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Home My WebLink AboutBuilding Permit #656 - 43 SCOTT CIRCLE 5/6/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION TYPE OF IMPROVEMENT PROPOSED USE /2AZfAi' Phone: S 6el, 5-,P Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE* PREFORMED: 2 A_ o "iv ( d e /� // A v,6;:- r Identification Please Type or Print Clearly) OWNER: Name: /3et� -� J��b,b �= /D�0 Phone: Address: CONTRACTOR Name: 1-10-(f /2AZfAi' Phone: S 6el, 5-,P Address: z.- A r� - . Q 5�- 14/�/�_ Supervisor's Construction License: Exp. Date: Home Improvement License: /3 1691wQ Exp. Date: 2 ,- 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: $ o-2 3 9C)C . FEE: Check No.: ,` Y Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaran fighd i nature of Aent/Owner �-- 9--- —_.9 _. 5ignature_of contractor " 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature 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 DPW Town Engineer: Signature: t_ocatea 364 USgood Street _ FERE DEPARTMENT Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 2008 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 ❑ 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) ❑ 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 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. Date 27469 �'�uilding Inspector TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ CH Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ IS Check # 27469 �'�uilding Inspector NewEnglandsbestrooftom Agreemen Betwe n INTERLOCK INDUSTRIES, INC. Unit 7, 25 Walpole Park South Walpole, MA 02081 Registered as a Massachusetts Home Improvement Contractor Registration #139640 Registered as a Rhode Island Residential Contractor # 18345 Customer Service: 866.588.ROOF (7663) Name `B�tti�t 4l.yL L Pdii5 ("Buyer") Date Job Address City/Town Buyer's Home Address Phone 11612 Af ayf-% 141A a Zip Codey /00"/V Zip Code (10g7S 2622: Home Phone ( ) Cell Phone 77,?��0195,2. The Buyer is the registered owner of the land and premises described in the job address above (the "Premises") and hereby contracts with Interlock Industries, Inc. (the "Contractor") and authorizes the Contractor to furnish all necessary materials and labor to install, construct and place the improvements according to the following specifications, terms and conditions (the "Specifications") at the Premises. (Circle One): SHINGLE SLATE SPECIFICATIONS YES NO ROOFING MATERIAL YES NO OWNER WILL ✓ Supply adequate electrical power. Shingle -Color:a� -� IB Low Slope Roofing - Color: ✓ Be responsible for all rot damage and other necessary 1-� Flash Skylights-.'N�u,�mbber roof repairs. (ie) Roof decking, fascia boards, etc. Flash Vents -�" ✓ Prvt Roof repair work will be undertaken by Interlock Underlayment Industries, Inc. at a cost to be mutually agreed upon in Snow Guards 9 Z PCs. advance between the parties. ROOF REMOVAL !/ Strip existing roof ! layers. f%-- Haul away roof debris and pay refuse fees. ote location for bin t/ Supply'/z"ywood. - D /7 . -� - CONTRACT INCLUDES: LOCATION OF SHIPMENT: START DATE: r l2krQ fil ,!1, V V �. COMPLETION DATE: JQ S Start and completion dates are s,►.Ibject to change a z I 3� LIFETIME LIMITED WARikANTY, TRANSFERABLE, NON -PRORATED FOR MATERIALS MANUFACTURED BY INTERLOCK ROOFING LTD. PLUS 10 -YEAR LIMITED LABOR WARRANTY PROVIDED BY INTERLOCK INDUSTRIES, INC. LIFETIME LIMITED MATERIAL WARRANTY FOR IB ROOFING, PROVIDED BY IB ROOFING SYSTEMS Financing Requested Yes Interest Rate: 11.9% to 14.9% Payment not to exceed $ O.A.C. (on approved credit) Sales Price Sales Tax Sub -Total Down Payment Total Balance on Completion $ 23R610 1 MAKE ALL CHECKS PAYABLE TO: INTERLOCK.INDUSTRIES, INC. IN WITNESS WHEREOF, the Buyer and Contractor have hereunto signed their names this day of 20Q eq,"' The contractor and the homeowner hereby mutually agree in advance that in the event that the contractyr has a dispute concerning this Contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES INTERLOCK INDUSTRIES, INC. 10 I Per: (Print name) c/o Unit -7, 25 Walpole Park Soutff Walpole, MA 02081 HIC. # 139640 Signed n . B SignedOICS(J�-�_ Buyer Witness Print Name Relationship to, homeowner This Agreement is a binding agreement and contract between the parties. This is not a credit transaction and will not be financed by the Contractor. If financing is required, the Buyer hereby authorizes the Contractor to obtain credit information and the Buyer hereby agrees to provide and sign all necessary documents required by any third party financial institution to complete the financing, immediately on request. The Buyer hereby acknowledges receipt of this Agreement. See reverse of Agreement for additional terms and conditions. All surplus material is the property of the Contractor. MASC CR0707 C7 A dNll zz 13 a� ol A Gq U o U C7 H U o a� �, o E�14 4.4 4. N o o o 3 °' a w w rx a a a z d z z V) w x %41 a W� as U w � U e Z04 o W WQ o Z U U dNll zz 13 a� ol A Gq U o U C7 H U o a� �, o E�14 4.4 4. N o o o 3 °' a w w rx a a a z d z z V) w x t ORDm CERTIFICATE MABIUTY INS RANCE POLtCtES.AGW=AZEm LItiIRSSHaYVpIT�RAYtlAVg•BESt BY_.PA®QI4I�AS.. .Nash Commercial Swine" center ss30 Cnlasmade sial. #40o ""NM 959520 -IS-M l� AS -A i�►T'lE3i -OF-INFO . AND CONFERS NO MOM UPON THE c�ICATg HOLDER. THIS CER=:WAM DOES NOT AMEND, EXTH+IR OR ALTER THE COVERAGE AFFOR® DBY THE POUCES BELOW. AFFOROM COVERAM NAICf OM!+IED Interlock Industries, Inc.- .a Massachusetts Cozporatian Unit V, 25 Walpole Park South' ley Mh-.- .02061. A14BRIM a= DSS RANM 00 ,N8UM9l tk Maslnle� � oaerw tis THE POLICIES OF 1WRANCELXM WOW HAVE BEEN TO.THE MMtD NAMED ABOVE FOR THE POM PERIOD IND GATED. NOTUnWAND81Ct� ANY 100UN SVt M TEAM OR COND=N OF ANY CONTRACT OR OTHER 0=00ff TM RESPECT TO WHOM THIS fl:itWMATE MAY BE WJED OR UAYVERTAIN.7f# WJRANCEA BYTHEPOUC03 iCMMiN 6 SCIB3ECT'TO ALLV*.MM1X1W=M AND CONDtiIONS'OF St= POLtCtES.AGW=AZEm LItiIRSSHaYVpIT�RAYtlAVg•BESt BY_.PA®QI4I�AS.. ANN= FOUCY wimmPoucY oaerw tis J► aLAapttr 36199 02/2008 /01/2009 Sum 00MMUCE a AL-061UPALUASWr CLAI1MSAfA06 a 000UR . _ M60 bi• ar igna, Dan i PeolsotwsAnvM�cMaIY s e�alAr" s . t aaemeoatE W+ut APPtNS oftPIlO01�tT8 -L�L,�xfP �uat • PoucY PMO'F1toe AvrotlfomtE tuleRmrComm"51=9Umfr AWAUTO eoOaxLNamY {q«._ ALL .AV= At1iOS y MAW vV emidw q . XON.Oi�RiED AUT03 iLAMA>rEtLAeaLTr ALIT OKY.EAACCR1W i up 61 ACC t At1i001iLY: AN i ANYAYiO. Ummm CAM .� i (' -odm AM5MME' l EJ AGOIfAciATE i i IIETfM10ft / i wo mC011p'ENiATLmmo ENPLiQvw UAIX iY ANY PI00/WkidtlPAM111E111E70 fL SPAM ACCMW t Chin^E7�CW0� asdlb� !afar. Catch fL.fA ELS-PoLmy MyMT i i C'ttOetOFOPH1Aia0NGftACAT�3liQtCWSo0MS1�OCED1tT8�R10Ri9Yl�if�tllpAt.lROtm?(ONC To rt Nay CCUCC= DS#40$%2T9 VWn ANY OF TNi AIM POiCM M CANOECAID 00 0 E THE OWMIM OATS . 7LIE IiRUM(0 OL6tMRTt yYRi t#MFJIYOR TO NAM. i4,,,,,� OAYti NINf[f01 KOLLCE 7O THE fgLfNLCATr: NOtOHt NAKED 7O iNE tl9'[ fNR fJ{pttNE TO 00 is iffatt mm to CmUwn= On LLAmm OP ANY RIND UPON TBE MBMEM. m Aam" an A11V8S. uerxewoa owsmsanfrArava_ fill RATION 198.8 i &mmomweaa C�`Eifi(.0 Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston, Mas usetts 02108 . Home Improveme ; ' actor Registration INTERLOCK INDUSTRIES INC NICK TERLETSITY #7-25 WALPOLE PARK SOUTH WALPOLE, MA 02081 DPS -CAI 0 50M-WO6-PC8490 7//m &ammwoua� o1✓liaaaac weA Board of Building Regulations and Standards HOME IMgRQVEMENT CONTRACTOR R is . 9640 9 = lement-Card d INTERLOCK IND J NICK TERLETS #7-25 WALPOLE P WAI PAI F RAA AWI Registration: 139640 Type: Supplement Card Expiration: 728/2009 late Address and return card. Mark reason for change. E] Address E] Renewal 0 Employment ❑ Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 yi14D1,,4'! ei?,eg4/4ry XT -a -liJ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street r Boston, MA 02111 M SV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): . r -J e/�`LW(r/,r �jc L) Address: alui'4 ,r. 0 S City/State/Zip: Phone. #: ? l.6 Sr�t�6 G S Are you an employer? Check fir appropriate box: 1 1 I am a employer with ' 4. [-]I am a general contractor and I employees (full and/or part time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These .sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5• ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required)': 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10..❑ Electrical repairs or additions 11. E:1 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *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. $Contractors 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 -contractors have employees, they must provide their workers' comp. policy 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: / ,�A / /� 1?.5y Policy # or Self -ins. Lic. #:' w/ C h r3 ;r ( -- O7 9? °- 3 /` OS R 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 Office of Investigations of the DIA for insurance coverage verificatinn I do hereby certify under the pains and pens ei jury that the information provided above is true and correct. not write in this area, to City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: =A,' CM -6 or town official. Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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." . 4. . 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 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 152, §25CO) 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 may 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 permitilicense 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 not related to any business or commercial venture (i.e. a dog license or permit to bum 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-MASSAFE Fax # 617-727-7749 Revised 1122-06 www.mass.gov/dia COWAKY UBERIY MMUAL INSURANCE COW ANY 447ERLOCK INDUSTRIES. INC.. FAHY . A MASSACHUSETTS CORPORATION UNIT $7.25 WALPOLE 'ARK SOUTH ' WALPOLE,. MA 02081; t COMPANY ID • 1H9i& t0' TW►fi ii1E.POkKdES OF1 tJAA E t1bTFA;ftE tMAY&tE�iC 155tJ®•TO THEt A.JutkEQ-l�ii91V P�R.T15 or ammam wmtAUD•xOnV WAtQW.AM!. REOUGOSW. TERMOR COMMON OF ANY COWRACT OR OTHER DOCUMENT, WITH RESPECT TO WHICH THE CERTWATE MAY SE MM OR MAY MTARL'iK`SOMANOE ANOROD BY THE' POlIC1E5 LISTED tOW IS SUBJECT TO ALL TWTERMS. COMMONS AW O CUISIONS OF SUCH POLICIES. tIMR5.SNOWN MAY WYE $M REDUCED NY PWD QltpAs. .. TYPEOlSURANCJE I tOUCT>!I TEOVAD" DATEpAB677D" UiKiE GUMIALbAaKtiY ►...•:.. GEHERALAOORFII.ATE i.. 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