HomeMy WebLinkAboutBuilding Permit #637 - 34 OLD VILLAGE LANE 4/2/2007Permit NO:
Date Issued: - o �"
A e /�Js,U?,�4e
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Recei.ved L -, i 2 — 0
Please Type or Print Clearly)
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ARCHITECT/ENGINEER Phone: r
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $_ ° FEE: $_ �-
Check No.: <3d Receipt No.: o Z) / U
NOTE.•Persons contracting with unregistered contractors do not have access to the L-mZwanty 7Y,
Signature" f Ager tt/Owner
t anaturP
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
PLANNING & DEVELOPMENT
COMMENTS
DATE APPROVED
El
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
.Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _
'r
PlAning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit _
Located at 384 Osgood Street
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
Doe.Building Permit Revised 2007
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obt�
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
Addition Or Decks
- - . _1111..
❑ 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
Li 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
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nnlln'n*
Name (Business/Organization/Individual):
City/State/Zip: b k ., /h7SS ,
0 196-1/ Phone #- Q? A — 4-S 4—.6 9 6 ,-�
Are you an employer? Check the appropriate box:
1.0 I am a employer with
4. 0 I am a general contractor and I
2. �employees (full and/or part-time).*
I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.#
required.]
5. 0 We are a corporation and its
3.0 I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp, insurance required.]
Type of project (required)
6. 0 New construction
7. [] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
ow showing their
t Homeowners who submit this affidavit indicating they are doing all work and then hire ou�,de contractors ution must submit amnew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees, they must provide their workers' comp. policy number.
I ani an employer that Is providing workers' compensation insurance for my employees. Below is
information. the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
City/State/Zip:
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 the violator. Be advised that a copy of this statement may be forwarded to the Off!
Investigations of the DIA for innrrranew , ,,..o.�,.e ..e-:a__�__ ce of
I do hereby certify under t ains and na
Signature:
,
Phone #: �`! �`
use only. Do not write in this area, to
that the information provided above is true and correct.
Date. Z/143 / '?
or town offi'cia[
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 #:
Information and Instructions
Massachusetts General Laws chapter 152 requires `all emplo provide
service of another workers,
�ation for their nder any cQ �a�n° lime's.
Pursuant to this statute, an employee is defined as .. eery Person in
express or implied, oral or written."
Ais defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
An employer the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
of artnershi association or other legal entity, employing employees. However the
receiver or trustee of an individual, p P+
apartments and who resides therein, or the occupant of the
owner of a dwelling house having not more than three
dwelling house of another who employs persons ots�dollma' not beecausce of construction
employment be deemed t be an employer.e
or on the grounds or building appurtenant then
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 -contractors) 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. Be, 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 !EpLoLnate line.
City or Towa Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
u to fill out i
of the affidavit for yolicense nun the event the Office of Investigations has to contact you regarding the appliclan
ant
Please be sure to fill in the permit/t.
number which will be used as a reference number. In addition, an app
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 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 # 6174277749--
Revised
17 427-774 -Revised 11-22-06 www.mass.gov/dia
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04/02/07 10:23 FAX 781. 278 0741
cusItnrw C;a*eauT & Remodeling Int
w03 Mt. Hope St. rear
Lowell, Mus. 01814
Name 1 Address
SSE. !3avt:ett
34 Old ViDW Lane
ldu. Andover. Mm 01845
MCC Bldg Ten
Z 002
Esti ill ante
Date
E16mato #
3/27/7007
CCI -100
P.O. No. i Jab Area
2nd Bathroom
Projed
` Item
Fax #
oescdoon
Total
02.10 .Dema
tgQU$t0 CWPt tiryIOvOria+on.net
Demolition: Darn 811 walls in 2nd k#uvoru from floor to ceiling, sntim tub, aid
3.289.D0
suaround, and R11 oeilingt. includiftgell ccearaio ti10. Ras mfmish floor, and one
100 of undcrlayment. Itemrove all wcvftm to Ire ra4AW at Wsh. haul away 8I1
debris. Provide dost rsnd carpet protection, vocuum'ell Rti'e cW areas. Not inchsdtDg
toilet and vanity removal, which will be required berom start oedema
17 Insulatsoes
Insulation: insulate all e8r{.insed walls with um R13 faced fiberglass hual lion.
Insulate all ceilings with R39 Sailed fiberglass instllatlon- lneluded with 4rWI vapor
barrier, stapled to fuming, through out.
13 Windows & lr;m
Windows & Telm, Replace window wfth Harvey Brand vinyl window as described
its Estimate * 102
d is Interior WRl.ls
Interior Walls & Ceili;agsi Resurface all wells & ceiligas with t/2" moisture
ktsistant drywall, taped 3 coats ra a paint grade: anisk serried and prittme;d with arc
coat of lamx KRZ prinw.
19 interior Walls
Interior Walls; Resurface entire tub surround with 1l2" wonder board, eut wall.
back wall, and colling_ All joints to be fiberglass mesh taped with mortar. Ratrap
ceiling w aeaotrtnrodatc 2 new eecosscd light fixtures.
We hope tins meets Your expectations, we arc looking forvrsnd ro vrot'kins with YQU..
Phone #
Fax #
E -M ad
9?A-X54-Otk50
97"53-3204
tgQU$t0 CWPt tiryIOvOria+on.net
Z9 3S)Vd
ONI g01436 dHV3 15f1O
Total
GI2ZE99b6L6 se:lz L30VT0/b13
09.021/07 10:28 FAY 781 278 0711
CastAln C"nUy & Rtmodeft Inc.
93 Mt. HfVe St. rear
Lowell, Mass, 01854
Name 1 Address
Bob Hailnett
:W 0!d Village lane
PSn. Andavar, Mass 01845
XCC Bldg 'Ten
Z003
Esbmate
Dace Satimals #
3/21/1007 CCI -100
P.O.No. r� Job Area Project
2nd Ruhroom
— —A lleM Deation Total
23 Floor Covarinp Floor Coverings; Instail 1/2, wonder board % entire floor ares6 m9wdded in morin
mix. all Joints to be mesh taped as weIl.
This estimate does not fnolude, plumb, oloatriwL ccMuc file uts1041atian, bath
room uuecorles, finish paint, finish wort, re chroining of axaiudng ffxdu"- MS
scope is for pre fmishen only, demo, daaulatdM restu*Ing walls and
Celling5,andertE0+rslettt of floor, arc rubbish rttnoval.Perruit fee bas been calculated.
as quotod by N.Andover Building Dept, st 512.00 per $1400 only. Sr40.00. If
additioeai chwgas are requirac b� the Town, additional charges may be Vplied to
the final cost of project.
Paym=t Terms;
TbiS scope of work will require a good faith deposit of SIM0.00 at start Of demor a
umtor;ols and partied labor payment MVe5t of S 1200.bo at clams -up snd diaposgt of
debris. A payrrrent request will bo made of S769.00 U walls and eeilings are
primed. I.aaving a Bs daaco of 5300.00 Due U Pinel kaspe04ion of Town Building
Dept.
If. Phis Estiu me is sow , PI ' s1/ below, an no* this 4ffiGc for depoaut
and schodWing atraigtt fe s, A r+ct+rns usstiod for acu'ptanco.
Qwncft 5
Plc- hope iltis [ nem your enemions, we are looWng forward to working with you.. I Total S12S9.10
4}honer Fax# E-tt18d
y^$ 454-0860 973-453-3209 tgonsamearpentryleverizorr.net
CO 39bd ONT aOW3N d8VO 1Sf1D
507EE5b8LG 90 1/.Z LOK/tC i"
04/02/07 10:26 FAX 781 275 0741 MCC Bldg, Ten 0004
custom Ca meguy & R emoilebut Inc.
93 Mt, Hope St. rear
Lowell, Mass. 01854
Norio J Andress
Bob Barnett
34 Old Village Gane
No, Andover, Mass 01845
Estimate
Date Estimate #
3J27/20U7
CCI -99
1 P.O. No. I Joky Area { Project j
Bath nn -41
Item
Description
02.10 Dem
Dern; Provide all labor to demolish all wake in Iat bath room, above floorw
ceiling, entive rub surround, including tats, and ceilings. & all ceramic lite. RMOve
finish floor and one layer of sub floor. R=tovc all wood trim to W to-useQ st
finish. Haul away all debris, Prov1140 dust and carpet protection. vacuum all
effected areas. Not Including toilet and vauity removal. *Well will be required
before swat of demo.
04 Roof Flashing
Rcoofu►g, Flashing: Pennate roof for now exhaust vent cap, to service 2 bath
rooms. Install and flash, patch "Sits as reauimd, Vann to be installed by otbers.
17 Insulation
Insulation; Insulate all exposed Wali arms with flew R,I1 faced fib"Ioas
insulatioti, lasulate ail ceiling area V41h R-39 TUCd IMIStion. Included 4mil.
vmporbatslor, staplcicd through -out.
13 windovvq & Trim
Windows & 'Crim: Replace window with Harvey Brand vinyl window a described
in Estimate, # 102
ii Interior welts
InIcTior Wells & Ceiling: Resurface all walls & stalling with I/2" moisture resistant
dryvrall, tsrd 3 coots to a smooth paint grade finish, prinwd with one coat of Kilz
22Specialty
Latex primer,
Specialties: Build-up nab for now shower stall with 20 prossuas tsoated > voldug,
to plumbers required height of ,
18 Interior Walls
Interior Walls; Reswiace entire shower stall area with 1/2" wonder board, end
walls, back wall. ceiling, & curb. All joints to be roinforoed with Aber glees mom,
with mortar. ReStrnp ceiling ai shower to aecotmnodame 2 oew a+eccssod light
j
fbautts, installed by others.
We, hope this gets your expcctuion% we are looking fbrward to worildn with You. -
P
hone 0 Fax 0 E-17134
976.454-0860 978-4333209 wustomcsrpeoU71(overizon.net
Total
Total
3,525.50
'!�A Invl,a ')NT aow:i ! ciLgvo isno 60LEEG081 6 90 I TZ L0>371 L�11bv7
04!02:07 10:26 FAX 781 2.75-0741 MCC Bldg Ten Z003
r
Custom Carpentry & Remoadding Inc..
93 Mt. Hope St. rear
Lowell, N m. 01854
Narme. E Addreas
Bob 'Bam at
34 Old Village Lula
No- Andover, Mass pl $45
Estimate
011te Estimate 0
3/27/2007 (:r-1-99
1 P.O. No. i Jeb Area I Project
Rech mc.# 1
Item D"Cliphon Total
21 Floor Coverings Root Coverings; Insrell 1/2" Vkondor baud m entim floor we%k embedded in
mortar mix, all Joints to be mcshod as Weil.
This estimate does not include, plombin& almxrienl, ceramic file haftllation, batt►
room mworlm finish painting, fmish avant rer ehro tllag of wasting fbdwm This
Sevpo is for pre-fnipbas oWy, demo, insulation. ruMfaoing wall$, floor Sr rubbish
removal.'Permit fee has beet cWaulatad, as quawd by KAadover Rending, Dept,,
at S 12.68 per $ 1000 only. S42.DD. If addi Tonal charges air required by the Ttrwm
additional ahatgos may be applied ro the final cast of pmjact.
Payment Terms;
13sis scope of work will mquirc a good faith degoait of x$1000.00 ai start Of demo,
a mrrraeials de partial labor pwmml mqwx 0($15M.00 at clesm-w Qmd di�s� of
debris, A peymem raqutw will be made of $7x5.00 as wal Is & ceiling are primal.
Leaving a halmee of $300 Due at Fuml inspeotioll Of Town Building Dcgt.
I'fthis Estimate isse, Flees Blow, and norm oris OfYim for deposit
tri
end snc�+fulitS and A si fax i6 tad for scregtsace-
Chvnees
We hope this mv9W yout txpectattons, wo we lcd&g forward w vvorl tag with you..
Total E3,525.58
Phone 9
For 0
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971x-4yt.p$60
9753-3209
tge��omcatpaniry'i(�veri:on.ta~t
5e 39vi ;3NI GOW3�1 ckiV0 13110 6ozecsoeG6 99!TZ 1-0AZ/T311,1=0
04.02/07 10:24 FAX 781 275 0741 MCC Bldg Ten
custom Carpentry & Renn+ during Inc.
rAmm Bey I pavwdit kw, 97&4S4AW ph
93 Mourn Hops k Mr 978.1511m9 bx
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Fax 7"rorevv*af Form
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Not , Tom Godard
GoswakathwNo�
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Locaxion
N o. Date 0
TOWN OF NORTH ANDOVER
Certificate of Occupancy
IA6?
C U Building/Frame Permit Fee $
Foundation Permit Fee $
4
Other Permit Fee $
TOTAL $
Check #
20 U �;O
Bwiding inspector