HomeMy WebLinkAboutBuilding Permit #222 - 42 HIGH WOOD WAY 9/22/2006 4�. 3
TOWN OF NORTH ANDOVER
NORTH
APPLICATION FOR PLAN EXAMINATION 0 -9"o #6
O p
(� #
Permit NO: Date Received tS —o2 "®(,oAVID
/ Z � �9SSAGHUS���h
Date Issued: G�
IMPORTANT: Applicant must complete all items on this page
e
LOCATION ,)--.
PROPERTY OWNER
L�aln
Print
MAP NO.: PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
ResidpR Ial Non- Residential
❑New Building One family
❑ Addition ❑Two or more family ❑Industrial
❑ ration No. of units:
Repair, replacement ❑ Assessory Bldg ❑ Commercial
❑ Demolition
❑ Moving(relocation) ❑ Other ❑ Others:
❑ Foundation only
DESCRIPTION O W RKn,TO BFORM
tc� E
e _
Identification Please Typelr Print Clearly)
a
OWNER: Name: dy 1y) kkdn ka Phone(q 1 (06-0 301
Address: 7,,(, 1. l
CONTRACTOR Name: Joh �1 ,, Phone&
Address: 1 ua) pike RaJ
Supervisor's Construction License: Q rW c;�5 t Exp. Date:
Home Improvement License: l �o Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING_PF,R IT-$120 ER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost :$ `r l 1 ,7 FEE:$ 1:70 f - 51
Check
Check No.: �a Receipt No.:�
Page I of 4
�2b�
T
s
TYPE OF SEWERAGE DISPOSAL Swimming Pools 11Tanning/Massage/Body Art E]
Public Sewer
Well F1Tobacco Sales ❑ Food Packaging/Sales ❑
❑
Permanent Dumpster on Site
Private(septic tank,etc. Ll Electric Meter location to
project
NOTE: Persons contractin tit Unregistered tered contractors do not have access to the guara fu
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ P ans Waive ❑ Certified Plot Plan ❑ Stamped Plans ❑
FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
g COMMENTS
ti
DATE REJECTED DATE APPROVED
HEALTH- ❑ ❑
COMMENTS
Zoning Board of Appeals: Variance,Petition No:
1
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water&Sewer connection/Signature& Date Driveway Pen-nit
Date Driveway Permit
Temp Dumpster on site yes no Fire Department signature/date `
i
s
I
Building Setback (ft.)
Front Yard Side Yard Rear Yard E
Required Provided Required Provides Required Provided
/ / I
Dimension
Number of Stories: Total
square feet eet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
NOTES and DATA—(For department use)
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Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC.Jan.2006
i
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
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit t
❑ 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)
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
❑ Mass check Energy Compliance Report
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:BPFORM05 Y
Page 4 of 4
Alvah MacDonald
Pern4it Coordinator
Renewal by Andersen
104 Otis Street
�+ ® ® /] l Northborough,MA 01532
1 ClPhone:508.919.0990
` Fax:508.919.0903
I amacdonald@rba-wm.com
BY ANDERSEN'
Window&Door Replacement
` Location
No. C7 6a'I e
t:
NaRTM TOWN OF NORTH ANDOVER
0
41
F 9
Y
" Certificate of Occupancy $
• i �
�'�s'•^°•;<�'
Building/Frame Permit Fee $ -
4CMU5
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ - ;
Check #
1960
' Building InspecA
�yORTH
s
Town of : tAndover
No. z Z LOW ®
dover, Mass.,0 LA
'
COCHICHE WICK
�®A0RATEO PPS` "♦C:1
S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
THIS CERTIFIES THAT.. BUILDING INSPECTOR
........ .................................... ... .
"� Foundation
has permission to erect...............................�...... buildings on ........14.5...... .. ........ .......... ....... ........................ Rough
tobe occupied as.....��........... ----IV................................... ..................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
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
PERMIT EXPIRES IN 6 MONTHS Final
ELECTRICAL INSPECTOR
SUNLESS CONS TIONS Rough
.............................. ............................................... Service
DING INSPECTOR
Final
Occupancy Permit Required to Occupy Bui ing GAS INSPECTOR
'
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE j Smoke Det.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, AM 02111
,M '¢ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/E�ectricians/Plum hers
Applicant Information Please Print Legibly
Name (Business/Organization/lndividual): Ren ` *odetrSeo
Address: fog a k-`6
City/State/Zip: lUor4 KJC or 14 Phone #:
Are yo n employer? Check the appropriate box: Type of project(required):
1.E911 am a employer with ® 4. ❑ I am a general contractor and I
6. New construction
employees (full and/or part-time).* have hired the sub-contractors
2. 1 am a sole proprietor or partner-
listed on the attached sheet. 7. ,emodeling
❑
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me'many capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have.exercised their
right.of exem per MGL 11.❑ Plumbing repairs or additions
3- n 1 am a homeowner doing all work tion p 'p�
c. 152, §1(4 d h
, anwe have no 12. Roof
myself. [No workers' comp. � repairs
insurance required.] t employees. [No workers'. 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the.policy and job site
inforntatiom
Insurance Company Name:
Policy#or Self-ins. Lic. #: 7 1�� Qa- �' Expiration Date:
�7 r 1 fN City/State/lip:/V /��'K1l Q!✓�0� /G'/�
Job Site Address: �-
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 Office of
Investigations of the DIA for insurance coveragq verification.
I do herebytld pen !ties of perjury that the information provided above is true and correct-
Signature:
orrect.Si afore: c er
Date:
Phone#: N)?? f q' O?q®
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitlLicense#
Issuing Authority (circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
I
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 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 construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGrL 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
reouirements 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. .Re advised thatthis 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
t; at must submit multiple perrr>;t/1_;cPnsP 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 pemut to bur leaves etc.) said person is NOT 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 ext 406 or 1-877-N ASSAFE
Fax # 617-727-7749
devised 5-26-05 www.mass.gov/dia
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JP MoKsons Insuranos AprnCy, InC. AL ArrO e0 Y tM8 POLICI9s �
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<. Board of Building Regulations and Standards
Reit t 49601
One Ashburton.Place Rm 1301
i~kplc t f Yl d/2008 Boston,Ma.02108
hvate Corporation
RENEWAL 8Y
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WESTBORO, MA 01581 Administrator. Not valid without signature
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78 TURNPIKE RD
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commissioner
• 1
200 Tilt-Wash & Specialty Page 1 of 1
9 " ; Andersen®200 Series Tilt-Wash Double-Hung &Specialty Windows
.ems;
Performance
See 400 Series for more choices.
200 Series Air Infiltration, Testing, and Light Transmittance
.................................................
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DP 30.0._4 (.73 255AP030 95X
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* These units have been tested to the requirements of NWWDA I.S.2-93.
t In conformance with the applicable AAMA/NWWDA I.S.2 testing requirements,a sample unit in a particular type of window or
door at the minimum required test size has been tested.Larger or smaller units of a particular type may vary from the tested
performance rating.The sample tested may not be a standard production unit.Contact your Andersen supplier for more
information.
tt Information not available at the time of printing.Contact your Andersen supplier for more information.
• The Andersen 200 Series tilt-wash double-hung unit is not currently offered in the AAMA/NWWDA 101/I.S.2-97 required
minimum test size.The unit size tested was 4'8 1/2"x 29 1/2".
^ STC and OITC ratings given are for individual units based on independent tests and represent the entire unit.Higher STC and
OITC values may be available with other glazings.contact Andersen for more information.
This data is accurate as of August 6,2002.Due to ongoing product changes,updated test results,or new industry standards,
this data may change over time.Call your Andersen representative for current performance information or upgrade options.
? Not available for TW34 and TW38 unit widths.Unit size tested:3060(unit size 35 1/2"(902)x 71 1/2"(1816)).
http://www.andersenwindows.com/LTE/ProductGuide/Residential/2O0TW SpecialtyPerform... 8/22/2006
200 Gliding Page 1 of 2
Andersen®200 Series Gliding Window
Performance
See 400 $eries for more choices.
Center of Glass Performance Data
.................................................
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Narroe"" Gliding Patio Door ....... �� 0.87 _.. 191 4
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GAdlr Ilnclaws{qOt?Series) ....,.. _7 6 0 5(} �Or4 104 1 4" ..,.,... 4 ., 4128 6 ,
Circle Tap E.t�tirai_Top,Circk'99! 73%f 0 50 43"' 104 7% 34% 0 28 ' 64� �g
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Wartotroe`'Gliding Patio Door 1 7 �; 0 49 42 101 1 32% 027 609 56'°
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Picture Baits: CA,»NL,.._ORP _., 40% t 0 350 74.. 5% 23% 0 30 M 579 54°
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Finarood® Hiad, G king 3 'nr 0.35 } '',�,. 7 1 % 22% 30 59� 54
Fisxiirame;Air 3i� 0 33 0 2 �.?1 a E 13 21%
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21
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http://www.andersenwindows.com/UE/ProductGuide/Residential/200GIidingPerformance... 8/22/2006