HomeMy WebLinkAboutBuilding Permit #620 - 383 SALEM STREET 3/27/2007oHonrH 1
p TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
95gACHUSE
Permit NO: 620
Date Issued:
IMPORTANT: Applicant must co
LOCATION_ 3
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PROPERTY�+OWNER
hIAP NO.: V 3-7. b PARCEL:
TYPE. AND USE OF RI t 11 MINC.
Date Received:
lete all items on this page
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ZONING DISTRICT:
4II4ZTf1D1f iI1FCTD1f'T VL'e n
j TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
=; Addition
Alteration
_ ne family
G Two or more family
No. of units:
L__ Industrial
_' Commercial
,LvRepair, replacement
C Demolition
C Assessory Bldg
Moving (relocation)
_' Other
_; Others:
-' Foundation onlv
i iUiN t,)r wUtCK t U tit FKt PUKME )
igen[ulcation Y
I W OVITiER: Name: r 1
A:�� �� s �A C ^ Signre
ddress_ L
CONTRACTOR Name'
.Address:
4 C37 /vo -�
Print Clearlv+:
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Phone:
9%�'��'�^���� it
Phone:
r oZB- t`
Supervisor's Construction License: Exp. Date:
Home Improvement License: joc/''2g'k- Exp. Date:
,'\RCHITECT: FNGINEF.R Name: Phone:
Address:
No.
` �� E SCHEDULE: BOLD1,VG PERMIT.• 570.0 PER .51000.00 OF THE TOTAL ESTLVIATED COST RASED OA'
v .5125 F.
.00 PER S.��
C) Total Project Cost :$ �T % _ x 10.00 FEF':'
Check No.: 10?6) Receipt No.: Z &:C f
TYPE OF SEWARGE DISPOSAL
Public Sewer --
k4' e I
i
Private (septic tank, etc.
Tanning/Massage. Body Art
Tobacco Sales
Permanent Dumpster on Site
Swimming Pools
Food Packagin�,,-Sales
':Si TE: Persons contracting,4quit unregrster a contractors ao not nave access ro me gttartwrj junrt
C C
Signature of Agent/Owner Signature of Contractor -
Plans Submitted 'J Plan aived IJ Certified Plot Plan ❑ Stamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT LI U
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
CONSERVATION
" COMMENTS
HEALTH
COMMENTS
DATE, REJECTED DATE APPROVED
❑ E
DATE REJECTED
n
Zonin, Board of Appeals: Variance, Petition No:
Zoning Dccision'receipt submitted yes
Planninu,, Board Decision:---_----—C'onunents. ---
Conservation
\Aiter d:. Sewer connection signature & date
Temp Dumpster on site ycsno Fire Department signature.'date —_
1,.
Building Pertiiit .Approved and Issucd by:
DATE APPROVED
I
I Building Setback (ft.)
F -Front Yard Side Yard Rear Yard
Required Pro-vided Required Provides Required Provided
DIMENSION
NUmber of Stories:
Total land area, sq. ft.:
NOTF.S and DA] A —11 -or department usc)
Total square feet of floor area, based on Exterior dimensions.
-
4
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
�j Building Permit Application
• Debris Removal Form
• Workers Comp Affidavit
• Photo Copy Of H.I.C. And/Or C.S.L. Licenses
a Copy of Contract
o Floor Plan Or Proposed Interior Work
Addition Or Decks
Building Pen -nit Application
• Form U
o Surveyed Plot Plan
o Debris Removal Fon-n
a Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic
Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
a Building Pen -nit Application
:j Form U
• 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)
zi Copy of Contract
0 Mass check Energy Compliance Report
In sIII 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: I\SPEC IAONAL SERV ICES DEPARTNIENT:RPFOR\IU5
Locaxion -'7, P
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check &B�11 - —
2 00 6 9
Building Inspector
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The Commonwealth of Massachusetts
Department of Industrial Accidents
= Office of Investigations
600 Washington Street
Boston, AM 02111
,.•�'y www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect ricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): PO Box 63 7
Duval Roofing, LLC
Address: No. Reading, MA 01864
City/State/Zip:
Phone #: �f -7 t- 6 6 / e�, � 2
Are 1pu an employer? Check the appropriate box:
I. VI 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. $
ship and have no employees h
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 ave
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
11.0 Plumbing repairs or additions
12.E&It000f 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 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. #: -3 3 J `l A & Q A d —7 Expiration
Job Site Address: �) �R�'1'1 City/State/ZipaA
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 certi nder the pains and penalties of perjury that the information provided above is true and correct:
Signature
Date:
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 #:
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
1 OA.
The debris will be disposed of in:
Fire Department Sign off:
Dumpster Permit
Signature of Permit Applicant
Date
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:
Registration: :109288 Board of Building Regulations and Standards
Expiration -9/9/2008 One Ashburton Place Rm 1301
Typ6 DBA,'
Boston, Ma. 02108
DUVAL ROOFING
Kenneth Duval `
72 NORTH ST
N. READING, MA 01864 Deputy Administrator Not valid without signature
NOTICE
EMPLOYEES
NOTICE
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this u^:ll give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
ensuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
ONE TOWER SQUARE
HARTFORD CT 06183
ADDRESS OF INSURANCE COMPANY
(7PJUB-7334880-A-07) 03-11-07 TO 03-11-08
POLICY NUMBER EFFECTIVE DATES
� GILBERT INS AGCY 137 MAIN ST
READING MA 04.867
NAME OF INSURANCE AGENT ADDRESS PHONE #
DUVAL ROOFING LLC 184 PARK STREET
o.�
o� NORTH READING
o� MA 01864
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPEIt'SATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
003,17-5 W20P1002