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HomeMy WebLinkAboutBuilding Permit #613-11 - 42 CROSSBOW LANE 3/15/2011Permit N0: OWNER: Name DU1LUIN" rrcr%mr 1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION FA - .Date Received Type or Print Clearly) ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING P RM/T: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. i Total Project Cost: $ / (goo FEE: $ Check No.: A Receipt No.:���1 NOTE: Persons contracting, tIz un7gi ed rtractors do not have access to the guaranty fund n , Location. No. il, Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ S Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 3 9 %F -O 8 Building Inspector 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street 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 Doc.Building Permit Revised 2007 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 o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o 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 o Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract a Floor/Crossection/Elevation Plan Of Proposed Work With. Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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) o Building. Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ 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 El 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 011 C otoup �uitbvv5, �iic. 13 SEWALL STREET %PEABODY, MA 01960 •"Tca, OFFICE: 978-922-6120 SPECIFICATION SHEET Owners Name .. ?.;�_ ........... ... 14Z .......... HIC # 126-356 Home Phone: ........... tlork Phone: ..................... . State .. zip ......... JobAddressT .................... ...................................................... ........... SJDI,NiG 1. Siding 7:yjye.4A<_ .. • .. ........ dth ......... Color.. 2. Area to be done. Alain House . Bree 701rav A . ....... Garag - — Additions` I . ........ Dormers O.Ar ................................. 3. Insulation I ..... ................... 4.Truer cover U-7e's ONO Color.6� Trim to be dotie: Sufft Fasci('1 Rakes . ........... Ceilings .1,-rT,-&-:)....... ............................... .............. S. Miida]Vand IDoor Frames . ;? . . . . . . . . . . . . * . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . 6. Gutters and spouts El )es Use heaiv gauge seamless ... Color . . . 7. S J i i i t t e i F 0 1 r'e s U Rb . 4 -,- �-- - , - - �- am- -6( � �.w . —a, a , ..17. S. VI, indows and .Doors ....................................................................... ROOFING Material Type . . . . . - - ";� .. ... . ........................................... Color .. ................ .... Areas to be done ................ . / ................................................ .................. ... Remove existing shingles Q )e*s 1�, ;o ) ?. felt ...... . ........ ..... Metal &4ing ......................... Chimnev (it i�mnts It'. ....... ...... c ..... . .......... 15 Ib. ...... "'g ........... ............ AIOTI'�. 4 z ....... ....................... ...................................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6 . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . &e'...Deposit Material and labor to cost $. �.Cl .... 06F�. . pqyal)le as follows: ...1st Installmelft DO NOT SIGN THIS DOCUMENT' IF THERE ARE ANY BLANK SPACES.... 2nd Installment 371ance on completion Contractor it -it/ do all strict work in a I od workmanship maimer. You inav cancel this agreement i f it lun been consummated by a parts thereto cit u place other ffian an adchzww v of the seller. which imq lie hi.v main qffice or brunch.thereef. provided %'(w ttotifv the seller in wrifing at Iris main gffiee or branch In, ordinan, mail posted, he telegram sent or by delivery, not later than midnight of the third bukine%.% da v 01knving the Signing of this agreement. f IN IVITAIES THEREOF. the lktrtie,� have hereunto signed their names this.......?` . 20. Arc c+pt Owner Si. ed z01b0t0;I1j1)'�'k"1lli vv . Jim. .................... Per. Ix . . ..... ......... Repre"1 0 1, s" AM, kifthori:.ed Rell .................................. Strikes. labor d6pilles. inclement weather. or intacrial sandier delaY.5 resulting in work- stoppage (irc bevon,! t1w •:*omrvl of tine company. ERI * • W W :9 a N 'O CDH C cm CD cm m O O! C �C N O r 0 Z O J O I 0 CD O C• L O V Z co CL O CO) ICD cm CD O 'O CO2 O O m •— m coC = .0 � � L cc o a a ' CM< c CO) -I-- c ccCc v J "0 ■y Z v CD CL V CO) 0 C C cc■ C COD 11 W U) U) 19 W W 19 W co °o w aai cn Gco o w o w :c u 0 a rx x U w uw cn Lr. U w u. a_ O o � cn v Q ° cn :9 a N 'O CDH C cm CD cm m O O! C �C N O r 0 Z O J O I 0 CD O C• L O V Z co CL O CO) ICD cm CD O 'O CO2 O O m •— m coC = .0 � � L cc o a a ' CM< c CO) -I-- c ccCc v J "0 ■y Z v CD CL V CO) 0 C C cc■ C COD 11 W U) U) 19 W W 19 W co O ' L C CO) O C "~ O CJ CJ O. C ev � O o y � :9 a N 'O CDH C cm CD cm m O O! C �C N O r 0 Z O J O I 0 CD O C• L O V Z co CL O CO) ICD cm CD O 'O CO2 O O m •— m coC = .0 � � L cc o a a ' CM< c CO) -I-- c ccCc v J "0 ■y Z v CD CL V CO) 0 C C cc■ C COD 11 W U) U) 19 W W 19 W co 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 Number 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. The debris will be disposed of in: �� 0 f0 r / S" j�r9 � 6 � f 14 (Location of Facility) ,�AQ- awlo�:�, Signature otEpimit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: "159019 Expiration:.--�3126/2012 Tr# 292297 Type:Vlnmd victual .- 11 1 PAUL A. PIEROG F US PAUL PIEROG ' := 1000 TURNPIKE ST,'� NO. ANDOVER, MA 01-845 Undersecretary Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License tkense: CS 39928 Roiricted.tq: 00 i~- /' r� PAUL A PIEROG 1000 TURNPIKE ST N ANDOVER, MA 01845 Commk4orICT Expiration: 3/16/2012 Tr#: 17949 ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street .Boston, NIA 02111 h www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plambers .._tt:...._� r—r--- Name (Businessiorganization/Individual): Address: City/State/Zip: 0 -/ J Are you an employer? Check the appy 1. ❑ I am a employer with ' 2Yemployees (full and/or part-time).* I am a sole proprietor or partner- ship and have no employees working forme in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. (No workers' comp. msurance required.] t 4. Phone.#: 97P -49_i-/0 v to box: 0 I am a general contractor and I have hired the sub -contractors listed on the -attached sheet These sub -contractors have employees and have workers' comp. insurance.x 5. © 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 reotiired 1 Type of project (requiredJ, 6. ❑ New construction 7. ❑ Remodeling . 8. (] Demolition -9. ❑ Building.addition 10.[] .Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. Roof repairs / 13. Other V �iC7J 1116 *Any applicant that checks box #1 must also fill out the section below showing their workers' I compensation policy information. Hameov.; e s who submit this adz: it indicating they are doing all work and them hire outside contractors must submit a new affidavit indicaiira such. 'Contractors that check this box must attached an additional sheet showing the name of the sub contractor; and state whether or not those entities have employees. If the sub -contractors _ have employees, they must provide their workers' comp. Pc3' oli number. 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. #: Expiration Date: 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 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 Ofnce of InvestiQatinncnftl,pT)Te f...;.,�,.... e —_ ------t__ I do hereby under the pains -and penalties of perjury that the information p A /-% ✓1 rovided above is true and correct WNWIlwal F.Ai�L/n =,Use onty. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuin; Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other jY_a Contact Person: Phone #: 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 employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the.occupaut 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 required." Additionally, MGL chapter 1.52, §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 fill 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 (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 maybe 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 youare 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 permiVhcense number which will be used as a reference number. In addition, an applicant that must submit multiple permitllicense 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 not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is 1-40T required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone -and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 e ft -4 6 or I-877-MASSAFE ` Fax # 517-727-7749 Revised 11-X22-06 rvm,.mass_govfdia