HomeMy WebLinkAboutBuilding Permit #46 - 34 RICHARDSON AVENUE 7/19/2007Permit NO: /-/,6
Date Issued: 7 A 4 07
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
11
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
tone family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
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DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly) t
OWNER: Name: 6n Phone:
ARCHITECT/ENGINEER Phone:
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: $ `F— FEE: $
Check No.: 'Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the g aranty fund
Signature of Agent/Owner Signature of contractor
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
TYPE OF SEWERAGE DISPOSAL
El
0
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision: Comments
Water & Sewer Connection/S9nature & Date Driveway Permit
Located at 384 Osgood Street
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 No
MGL Chapter 166 Section 2 1 A —F and G min.$100-$1000 fine
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
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
1. 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
o Engineering Affidavits for Engineered products
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 DEPARTMENTMITORM07
Revised 2.2007
Location '"" lh 4i14:0so'V /a
No. �" Date -2,//'9/0 7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
�7.
'"•�°''<t' 9Buildin /Frame Permit Fee $ %�sS_ _....cE
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # /21
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uilding Inspector
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PRODUCER,
Internet Insurance agency
522 Chickering Rnad
North Andover, MA 01845
INSURED,
COVERAGES
EI Y F I `:I A S E OF- LIABILITY FI E 1DSTE IMNJDD/YYYY
JOHN LAN 4FAME
DBA.ALL LJNI CTER OINE 1LN
30 TEMPLE OR
METHUEN, MA 01544
11 !09/2000
THIS CERTIFICATE IS ISSUED ASA IVIA eER OF INF-OR31 ATiON
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EK T END OR
ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE MAIC; #
INSURERA NORFOLK & DEDH.AM INSURANSE COMPANY
IINSURERB: AIM �- -
riNSURER,C.-
I INSURER D I
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE iNSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NO] WiTHS'IANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICAEES. AGGREGATE i.wITS SHOWN MAY HAV= BEEN REDUCED BY PAID CLAIMS,
LTR INSRD TYPE OF INSURANCE POUCY NUMBER
DA r I 1VIIr I DA (I�f_ LIMITS
A I LIAGIUTY 1201550636
i 6/3{2006 J 6/3/.2007 EACH OCCURRENCE S 1,000,000.00
LENERAL
�.! COMMERCIAL GENERAL DABILIT'.' I
I ! -DAMAGE T - _ 1.000,000.00
PREMISES (Ea
�MEDEXP
° L7,/ CLAIMS MADEOCCUR
I I (Any one parson, S 5.0(:0.00
I
jPERSONAL & ADV ,NJUR}' S I,CDD,OOD CU
E-• J—,_
GENERAL AGGREGATE %'.000,OOC.GO
N'L AGGREGATE LIMIT APPLIES PER.
I PRODUCTS - COMP/OP AGG $ 2,000,000.CD
POLICY 7PROJECT 1`7 LOC—
QUTOAEOBILE l.fAB[LITi ^`� i
LI OM81NED SINGLE LIMIT
J ANY AUTO
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( j ALL OWNE'DAUTOS j
I �j} SCHEDULED AUTOS I (Feer person)
5
I '?ODILY INJURYS
HIRED AUTOS
j 17 NON -OWNED AUTOS I (per accident)
-- -- ( I PROPERTY DAMAGE
I i ,Pc
GARAGE LIABILITY � I—
AUTO ONLY - CA ACCIDENT S _
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ffJ ANY AUTO llj
'--' OTHER THAN EA AGC g
! n AUTO ONLY. AGG I$
T�EMCESFSJUMBRELL.A 1AAEULI7Y
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AGGREGATE 5
1 {—� DEDUCTIBLE
I I RETENTION 5 _ I—
I IWLIRKERFiCOMPENGkTIONAND AVVC7OOy464.012OQ3 11!19/2000 1ilSi200% ® TORY LIMITS ER
EMPLOYER -l' LIABILITY
ANY PR,JPRIETOiI,'PAKTNER/EX.ECUTIVE F..L EACH ACCIDENT S 1D0=0DU.CD
(1F F.'CEA'MEMRF.R EJ(CLLCEDY
rib( undT,
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SPECIAL PROVISIONS eh _E-IdPLO_YF.E
_— 5
10(,000.00 —
Gatt>w I IF. L. DISEASE - POLICY LIMITi S SOC.D00 00
HOLDER
("ORD -"I; (2009/08) --
^AWC'�1 I l 7lnnl
SHOULD ANY OF THE ABOVE OBSCRIEED POLICIES BE CANCELLED BEF�ir7_s'l, THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO F"—J 30 DAYS WRI1I EN
NOTICE TO THE CERT1Fi:ATt:,HOLDEP, NAMED TO T!e LEFT, SUT FUnE TO DO SO SHALL
IMPOSE NO OBUGA710H OR LIABFLITY OF ANY KWO UPOfi THE 1"U?EP ITS AGENTS OR
REPRESENTATIVE
L. 1
:
Construction Supervisor License
License: CS 69120
Birthdate: 413/1959
Expiration: 4/3/2009 Tr# 11855
Lstriction: 66
JOHN W LANZAFAME
30 TEMPLE DR
METHUEN, MA 01844
Commifv4-4er
Board of Building Regulations and Standards
S One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 137057
Type: DBA .
Expiration: 10/2/2008 Tr# 128146
ALL UNDER ONE ROOF
JOHN LANZAFAME
166 A MERRIMACK ST.
METHEUN, MA 01844
Update Address and return card. Mark reason for change.
PS-CA1 0 50M-05/08-PC8490 E] Address [] Renewal R Employment. Lost Card
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration: 137057 One Ashburton Place Rm 1301
Expiration: 10/2/2008 Tr# 128146 Boston, Ma. 02108
Type: DBA
ALL UNDER ONE ROOF
JOHN LANZAFAME
166 A MERRIMACK ST.
METHEUN, MA 01-841 Administrator t valid without Signa
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MM 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LelZibly
Name (Business/Organization/Individual): C (_ �l✓tf>Ln 2 2`� ��
Address: 3- T c 66- V4
City/State/Zip: m ^/-7 Phone #
9t9 -fir 125-3(
Areyouan employer? Check the appropriate box:
1. lJ 1 am a employer with 4. ❑ I 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- listed on the attached sheet. 1
These sub -contractors have
ship and have no employees
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its
. -A+11
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
officers have. exercis %,
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
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. []'Roof repairs
13.❑ Other
*Any applicant that checks box #1 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
tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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: A,�/
Policy # or Self -ins. Lic. J e-- 7 0- 91 Expiration Date: ///I
Job Site Address: 3'4 2 S -c (4/4r'L �-S 02 /lJZ-f Cit)/State/Zip: /tf �
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 Office of
Investigations of the DIA•for insuzane.e coverago verification.
I do hereby certify %under he Y�'li-'r'_
paiinss andpenalties of perjury that the information providedabove is true and correct-
4iunA��""` amre. Date: � // ? / , '
PhnnP#• V ?4,2 — ,-- -%J 3/
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
11 Contact Person: Phone #: A
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 6r 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 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 appropriate line.
Cify 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 permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple perniit/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 burn 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-NIASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
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Chimneys Residential & Commercial Roofing All Types Of
Siding CHIMNEYS POINTED -REBUILT -CAPPED Expert Mas my Work
Mass Toll Free * Roof Leaks Experts * Licensed & Insured
1 -800 -WAIT -4 -US Loca!!y Owned & Operated Since 1976 a'•gpt License #034200
(924-8487) IKO® azee Wazw We Work Year Round
V�lGI�tiA�I�JJU U►�ll7AJ • • �, �E• // , CJ'J� JJ • _' I-- y E 1d
Proposal Submitted To Phone- Date
no
Street Job Name 4--`,
City, State & Zip Code Job Location Job Phone
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of:
/ ��'✓J L"4 T J//:7/ o rI C.. _1,.'�Vc T, d yJ Dollars ($
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized 1
manner according to standard 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 charge over and above the estimate. All agreements contingent upon strikes, accidents NOTE: This proposal may be
or delays beyond our control, Owner to carry fire, tornado and other necessary insurance.
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within 7, days.
We hereby submit specifications and estimates for: ?
UInstall 3 feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley. 0 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 ( c9 ° ' ) per linear ft.
or ( ) per sheet of plywood.
La Install heavy gauge aluminum drip edges along every edge surface of each roofline. kms+ r
"Cover entire roof (s) with IKO 25 ye.ar sph.aU,rg!Fa=fiberg lass, premium grade shingles
(Color of choice)./_;?TL&' _J�i CL ��'�� S 51f2
I Replace all pipe boots where possible.
Seal all flashings with clear Geo -Cel sealant. No black tar unless previously applied.
0`Remove all work-related debris.
Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under
normal circumstances.
lZi Local current references and proof of workman's compensation insurance gladly given.
4Ramarkc 1 (a' J i�S//1,t Cc+�,. C'?A �,�_ C.� J<, _(/- k.C< /�cs c
Acceptance of Proposal - The above prices, specifications
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment Signature:
will be made as outlined above. U
Date of Acceptance: Signature: �� n 1