HomeMy WebLinkAboutBuilding Permit #550-2017 - 41 PINE RIDGE ROAD 11/21/2016 BUILDING PERMITF "ORT�`
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TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
Permit No#: ,�5-0 ' �)Lo 1 Date Received I° 3 k �0
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Date Issued: 1 i - a IG
IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 9 One family
❑Addition ❑ Two or more family 0 Industrial
0 Alteration No. of units: ❑ Commercial
4 XRepair, replacement 0 Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Sept' icWell 0 Flo do plain }❑WetlandsD �Water sfiedrDi t ict "-' 4
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DESCRIPTION OF WORK TO BE PERFORMED:
s�<%� �` /pG'iQOo�' �yS� 9L �4Rf9L� •�iZf�vo/C�
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Identification- Please Type or Print C1earIy
OWNER: Name: Tole,cr V- Phone 417- zs'7-�3s�
Address: yl �,nc � ��c IZoL•
cx ._.�♦ .,q 5.-. s...
� `..tib s � a Nr J TeG% 'sG✓�Ilo�6l✓T�SiG�i�f ,.. *,-s4..,•., r - sem.. }"�;�t* x� �-
t�`"r=,+- ° �.,+. wc. _-s..«, P .,«JK ✓ `c't '> 4 c -ice � -1 'f�:+' .r}:.. �'�f �a'ji F1 +r*� �T�*h t ...
ContractorpName. � P-hone
yy.. � t a {§ -�;'�. t� """"r�'."'.#,�, .. }.�e+ ,*$+ten-n•v.rias'� =§..Cc „r+�j„ s' e'�- ,�.,, �s ,•.._,,...... .
f , � � W � i.. t "v 4 H-&t „s•.. *r} r# T� .; '; £ �. . .. tit f�4
Supewvsor�s Cz ns�tructioriiLice seEx tDate -y-�8_
a9l�r/G p
H�}ome InrovemeriLc p �
.P a� Exp; ®ateF�, r
ARCHITECT/ENGINEER Phone:
Address: Reg. leo.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
.Total Project Cost: $ FEE: $ 0 Ll
Check No.: -7 I Receipt No.: S I d-1- b
NOTE: Persons contracting with unregistered contractors do not have:access to the guaranty fund
Signature of Agent/Owner' Si nature of cohtracto
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o 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
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Cross Section/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
NO 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
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
VOTE: 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
t
Doc:Building Permit Revised 2014
limension
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: lies No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
Ll Notified for pickup Call Email
ate Time Contact Name
Doc.Building Pennit Revised 2014
. r
Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
IYPB'OF SEWERAGE DISPOSAL
Public Sewer ❑ Tannin g/MassageBody Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
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t
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW'Town-Engineer:. Signature:
Located 384 Osgood Street
FIRE DEPARTMENT ->Temp Dumpster on site yes
Located at 124 Man Street t_. w �{' .. ,� # Y�. s. °" �`'
Fire;YDeparfinent signature/date, ° i, �: ;. �� �� ° :,� r .� y�► .r � t. . .s
1. F -..
COMMENTS'`
Location 44 1 f�r N E '!Z't D CY E
No. SSO - Of _'/ Date 11 • J- 1
• - TOWN OF NORTH ANDOVER
- Certificate of Occupancy $
Building/Frame Permit Fee $ 9�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# -72-1 1� • °
:3 *f 2 2 6 Building Inspector
� NpRT11
Town of
o
No. Af
h ver, Mass, It • a I • X101 to
WIC
x,95 RATED
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT AIIA......TUA/...k#V.W.%V..... 5......##„hjj„ .,,,,,,, BUILDING INSPECTOR
has permission to erect.......................... building/in
.... .1.......... ... ..N ........A.�..� &.... Foundation
Rough
to be occupied as .............. ..�...�..... .. ..... ...�0.0............................................... chimney
provided that the person accepting this permit shavery respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI N TART Rough
cService
.......... . ...... ................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Iii-Tech Window & Siding, Inc. Roofing
bV;IN�id
20 Aegean Drive Unit 4 e
MA Reg. # 118886
Methuen, MA 01844 y
MA Lic # CS - 106508 1-800-851-0900 e
1 www.hitechcorp.biz �� MFM$
Date: 1 / If _ 1 Consultant,
Job Name: ti 9 _ Telephone:, 354
Job Addres AJ44 :44- -- Town: me
Contractor agrees to start described work on or bout weeks after final fittings,and complete described work in about — working
days.Contractor shall not be held liable for delays due to cause beyond our control.Hi-Tech shall not be held la—m—a-0 to lawns or
plants.Contractor shall not be liable for any damage to painting or stain during installation of windows or doors.Hi-Tech does not do any paint-
ing or staining.In the event that a punch list should accrue at the end of the job,a maximum of 2%is the all ab a amou to be held back.
The following work In all labor and materials needed to complete your job in a workmanlike manner. t►
!LF My Alf
Job Includes * An alai Shield Tse!fie Deintl '
Combination Job-Roofing With Other Work is eat Eaves -
'11dtng Penult emoving Existing Shingles All Va ys and Chimney
Dint Guarantee Program Wind Shingles nd Vent Pipes ❑Other
Going over Existing Shingles ndedayment
❑ New Hug Edge N Drip Edge VB ti ale t3ftne� r
❑ Venting — f2lice Water Shield nstan Ridge Vent 0 Install Roof vents
❑ Sealing ❑R ant ❑InstalLeoffit Vents ❑install Roof Fan
❑ Guti. ork utter Cleaning LE
kylights. _ - -. ❑Other ff
omoving Debris in a Legal manner - - ----- - -- --- _-
o u -. -_
Roof Removal To Be Done
❑ No 5WAemovalct
e ve Complete House .mover Complete Garage -butter work,o-BB Doris.
1 L ar Removal ❑2 Layer Removal Locations To Have Gutter.
apply Dumpster D Yardar ❑20 Yarder
Dumpster Location: 12 j1V700J&Io Ne utter Work To Be Done
an Gutter After Removal
s Roof Undedayment To All Areas Removed 13 Gutter Removal
IzKeplace Roof Boards As Needed-Extra Charge As Neaded 0 Seamless Gutter Color
I Roof Atroas To Be Done; v ❑Pipe Color
kle House feta Garage ❑Fascia Wood
❑ Other ❑Gutter Guard ❑ water Fall System ❑Engiert System
- Special 1ii6tes:.
Roofing Material To Be Ela
Manufacturer: rrell ; style: r4
Shingle Color.
3 Tab Shingle rehitectural �:jiAezrj 4U40% Mud (M-Amm
Fiberglass ❑organic
❑ 25 Year Shingle j]30 Aar Shingle A0 Work Areas To Be Left Broom Clean
❑ 40 Year shingle50 year shingle Payment Policy —
Drip Eke And Sealingto Be Done Bank Financing ❑Owner To Arrange ❑ Hi-Tech To Arrange
install a-Drip Edge ❑Install S Drip Edge ColorCheck- - -- -. - - -
_ �/��� ❑Cash Or ❑ Mester Card
❑ Install 5-Hug Edge-(Go Overs Only) Color
❑ Re-Seal Vent Pipe ❑Replace Vent Pipe Flange Total Investment
❑ Re-Seal Chtmney Soso ❑Re-Lead Chimney 113 Deposit
❑ Re-Point Chimney-Roof Up ❑Stop Flash As Needed 113 Payment at Halfway Point a,
113 Balance Day of Substantial Completion
You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller,which may
be his main office or branch thereto,provided you notify the seller in writing at his main office or branch by ordinary mail posted;
by telegram sent,or by delivery,not later than midnight of the third business day following the signina of this agreement.See
the attached notice of cancellation form for an explanation of this right. D
An interest charge of 1.596 per month(18%per year)will be
added to any amount unpaid after 30 days from invoice da Date Of AC--- tan
inthe avant of dateuit M _ d tlhb order or any Pa elx70un1 is referred SI na
to an attorney for ONtees. ( j
I I We give Hi-Te mi o n n a Its.
j Signat
Signature (ltw-Tams
..The Commonwealth of-j�/jassachusetts
Department of.rndustrialAccidents
Congress Street,,5`icate 100
M d02114-201 7
Boston,MA
b' www rnass.gov/dia
/plumbers.
Workers,kers,Compensation InsuranceA£Ttdavit:Buildex�CGALITHOmtractorsztIsle
TO BE FILED WITH TRE PERMITTING Please Print Ise 'bl
A ' licant It�formation /
lee
Null(Business/Orgm,
ation/Individual): eK ,iso /%>1'�r��rcJ•�$ /
Address:
�o�it'oe� .tea o/�lyy Phone#: �'7�"y79-"PgG7
City/State/Zip: ' .�
• Axe you an employer?Check the appropriate box:
`Type ofproject(required);
1.3[ I am a employer with
,.$� employees&11 and/or parE time).�` 7. ❑l�ew'dol��5firiiciioli
2.❑I am a sole proprietor or partnership and have no employees Workin 8. Remo deluig
ing f')"e
any capacity.[No workers'comp.insurance required] 9. Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]' 10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors eitherhave workers'compensation insurance or are sole
ILEI Electric,. repairs or additions
proprietors withno empioyees.
12.Ej:Plumbing repairs or additions
5.1711 am a general contractor and I have lured the sub-contractors listed onthe attached sheet. 13'. Roof repairs
These sub-contractors have employees and have workers'comp.insurance. 14.rl Other
6.Q We are a corporation and its,officenshave exercised their right of exemption per MGL c.
pldyees.[No workers'comp.insurance required.]
152,§1(4),and we have no em
*Any applicant that checks box#1 must also fill outthe sectionbelow showingtheu workers'compenactionpo st s bmit eaiion'
t Homeowners who submit tIvs affidavrt mdicatmg they are doing all work andtheu bire outside contractors must submit a new affidavit indicatung such
Contractors that checkthis box utast attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub confiactors have employees,they must provide their workers'comp.policy number.
X am an employer that is providing workers'compensation insurance for my employees below is clue policy and joXa site
information.
Insurance Company Name: 4Ax'/ /i°¢� e i�s�re•1/�ee
Policy#or Self-ins.Lie.#:. �✓er—I-r��$'��° _���
e n� City/State/Zip: Oe
lob Site Address: / ° �'
Attach a copy of the yvoxkers' compensation policy declaration page(Showing the policy number and expiration date).
to
0.00
Failure to secure coverage as required ired unsd civil Waltzes MOL o. ,§25A is a the form criminal aTOP WORK ORDER and a fine of up to $200.00 a
and/or one-year iznprisonmcn
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for lnsurance
coverage verification.
p do Hereby cerci fy under'theTarns and Penalties of Tel jury that tTie infoYrnation provided move is true and correct
Date:
Signature:
Phone#:
Official use only. Do not write in this area,to be completed by city or town offzeiaL
City or Town-
Permit/License#
Issuing Authority(circle one): Inspector 5.plumbingInspector
X.Board of Health 2.Building Department 3.City/To•wn Clerk 4.Electrical
6.Other
Phone#-
Contact Perso)a'
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their entiployees.
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
receivafor.trustee 6f 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 o£the
dwelling house of another who employs persons to do maintenance,construction or repair work on such duelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or to cal 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 wl%o Ras 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
Pleasbfill,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 certif cate(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 ofinsurance 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•Accident's. 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 r'eg`arding 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 applic.'ant-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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 wwwmass.govldia
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-096516
Construction Supervisor
TIMOTHY W WICKS
3 ELLIS STr�
METHUEN MA 0.1844
i / 1
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'_ tl 15i\•\ 1
Expiration: f6
Commissioner 09/09/2018
C wl roll",7n,n7t,cveaC/�z a�
Ice of Consumer Affairs&Business Regulation
E -
T CONTRACTOR
F tMpRoVEMEN y Type
egistration 1 883Fr 1 Supplement C
C Expiratio"tl� 4/26/2017 !,
HI TECH WINDOWS
SIQt:G INSTAI LIN i
A
TIM WICKS ', 1
.-
29 ARROWWOOD ST
METHUE'N-,MA 01844 Undersecretary