HomeMy WebLinkAboutBuilding Permit #883 - 425 GREAT POND ROAD 6/11/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 632-)�£A 7- Po w D 9.6 A I%
Print
PROPERTY OWNER /A 1J D R F—w Y84tZ7-"Y Unit #
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Shop g Y
Machine Sho Village es
100 year-old structure yesno
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
ane amily
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
trRepair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
El Other
�ISeptic O Wella
_
❑`Floodplam� ❑'Wefl'ands _
_ — ._
',WatershedlDistiicv
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
(Identification Please Type or Print Clearly)
OWNER: Name: A N Dgg-w 6NS=V—^,Y6"i Phone: 97
Address: Y/.�6__R POND R,01 'D No P,� pf-tiDe ;y n v9
CONTRACTOR Name: 6R -r �- AN C -E vI N Phone: 7 7 KL�'?6'3K'Q 7
Address: 57- N®} dVEx 3
Supervisor's Construction License:
dZ ® �� Exp. Date: ! '
Home Improvement License: % 1 I g q d Exp. Date: -)-/ I 1 3
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: $ � FEE: $ �Z—
Check No.: � � Receipt No.:Iq
NOTE: Persons contracting with unregistered contractors do not have access to gua my, f d
_
;Signature of Agent/Owner : Signature ofjcontractor.
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
❑ 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
a Workers Comp Affidavit
❑ 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)
❑ 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)
u 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
❑ 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
Doe: Doe.Building Permit Revised 2008mi
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
PLANNING & DEVELOPMENT
DATE REJECTED
is
DATE APPROVED
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
r
Zoning Board of appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comme
Water & Sewer Connection/ermit
DPW Town Engineer: Signature:
I ti. Located 384, Osgood Street
FIRE DEPARTMENT: - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
1 a • Y, 1
COMMENTS
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
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
Location 4�? 62~ 7- e0ei ,el -
No. Date
Check# n o"-)-
25393
TOWN OF NORTH ANDOVER
Certificate of Occupancy $—
Building/Frame Permit Fd'a $5-a— 1�
Foundation Permit Fee, $
Other Permit Fee
TOTAL
(3 (Y-�2-,
Building Inspector
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The Commonwealth ofMowachusetfs
4 Depoftent of fndur&W Accidents
Orwe ofInymtigaiions
600 Washington Street`
Boston, MA #2111
' =� wruw.maMgovldia
Workers' Cumpensafaon Insurance Affidavit.- BuOders/Contractors/Eleciricians/Plumbers
A licant Information
Please' Le 'bI
NSl]]e {Business/OrganizariantIustividaat): ��(%��T 1•V1 u t�L�� �' �+�1N101�� I (�i �- %-t- �
Address:
GI �WPhone #: q i Fiir Fr(3 izro %
Are you an employer? Check the appropriate boxy
I.0 I aa- a employer with
4 ❑ I am a general contractor and I
_
emplgyees (full andlorpart time).*
have hired the sub -contractors
2 I ata a sole P MPieb)roarparh-er-
listed on the -attached sheet
and have no employees
These sractoa have
working for me in any capacity.
Moyes and have workers'
[No v1011s' camp. ksorance
comp. msurance-t
required-]
3. ❑ I am a hameownec doing
5.0 We are a corporation and its
have
all workmaces
exercised their
taj►sel£ [Nowiiork - 6 cusp: ` . -
. . iigLt of exemption per -MGM
himnance required.] t
c.152, §1(4). and we have -no
eu�P3oYees=>�Nowoa3ct' ....:.:.__.
Type of project (required):
6. 0 New construction
7_odeiing
8. 0 Demolition. .
9. 0 Building addition
10.1-1 Electrical repairs or additions
I I.0 Plumbing repairs or additions
220 Roofrepain
13.0 Other
'My apptir.�at ghat dnxkshmi #J =MAL a fin oM d= section below sbawiog timawokss �
t Hornwwners who submit this ai6devitindic n g they am doing at1 w=k oud thea Lire antside eIitactors PoistYsubun't a new affidavit indicating sari.
tCantractws that check this hax m►tst.attedad an additional sheetsiovving the name of tie sub=s and state whed er aunt nose entities have
emgioyem Irene sui-ciinttac m have employrees, they mnstp *vide their "*C& WMP- lmUCY mmiber
I am an employer thatIsproviding Workwer comp it fimrrance for my em
informatiom ployeeS Below is thepolicy and jab site
Insurance Company Name:
Policy # or Self -ins. Lir, #:Expiration
Job Site Address:tylStatelZ-P-
Attach acopy ofthe workers' comptarsation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of M ,CL c.152 can lead to the imposition of criminal penalties of a
fine up to $1,500-00 and/or ane -year imprisonment, as well as civ --1 penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cRngi/ y u j r theP" and pmrwtfies of perjury that the infor-,nationPmmded move is/ we and corrant
2-
tf,60 5-6^0
Official use only- Do not write in this area, to be completed by efty or tonin offu3aL
City or Town: PermMicense #
Issuing Authority (circle one):
i. Board of Health 2. Building Department 3. Cityirown Clerk 4. Electrical Inspector S. Plumbing inspector
6. Other
Contact Person: - Phone.
s Massachusetts - .Department of Public Safety
Board of Building Regulations and Standards
�'ers�'t•ttco#<ari ��ai��°rs
License: CS -002685
ROBERT M LARGEViN
795 DALE S - r..
N ANDOVE$ MA 01845:
NO
Expiration
Commissioner 02/2412014
moo, 21-1--
Officeof CO' erAfiairrss& risraV R¢gn bo �a
HOME IMPROVEMENT CONTRACTOR
Registration: I- -1.11990 Type:
Expiration i11-1/2013 . LLC
RO ERT LAIVr=(i►nRay
ROBERT LANGEy
795 DALE ST
N ANDOVER, MA Q
Undersecretary
Homeowner Information Contractor Information
Name
Company Name
FW LIAg-S,
iNb
� A
80-r f v1.� 6 vl "tN n>ro yt
Street Address (do not use a Post Office flox
address)
Contractor/ Salesperson/ Owner Name 17- (fg/1= — GA" t//
&fbf ffr
f -'Alb
Ai2- :9 r7
City/rown
State
Zip Code
Business. Address (must include a street address)
v, AICD o vi-lL
114
e]945—
- ff-. —
Daytime Phone.
Evening Phone
Cityfrown State Zip Code
G a 18
Mailing Address (ft different from above)
Business Phone Federal Employer ID or S.S. Number
Home Improvement Cmmactor Reg Nirtriber
Expiration date
law that most home
improvement contractors have
improvement
a valid registration number
113
i+ (1
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.)
Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will -
and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work
MGL chapter 142A.) j
ate when contracted work will be substantially completed.
Total Contract Price and Payment Schedule r�
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of �! U t _(*)
Payments will be made according to the following schedule:
– -,inn n a .contract nice or er- ms w tc ever Is pieate – .
ti& -IX
NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule,
G(
impro regia t watra tursnumber have r ` t
a valid cegistntioa aam_ber j) tF(
The.Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if ttecessarv.)
Required Permits - The following building permits ate required Proposed Start and Completion Schedule The following schedule will
and will be secured by the contractor as the homeowners agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will. be
excluded. from the Guaranty Fund provisions of Date when contractor -will begin contracted work
MGL chapter 142A.) # tI
11 ate when contracted work will be substantially completed.
$ U U _ _ _ or upon comp on o
4 %�v W oy -A" �4� r/ -/V f
$ as upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following materiMquipment must be special a pat or
ordered before the contracted work begins in order
to meet the completion schedule.(")
NOTES: (*) Including all finance charges (##) Law requires that any deposit or down -payment required by the contractor before work begins may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this Bement
Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
• Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear.
• Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
® Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document
• Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the
third business day following the signing of this agreement! See the attached notice of cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THN;KE AKIN: APl Y 1$LA1NW arA%-V a:::
Two identical co -es of the contract must be completed and signal. One copy should go to the homeowner. The other copy should be kept by the contractor.
Homeowner's Signa re Contractor s gnature
�Z 6 / A,
Date Date
S Building & Remodeling, LLC
795 Dale Street North Andover, MA 01845 (978) 686-3607
HIC # 111990 FID # 26-0816298
www.LangevinBuilding.com
Job Description
Exterior repairs
• Remove bay window, storm door and part of the wall on farmer's porch
• Re -frame the large opening and trim all sides with primed pine
• Re -configure clapboards around opening
• Replace damaged molding at base of front entry
• Install new PVC sill nosing on bay window at rear of house
• Replace a 12' section of 1x5 rake board with Azek
• Replace rotted section of plywood and two damaged quoins on the corner of the
house near the gas service
• Replace damaged 2x4 post on rear deck using pressure treated lumber
• Reconfigure the section of the roof at the rear valley, adding new roofing,. siding
and trim in affected area
• All cleanup and trash removal
Contractor's Signature
?�,-5r-
- -ZeT
—1 a
Date
Homeowner's Signature
r4
Date= ��� /?–