HomeMy WebLinkAboutBuilding Permit #458-13 - 40 WEBSTER WOODS 12/10/2013BUILDING PERMIT
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINATION s
Permit NO: `S ��J3 Date Received
� o9q c«..cw ��•
Date Issued:
0 �9SSACHUS
MPORTANT: Applicant must comTete all items on this page
LOCATION �/L) I J .S e!Z 0 0G JJ AAS
I /" b Pring C i JA%%A
PROPERTY OWNER —��(=/s-1,
Print
MAP NO: PARCEL/� ZONING DISTRICT: Historic District yes no
Machine Shop Villaqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
❑ Industrial
JK'Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
Identification Please Type or Print Clearly)
OWNER: Name: ! AAJkJAJC Phone:
Address: Va W tlesm WOE S IAJvC
CONTRACTOR Name: Phone:M.D. R'.... Cws' vm"
Address: n
T_ N_7TJ A ve 7D.4A)v(UJ 15M
Supervisor's Construction License: S Z 31l 3 Exp. Date: JV2, !;1,1,3
Home Improvement License: 3 Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. ~ ,
Total Project Cost: $ L/J FEE: $
Check No.: r R.peipt No.:
NOTE: Persons contracting wit unr gistered contractors d� of have access to the and
Signature of Agent/Owner Signatureof contractor
Permit N0:
Date Issued:
LOCATION:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
Print
PROPERTY OWNER _
Print 100 Year bid structure yea no
MAP NO: PARCEL: ZONING DISTRICT: ;Historic District yes no.
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
0 One family
0 Addition
0 Two or more family
0 Industrial
0 Alteration
No. of units:
❑ Commercial
0 Repair, replacement
❑ Assessory Bldg
❑ Others:
0 Demolition
0 Other
0 Septic ❑ Well
0 Floodplain ❑ Wetlands
❑ Watershed District;
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Addrin -
CONTRACTOR Name:
Address:
Phone:
Supervisor's Construction Licenser Exp. Date:
Home Improvement License:
ARCHITECT/ENGINEER
Date:
Phone:
�i
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.: Rs ;eipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of�Agent/Owner Signature:of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
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
COMMENTS
HEALTH
COMMENTS
Reviewed on Siqnature
Reviewed on Signature
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 Towp- Engineer: Signature:
PIREbEPARTMENT - Temp Dumpster onsite yes
Located at 124 MainiStreet
Fire Departinerit,signature/date
COMMENTS
LOcatea ob4 us ooa Street
no
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 de
I
El Notified for pickup - Date
Doc.Building Permit Revised 2010
use
Building Department
The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Li 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
❑ Building Permit Application
Li Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o 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)
o Mass check Energy Compliance Report (If Applicable)
o 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
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
o 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 subm;tted with the building application
Doc: Doc.Building permit Revised 2012
Location 7 U �F��s ��� [.cJaof 1471vI
No. — Date � /0 2.
Check # /y-�T
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 102—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
26025 Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 8,450.00
m
$ -
$
101.40
Plumbing Fee
$
12.68
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
12.68
Total fees collected
$
226.75
40 Webster Woods Ln
458-13 on 12/10/2013
Home Office Renovation
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Mfr. :fie::--annlna
4:; Webster hccds -are
N. And='-%er aH
We Hereby Submit Specifications And Estimates For:
MDB Construction
4 Tibbetts Ave
Danvers, Ma 01923-3914
WEB SITE
www. MDB-Construction x-om
PHONE
:,;a_ .3?9':
JOS NAME I LOCA -i-10,14
Base~:ent office
JOB NUMBER
_^:stalla..ion of ..:-�1:._. i:. .base,.._.._ _`•ic, __ COnsis� :.f - e fi__9w it�iq :cents.
LICENSED & INSURED
H.I.C. #100273
ESTABLISHED 1986
GATE
J0° ?I ONE
We Propose hereby to furnish material and labor -- complete in accordance with the above specifications, for the sura of:
igh- Thousand Four Hundred 9• f=p and 00110n. DC-Iars dollars ($ c�C.04
Payment to to made as follows:
:aynen- .. S-M.l.'r upon contiac., signing.For permit fee and drawings
Payz::er._ cr g:ar_. pea -.en !.. �pp �f�r. � 'Spon, elegy ricai start.
44: $2,4J -00 upo-- paste.. .,-art- Imre-t ':. .1i=�..t.L Upon cos:pie__^n.
Att material is guaranteed to be as specified. Ali work to be completed in a professiorat manner
aaord`.rfg to standard practices. Any atterabor. or deviation hon above specifications Authorized
invotvmg erta cosy wJ be executed or4y upon written orders. and wtll became an e&a Sign2ture:
charge ovef arx above the estmata. A6 agreements cortingent upon strikes, accidents or
celays beyond our control. Owner to carry fire. tornado and other necessary insurance, our Hose This proposal may be
workers are fully coverod by Workers C rrgensaluon Insurance,
withdrawn by us rl net accepted within ? C Says.
ikceeptance of Proposal — The above prices, specifications
and conditions are satisfactory and are nereby accepted. You are authorized Signature
to do the work as specified, Payment wfH be made as outlined above.
Date of Acceptance — 0 3 Aky 2011, signature:
instai_at_on.
. __ _` aninfa :'ecess- _ „_ rea`_a
an adzit. .. _ l . -. _' ..� wai_?[lec a 'di=.. iiitridat1c, og�
_.
insta__a--on Of
a__ f"_'a^2_.^.a necessary --n,: :.'ge zme
_ O.Ose�.^.Jccunda•-_O^ 'wd.- .:ipprox C
3.
=T.sta_-ct_on of
a-- _raT:^:y necessary ta _reg -e
cel__n^y _Gwen . G ex'sting •i' 4 '+c_...
d.
Tnsta-,.at-ort of
wall an.. ce_-_.^.'y' _..n.5' _aL_on as
-oce'ssarV ex.p3s, on oe_Iu_ skin.
5.
,nStd._3t_G. of
_ h-uebGar='i an:! __aster :-.-far
3__ :.ew work .3f1.1ce side on__ an... Gi._,..
Coat plaster
ever e�tisiznc wails
in office area.
O.
Uf':nii=-t 1C:'. of e.`.:.szinq
wall __. .._oget and _Cil
as necessar-
.T'.:�5 _a ..la.._on L)1
st±ee�'ca se .��� a . aseLoara ter.. a__
_nz.erior office walls.
.nt .a..lam -onJf
e -_e and grc't in
ow-ier supe i- .
new off. -:e si ace and .a dfol_nlnq` ,haL- w.}.a'�
5--a .e.
Appror. - V sq:..
3.
nstalla-mon or
electrical 1:0 :,
o consist of, -- s_.ches,
_receptacles, - baseb3arr. seyle
e:e_-tr- c hea-e-
with tiiermcs_a'
:your._ =d on oaaseboar^.., one owner
su^.o_'-iec . .r `ace ? _C` : , one ocher slip, .:.ed
trac.:
--a--7 _ne run
:c e..Is--inn S'C7ii_-er
1./.
permits a... Qe
tJ .D-.
`G ^n
is Signed a dr.5wing will ie
a..b:t:1t_ed _nr yot.r approval.
}_clus_ons:
ser._:e panel :Pzrades,
s=.ke detec:crs, pain-ing
_:. - asement fin,-s^es, ,.uT.inc.
We Propose hereby to furnish material and labor -- complete in accordance with the above specifications, for the sura of:
igh- Thousand Four Hundred 9• f=p and 00110n. DC-Iars dollars ($ c�C.04
Payment to to made as follows:
:aynen- .. S-M.l.'r upon contiac., signing.For permit fee and drawings
Payz::er._ cr g:ar_. pea -.en !.. �pp �f�r. � 'Spon, elegy ricai start.
44: $2,4J -00 upo-- paste.. .,-art- Imre-t ':. .1i=�..t.L Upon cos:pie__^n.
Att material is guaranteed to be as specified. Ali work to be completed in a professiorat manner
aaord`.rfg to standard practices. Any atterabor. or deviation hon above specifications Authorized
invotvmg erta cosy wJ be executed or4y upon written orders. and wtll became an e&a Sign2ture:
charge ovef arx above the estmata. A6 agreements cortingent upon strikes, accidents or
celays beyond our control. Owner to carry fire. tornado and other necessary insurance, our Hose This proposal may be
workers are fully coverod by Workers C rrgensaluon Insurance,
withdrawn by us rl net accepted within ? C Says.
ikceeptance of Proposal — The above prices, specifications
and conditions are satisfactory and are nereby accepted. You are authorized Signature
to do the work as specified, Payment wfH be made as outlined above.
Date of Acceptance — 0 3 Aky 2011, signature:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
e
Name (Business/Organization/Individual):
Address:
City/State/Zip: A- A)X 1-f ,�J CO23 Phone#: 9
Are you an employer? Check the appropriate box:
1. ❑ I am an employer with 3
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
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. ❑ I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption perm MGL
insurance required] t
c. 152, § 1(4), and we have no
employees. [no workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7 V% modeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ 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.
}Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contactors that check this box must attach an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If
the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' co pensation insurance for my employees. Below is the policy and job site
info
Insurance Company Name:rmation.
V {4 w
Policy # or Self -ins. Lic. #: 1 W -311 /y 0 V Expiration Da e:
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coveralie verification.
I do herby certify undir th pAs and penalties of perjury that the information provided above is true and correct.
Signature: Date:�-
Print Name: /Cl^* Ute,, f r� Phone #: "2,ef
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):
I.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing .Inspector
6. Other
Contact person: Phone
I
r
1� Office of Consumer Affairs &Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: . -100273
1 F Expiration: 6/15Type:
/2014 DBA
M.D.B. CONSTRUCTI.ON
1 Michael Burgess
i 4 TIBBETTS AVE. -
DANVERS, MA 01923
Undersecretary
i
:llassachusctts - Depammcnt of Public a -ret
Boat'd of Buildim'. Regulations and $ftndards
Construction Supervisor License*
License: CS 23113
MICHAEL H D BURGESS
4 TIBBETTS AVE
DANVERS, MA 01923
nnmi>sinner
al:l
Expiration: 8/29/2013
Tr#: 20274
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PREPAW Dr. Engineering Alliance, Inc.
Land Planning Consultants
196 Central Street Phone (781) 231-1349
I
Campbell Forest
North Andover, Massachusetts
rf
PREPAW Dr. Engineering Alliance, Inc.
Land Planning Consultants
196 Central Street Phone (781) 231-1349
I
Campbell Forest
North Andover, Massachusetts