl:e information provided above is ue and correct:
Date: -C-// /_
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
PermitlLicense #
City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
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 "...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 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 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 thatthis 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 pemut/license number which will be used as a reference number. In addition, an applicant
that must submit multiple perrnit/liceuse 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 providers 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
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
Revised 5-26-05 www.mass.gov/dia
U L11q DO EA ED
(C":_ -Z ==eY8 Residential 8 Cornmercial aoofinq
F- CC.Tit9L3VS POINTED -REBUILT -CAPPED An Types Of
snaiaz*ta� _ - Eu ert a
Mass Toll Free Root Leaks Exerts �h� D Liceed & Inns ed,orlt
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1 1 -800 -WAIT -043S L -IfY Otvned & Opeiatcd Sirsce 1976~— License #034200
(924-8487) I:{O0 as& lZar= of _90/—v IM we Wort: 'V . U_ .—A
1 V_v-`-�
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Proposal Submitted To ph e
16 t'L_(_ J`o's 7115- GK6 -9?,0/
Street
3 L,�c:n S'2—
Job Name
City, State & Zip Codelob
/a ✓n d (/LTJ O�y���
Location
�J.bone
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of-
' d
� �T S'7%M� � �� Dollars ($ ).
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standerd practices. Any alteration or deviation from specifications be- Signature:
low involving extra costs will be executed only upon written orders, and will become an
extra chuge over and above the estimate. All agreements contingent upon strikes, accidents NOTE: This pAOWmayor delays beyond our control, Owner to carry fire, tomado and other necessary insurance./
Our workers are fully covered by Workmen's Compensation Insurance withdrawn by us if not
accepted within 6 days.
We hereby submit specifications and estimates for: SpZt?o f int
ba install 3 feet of special "Eave Seal" ice and water barrier protection along all bottom edges
of roof
and top to bottom in each valley. Cf roof is stripped, we will apply conventional ice and water shield
( -3 ) ft. high in the same locations previously described and tar paper will cover the
remaining bare wood. Any rotted or damaged boards will be replaced at ( ) per linear ft.
or (5!;-. o G ) per sheet of plywood.
stall heavy gauge aluminum drip edges along every edge surface of each roofline.wl4irt
AlicJ t,4 /Y Qthr a 0o7To^ 1 .
VCover entire roof (s) bQlt%�asphalt, c= -,fiberglass, premium grade shingles
(Color of choice) -e 2h c1 J/-5 Sln j 641z el+,�,,4Riv&G'
WReplace all pipe boots where possible.
!idSeal a(l flashings with clear Geo -Cel sealant. No black tar unless previously applied.
6dRemove all work-related debris.
4'Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under
normal circumstances.
&Local current references and proof of workman's compensation insurance gladly given.
CdrRemarkskSrr���-.�«J�,x J�Kr.dn /j loGc=- ------
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Acceptance of Proposal - The above prices, specification�u/a•O As 6--$T AS TS%T '`,
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment Signature:
will be made as outlined abov .
Date of Acceptance: ti Signature:
1 V_v-`-�