HomeMy WebLinkAboutBuilding Permit #939-15 - 414 SUMMER STREET 5/19/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: S� — I Date Received
A, - - - !�� -
Date Issued:
ANT: ADDlicant must complete all items on this
LOCATION (-_"n P"
Print
PROPERTYOWNER '26�-tA_r /'J
Print 100 Year Structure
MAP �0 a&PARCEL: ZONING DISTRICT: -Historic District
Machine Shop Village
IAORT#1
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yes
yes n
yes. ( no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
El One family
0 Addition
El Two or more family
11 Industrial
El Alteration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
0 Others:
0 Demolition
El Other
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DESCRIPTION OF WORK TO BE PLK1—UKMtU:
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SIC( oue-e- 9�
OWNER: Name:
Identification - Please Type or Print Clearly
11 9- A�) 0 q— " C4,P.,- 9- 0 I -,J
Address: -LI / Y -Y 0 P�f M e r _-:� -T
Contractor Name: kk 4.,� ov J �ti Q Phone:. Z f.
Email:
Address: /,t,/ e-> L,3 (Z- I/Zq -9
Supervisor's Construction License: C- 43 0 2 9? Z K -Exp.. Date: �2 za
Home Improvement License: / 0 � o?
Date:
ARCH ITECTIENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT.'$12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAS DON$125.00PERS.F.
Total Project Cost: FEE:
Check No.: ReceiptNo.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
r
Plans Submitted [I Plans Waived 0 Certified Plot Plan 11 Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools,",
well
Tobacco Sales
Food Packagingis�lesr,� El
Private (septic tank, etc. El
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FP13M
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature.
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comm
Conservation Decision: Comments
Water & Sewer Connectionisignature & Date Driveway Permit
DPW Town Engineer: Signature:
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)
13 Notified for pickup Call Email
I Date Time Contact Name
.......... ------
Doc.Building Permit Revised 2014
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
45 Floor Plan Or Proposed Interior Work
4� Engineering Affidavits for Engineered products
1OTE: 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
TE:, 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
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
10TE: Ali 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
Doe: Building Permit Revised 2014
Location j Oro -
No. Date
Check #
28797
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
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PROPOSAL
"HERB" ROUSSEAU & SON, INC.
Vinyl & Aluminum Products
316 Plain Street— Lowell, MA 0 1852
Free Estimates Tel. (978) 453-8626 or (603) 321-4733
V*nyl L Alum*num Siding - Combination & Repla"ment Wondows-M)-om
Proposal Submitted To: Job Site: Date:
Robert Henderson 414 Summer Street W
41 Herrick Drive North Andover, MA
Methuen, MA 01844
We hereby submit �pecifications and estimates for:
Certainteed or Mastic vinyl siding to be installed on house and garage.
Color and size to be chosen by homeowner.
Install 3/8" Styrofoam on entire home garage.
Cover all window and door trim with aluminum.
All soffit and fascia trim to be covered with aluminum and vinyl materials.
Vinyl fight blocks, and dryer vent to be installed where needed.
Yard to be left clean of all debris .................................. $9,500.00
Optional: Install vinyl shutters .................................... $65.00 per pair
All items on interior walls to be removed or secured.
Lifetime warranty on labor and materials.
We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum
Of: NINE THOUSAND FIVE HUNDRED DOLLARS AND 00/XX----$9,500.00
Payment to be as follows: One half down when job is started and remainder upon completion.
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration
or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tomado and other
necessary insurance. Price is good r I days unless otherwise agreed upon.
Authorized Signature:
ACCEPTANCE OF PROPOSAL - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are
authorized t the k sp ied. Payment will be made as outlined above.
P Signature:
Date of Acceptance:
YOUR RIGHT TO CANCEL - You are entering into a transaction that will result in a security interest on your home.
You have a legal right under federal law to cancel this transaction, without cost, within three business days from whichever of the following
events occurs last:
I . the date of the transaction, which is the date customer signs retail sales agreement.
2. the date you received your Truth -in -Lending disclosures; or
3. the date you received this notice of your right to cancel.
If you cancel the transaction, ihe security interest is also canceled. Within 20 calendar days after we receive your
notice, we must take the steps necessary to reflect the fact that the security interest on your home has been canceled, and we must return to you
any money or property you have given to us or to anyone else in connection with this transaction. You may keep any money or property we have
given you until we have done the things mentioned above, but you must then offer to return the money or property. If it is impractical or unfair
for you to return the property, you must offer its reasonable value. You may offer to return the property at your home or at the location of the
property. Money must be returned to the address below. If we do not take possession of the money or property within 20 calendar days of your
offer, you may keep it without further obligation.
HOW TO CANCEL - If you decide to cancel this transaction, you may do so by notifying us in writing at:
316 Plain Street, Lowell, MA 01852
You may use any written statement that is signed and dated by you and states your intention to cancel, and/or you may use this notice by dating
and signing below. Keep one copy of this notice because it contains important information about your rights.
If you cancel by mail or telegram, you must send the notice no later than midnight of the third business day (must
be dated) after you sign the RSA, (or midnight of the third business day following the latest of the three events listed in the section "Your Right
to Cancel"). If you send or deliver your written notice to cancel some other way, it must be delivered to the above address no later than that time.
I WISH TO CANCEL
Consumer's Signature: Date:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Www-mass-gov1dia lectricians/Plumbers.
Workers' Compensation insurance Affidavit: Builders/Contractors/E
TO BE FILED WITH THE PERAUTTING AUTHORITY. P1Pnzp Print
ADDlicant Information 46 Roug'3r_ u
Name (Business/OiganizatiOn/Individual): a _u k S n
Address: 42 t C P(_ A /A-,
t-,f_1P,f.fP/7;n- U 11h A
A
Are you an employer? 6liec,k, tiie appropriate box:
Phone#
I.F-1 I am a employer with ----,.employees (full and/or part-time).*
2.F] I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comP. insurance required.]
3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no 6mployeeg.
5.n I am a general contract . or . and I have hired the sub -contractors listed on the attached sheet.
' ' have employees and have workers' comp. insuranceJ
These sub -contractors
15. D/We are a corporation and its office'rs.have exercised their right oflexemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
7 �, 'If ? )--G 2 �
Type of project (required): -
7. E] NeW-co'nstruction
8. 0 Remodeling
9. El Demolition
10 E] Building addition , ,
11. E] Electrical repairs or additions
12.. h-Piumbing repairs or additions
13. E] Roof repairs _J
14. [j�,Other Vz 6o* I -S-L
-i policy information. I I
*Any applicant that checks box #I must also 1111 out tile �imuva U-_ a new affidavit indicating such.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those, entities have
employees. If the sub-contintors have employ . ees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation inSurancefor my employees. Below isthepolicy andjobSit�
information.
Insurance Company Name:
'D 1. 4-0--if-ins Lic #:
Expiration Date;
0 V.Y
C_ &-'
JL� Al hl r_ e— City/State/Zip:__4.,, A
Job Site Address: C,
Attach a copy of the w�r,kers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisoninent, 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. A copy of this statement may be forwarded to the office of Investigations of the DIA for insurance
coverage veri
Idohereby rti under the pains an penalties ofperjury that the information provided above is true and correct.
--I -A 1// nntw J 9//15
Phone#: 9-71, �ZG
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#:
hh'.M
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 employeeg. 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 r I equired."
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 t1l. 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 (LLQ 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 ndt 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
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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