HomeMy WebLinkAboutBuilding Permit #494 - 370 SALEM STREET 1/5/2007Permit NO: qq
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
-�� 0
IMPORTANT: Applicant must complete all items on this page I
LOCATION S --AO °���� S � k
Print
PROPERTY OWNER c�kY\ \r�L &v\0- C
Print
MAP NO.: PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Al eration
One family
0 Two or more'family
No. of units:
❑ Industrial
Repair, replacement
❑ Demolition
0 Assessory Bldg
❑ Commercial
❑ Moving relocation
D Other
0 Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED \\ ff
�t-r^c3Q ��.�5 t Ccry h S.V, g -,"
(Z-uo-�-
Identification Please Type or Print Clearly)
OWNER: Name: �a�� � � � v,, -t, �- Phone: -- XU71 °I
Address: 3r0 \ S \
CONTRACTOR Name: Qq -c R �G r �4 c e c Phone: Iq t
Address:'& vti
Supervisor's Construction License: Exp. Date:
Home Improvement License: We —LO,';a Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. 511.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ `W�-;Lod ' 0 FEE:$
Check No.:.'-�J � � Receipt No.:/55L2
If
Page I of 4
TYPE OF SEWERAGE DISPOSAL
Tanning/Massage/Body Art ❑
Swimming Pools ❑
g
Public Sewer ❑
t r, i
Well ` ❑
Tobacco Sales ❑
Food Packaging/Salesv ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
`< - "'"'t
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owner Signature of contractor ' X�-�
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Pans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
Q
DATE APPROVED
DATE REJECTED DATE APPROVED
A
U
DATE REJECTED DATE APPROVED
a
4
FIRE DEPARTMENT - Temp Dumpster on site yes % no
Fire Department signature/date
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
NUTEN and DATA — Wor department use
Created JMC. Jan.2006
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
Location '� 5'4 /40/!1
No. u'/ Date
t
�aRT�
TOWN OF NORTH ANDOVER
1- y
`
Certificate Occupancy
$
�,SSACNUSEt�
of
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
19916
%.j B i ding Inspector
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In 11u Sl0ess since 1982
8 Four Acre Drive
Burlington, MA 01803
(781) 272-7310
VaInsed and Ftnrylnaured
DATE:
12/29/2006
PROPOSAL SUBMITTED T0: JOB ADDRESS IF DIFFERENT:
John Leidner
370 Salem Street
North Andover, MA 018445
978-688-2679
We hanstfsubmitsperdfcadons and esdmates for.
We will remove existing shingles from all roof areas.
New roof will be installed as follows:
• GAF Weatherwatch along first three feet and valleys to prevent ice dam. Shed
dormer to have entire surface covered with Weatherwatch ice shield.
• GAF shinglemate applied to remaining roof surface.
• 5" aluminum drip edge to be installed along all eaves and rakes.
• We will use GAF Ultra Timberline shingles.
• Shingle -over ridge vent installed to entire length of main roof, extension and
garage.
• Protective tarpaulins to be hung around house.
• Legally dispose of all construction related debris.
Cost $14,200.00
^�
Authorized Signature: _
We Propose hereby to fumish material and labor -complete
in accordance with above specifications, for the sum of $14,200.00
PAYMENT TO BE MADE AS FOLLOWS: DEPOSIT:
One third when job is started,one third when half done, final third BALANCE:
when job completed.
The above prices, specifications and conditions are satisfactory and
are hereby accepted. You are authorized to do the work as specified.
Payment will be made as oullined above.
Signature:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
a 600 Washington Street
Boston, MA 02111
S<
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): (7A V- �Zdz.1
Address: ?' �, { K co, -,,v e -
Co
City/State/Zip: YAk 01-'60 -> Phone #:
2 6,Gq.4 S G XA 2
'R\-7- x -'1.310
Are you an employer? Check the appropriate box:
1. U 1 am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
?. ❑ I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
S. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
101-1 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.Eg-Koof 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.
Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infonnation.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Q0 ,
Policy # or Self -ins. Lic. #: VNQ C -10 0 `200 tA Expiration Date: \0�? j �cs
Job Site Address: 'M b SOL Q W) &A, City/State/Zip: 1�eit f�1 Ayt AOJ 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 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 insurance coverage verification.
I do hereby certify under thepains and -penalties of perjury that the information provided above is true and correct.
Signature:° �/\ ' �'" �`'`� Date: 1 S 10'7
I?l-2AZ2 - `1'1 l0
Official 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 #:
t
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 legal entity, 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. 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 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 permit/license number which will be used as a reference number. In addition, an applicant
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 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-MASSAFE
Revised 5-26-05 Fax ## 617-727-7749
www.mass.gov/dia
i"h o1onwealth of Massachusefts
Department of Fire Services
Office of the State Fire Marshal
P.O. Bos 1025 State Road, Stow, NIA 01775
PERMIT Date: � S-
North Andover permit No Dig :;/7;
(CityofTown) (ifApplicable)In accordance with the provisions of M.G.L_1 4 8 Chapter__] 0_ assprovided in sectionS27 (; MR 34 Start Date
This Permit is granted to: ® U M Ps e J b /
Full name of person, Firm or Corporation
rm
Peissionto locate dumpster for construction/renovation/demolition of building.
Comments: dumpster must be. 25' from structure if unable to place with required
Restrictions:clearance dumpster must be covered with plywood or tarp end of work day
at D ��il ✓�1
(Give location by street and no., or describe in such manner as to provied adequate identification of location )
FeePaidS 50.00a+ Fire Chief wx
i�
This Permit will expire J--AA (s teriatua; of offical granting pcm-iit) Of icai granting permit ( Title )