HomeMy WebLinkAboutBuilding Permit #770 - 4 TYLER ROAD 6/1/2010Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued: —/ 0
'SACH
IMPORTANT: Applicant must complete all items on this pate
LOCATION 7VLe—r V t� �Fl /IiJC,fQV2,r
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PROPERTY OWNER t �. L,Lnl{ r
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village ves
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
fi/ V L i
Residential Of
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition,
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
Coue•r &L
OF
y
� ayMPI19CCCz�,S`(; ry� a^'S Cl6/v-tse Al L e_x nig eN�
Identi icatio flpase Types or Print Clearly)
OWNER: Name: L&
Address: 4 -7—Y1 e -r cS l , No,
J
CONTRACTOR Name: fikul.
: 1000-ITirivAke- ST A16,
ver INA.
Phone: `l 1W -&k'30,
MR
Supervisor's Construction License: C 3 9 2 Exp. Date:
Home Improvement License: /Y7
(3 11 Exp. Date:
ARCHITECT/ENGINEER
Address:
Phone:
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: $ 11,E FEE: $�_�
Check No.: J (� • Receipt No.:
NOTE: Persons contracting with unregistere contractors do not have access to the guaranty fund
-
Signature of Agent/Owner Signature of contram
ctor-a"
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 DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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
DPW Town Engineer: Signature:
Located 384 Usgood Street
FIRE DEPARTMENT Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 21A —F and G min.$100-$1000 fine
NOTES and DATA — For department use)
❑ Notified for pickup - Date
._.__....._..._._ ............................... _........... - ............ ----- ...... _..— - --—.... _... _................................................. ... --.... _.... - ............. _...... _..---...— —-------- _--------------------------- _--- -------
..._._._.._............_.._—...-- ......._.
Doc.Building Permit Revised 2009
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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Li 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
L 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
❑ 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: Building Permit Revised. 2008
Location
No. --)70, Date
TOWN OF NORTH ANDOVER
y
Certificate of Occupancy $
T1s'•••° Eta Building/Frame Permit Fee $ 3�—
sacMus
Foundation Permit Fee $
Check #
Other Permit Fee $
TOTAL $
Building Inspector
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Home Imp. Cont. Reg. No. 103577
Mass. Const. Lie. No. 039928
Owners Name
Home Address
Job Address
PAUL A. PIEROG
& `172.51tl'Ar7`mf
1000 TURNPIKE ST.
NORTH ANDOVER MA 01845
978 685-1007
SPECIFICATION SHEET
SAVINGS
QUALITY
CRAFTSMANSHIP
Home Phone:
Work Phone:
t)0; State AYY Zip el •
State Zip
SIDING l
1. Siding Type 1�� 12 ge /r./� WidthD ' " � 4 , Color (," 1 T CS
2. Areas to be done. Main House VV Breezewayr Garage t- S Additions Jul j.
Porches Dormers Ile .S Bulkhead Other
3. Prepare exterior els for siding YES 4. Remove existing siding ❑ Yes ID No
5. Insulation �/F fexdl2I„ f '6 p"d
6. Aluminum friin cover E7 Yes ❑ No Color Trim to be done: Soffitts s, Fascia t -
Rakes Ir'/%S Ceilings /PJd
7. Casing: 11&,) C L; -61(!Over O1?_ tuid C' SSt7�
8. Gutters an(i spouts ❑ Yes ❑ No C/ 4 - S'
9. Shutters ❑ Yes ❑ NoL
10. Storm Windows and Doors h!/�
11. See notes for replacement windows, doors, awnings, carpentry, etc.
ROOFING
Material Type
Areas to be done
Remove existing shingles
Chimney and vents, etc. _
❑ Yes ❑ No 15 lb felt
Other
Color
Metal Edging
Material and labor cost $ payable as follows:
.u,-) t uvt
Deposit
1st installment
2nd installment
Balance on completion
Contractor will do all said work in a good workmanship manner. You may cancel this agreement if it has been consummated be a party thereto at a place other than an
address of the seller, which may be his main office or branch thereof, provided you note the seller in writing at his main office or branch be ordinary mail posted, by
telegram of be delivery, not later than midnight of the third business day following the signing of this agreement.
IN WITNESS THEREOF, the parties have hereunto signed their names this 5�1, day of 1Y, i, 20115;�_
Signed Vii, del
Accepted: PAUL"IWOG,EXTi*4)REMODELING & INSULATION Owner
Per:
Signed
Strikes, labor disputes, inclement weather, or materiilJ supplier delays resulting in work stoppage are beyond the control of the compaW The company guarantees all
workmanship for a period of I year from the date on installation Guarantee of workmanship assumes performance of product installation under normal wear and tear
conditions and does notguarantee against storm damage, acts ofgod ornature, neglect ofpropermatnienance or malicious damage or vandalism. Material guaranteesare
the sole responsibility of the manufacturers.
The Commartrvealtk ofjVfassachusetts
Department of Industria[ Accidents
Office of In vestig ationc
600 97=hington Street
Boston, MA 02111
Hnvw m=s gov/din
Workers' Compensation insurance Affidavit~ launders/Contractors/Eiectriciiaas/Pinmbers
�licant Information
Nandi (Business/0rganiz26on/IndMdua1):-
Addmss: 000/ (Arlt ke. J -r
City/,State%P: i
Are you an emPloyert Cheak.the appropriate box:
1: ❑ I am a employer
with
4. ❑ 1 am a general contractor and 1
P1oY (full andlor0art-time).*
2. I
havo tired the sub-cantraetots
am .a.sole proprietor or partner-
ship and have no employees
listed ori the attached sheet t
These su}3-contractors have
working fbr me in any capacity.
[No workers' comp. insurance .
workers' comp. insurance.
5. ❑ We nae a corporation and its
3. ❑required.]
I &111 homeowner doing all work
offices have exercised their
right of exemption per MGL
myself [No•warkers' comp,
.c 1S2, § 1(4),'and we have no
insurance required.] t
.=Plcryees. [No workers'
comp ins
Type of project (regoirep:
6. []-Now construction .
1. ❑ Remodeling
8. ❑ Demaiition
9. [] Btu7ding addition
10-0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof Mjx1rs
urance required.]
13-17 Other
`Any applicant tint ehecics bolt# f must also titf oat the section blow showing their workm' bumpma dice pointy mfomsattoa
t Fiomeownet� who submit this efiitiavit itu(icaring they ars flying an work end than hes outside ton
;Corttractars that the* this but mustattuohed an additional ahar shown
�o� must submit a new affidavit indite such'
mg the narrse of Ilse suh�couoactoes and their worlmts' ce s:-
. am an enV oyer that is ro , � p" , irtnm�Woa
� ending workers crripersatr{sri �iisiiraare or
infornratinrt -� �J' P�}'�s: Belnw is the pv&7' mad job site .
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' con nsation City/SwMaip.
Pe policy deciaration 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 fine up to $1,500,00 and/or one-year imprisonment; as watt es civil penalties in the form of a STOP WORK ORDER FIZ and a fine
investigations
of uP io $250.00 a day against.the violator. Be advised that a copy of this statement may be forwarded to the fie
investigations of the DIA for insurance coverage verification• CgEce of
.r —!1(-v un/a�er roe pa/ huts and penalties alPedWY *at the infnrnwlion Provided above is trite and aonsc�
I I V t i Y. L. a� ---- - ..
- Id
OffActat =e o*. Do not write in this area,lr/ be cnraPLetea!!ry city or town o—
iciat
City or Town:
Permit/license #
Issuing Authority (circle one):
1. Board of Health 2 - Building Department 3. City/Town Clerk 4. Elec
b. Other trical Inspector 5. Plumbing Inspector
Contact Person-
' Phone #-
Information a lad I Otructions
Massachusets General Laws. chapter 152 requires all emp Ioyers 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." 1`
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or arty two or mom
of thc'fomping engaged in a joint enterprise, and including the legal representatives of a deceased employer, br the
receiver ort mstx of an individual, partnership, association or other legal trutity, employing employees. 'Howeverthe
owner. of a dwelling house having not more than three apas-tments and who resides therein; or the occupant of the
dwelimg house of another who employs persons to do mance, construction or repair wdrk an such dwelling -house
or on the grounds or building appurtenant: thereto shall nae because of sucb employment be deemed to be an employer."
MGL chapter 152, PC(6) also states that "every state oa- local 6eensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or *o construct building in the commonwealth for any
applicant who has not produced acceptable evidence AF compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither t1he commonwealth nor any of its political subdivisions shall
enter into airy contract for the peribnnu3nce of public worie until -acceptable evidence of eompiiu ncx with the insur =
Tequiremetds .of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation• a$udavit complem-tely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name:K address(es): a-nd phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (iyLC) or Limited Liability Partnerships (LLP) with no empioyees other dum the
members or partners, are not required,to carry workers' cr,Tnpensa#ion insurance. Ifan LLC or UP does have
empioyees, 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 iicdnse is being requested, botth Depar went of
Industrial Accidents. Should you have arty questions regarding the law or if you are required to obtain a workers'
oompensat on policy, please• -call the Department at the numberlisted below. Self-insured cornpanim should enter their
self-insurance licMMc numiier on the•aippropi•iate Ene.
City or Town Officiais
Please be sure that the affidavit is complete and printed legibly. 'I'hc Department hes provided a space at the bottom
of the affidavit for you to fill out in tht event the Office of Invest pfions has tv contact you regarding the applicant
Please be sure to fill in the permit/license number which %%-ill be used as a reference number. in addition, an appikant
that must submit multiple permit/licw= 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
appiicant 2s proof that a valid affidavitis on file for future permits or licenses. A new affidavit must be filled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(Le, a dog license or permit to burn leaves etc.) said person is NOT.required to complete this affidaviL
The Office of lnvestiW ions would dike to thank you in advance for your cooperation and should you have any questions,
please do not. hesitate to give us a call.
The Deportment's address, telephone and fax number
The Commonwealth of Massachusetts
Departinznt of Lmdustrial Accidents
Office of rmv. eati aiiotns
600 Washington Street
Bosfan, MA 02111
TeL 9 617-7274900 ext 406 or 1-977-MASSAFE
Fax 9 61 7-727-774
Revised 5 -?r6 -(l5 VVIVw,mass_gov/dia
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
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
l OA.
The debris will be disposed of in:
(Location of Facility)
Qj Q. /��-
Signature of Permi pplicant
Date
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
_ Registration: „169019
Expiration:.- 312612012 Tr# 292297
/Massachusetts - Department of Public Safety"
9 Board of Building Regulations and Standards
Construction Supervisor License
License: CS 39928
Restricted to: 00
PAUL A PIEROG
1000 TURNPIKE ST
N ANDOVER, MA 01845
Commissioner
Expiration: 3/16/2012
Tr#: 17949
Type:,{; .Individual
PAUL A. PIEROG F, y°
PAUL PIEROG;, '
�"=_
1000 TURNPIKE ST;`
g'
NO. ANDOVER, MA 1)1845
Undersecretary
/Massachusetts - Department of Public Safety"
9 Board of Building Regulations and Standards
Construction Supervisor License
License: CS 39928
Restricted to: 00
PAUL A PIEROG
1000 TURNPIKE ST
N ANDOVER, MA 01845
Commissioner
Expiration: 3/16/2012
Tr#: 17949