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HomeMy WebLinkAboutBuilding Permit #009 - 45 FRENCH FARM ROAD 7/10/2006 TOWN OF NORTH ANDOVER NORT�y APPLICATION FOR PLAN EXAMINATION Of 4z,•o -.;�tio ° Permit NO: ® Oq Date Received +'* ;��'► Date Issued: 'd s,�e►+�5���� IMPORTANT: Applicant must complete all items on this page LOCATION rint PROPERTY OWNER -/�l (S L)C,/-�V Print MAP NO.: PARCEL: ZONING DIS"rRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building -- One family Addition = Two or more family Industrial L Alteration No. of units: Repair, replacement D Assessory Bldg Commercial Demolition i� Moving(relocation) Li Other Others: Foundation only DESCRIPTION OF WORK TO BE PREFORMED b � J Identificatio n Please Type or Print Clearly) "U C)u�o Phone: OWNER: Name: Address: �-t i/ ���-�"/ s'l? to CONTRACTOR Name: Phone:��'!'! ��y ������ Address: ��L'l"�!�✓` �/ Supervisor's Construction License: c �2 Exp. Date: 6 Flome Improvemcnt License: � "/ �;S Exp. Date: ARCHITECT. ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT-510.00 PEKS1200.00 OF THE TOT,4L ESTIMATED COST BASED ON 5125.00 PER S.F. Total Project Cost S f/ `�`-" ` c� x12.00=FEE:$_ Check No.: 02 Receipt No.: Y w Pale 144 Locations Jn Iet%iGI, t:,�24A-M No. 00 t Date NORTH TOWN OF NORTH ANDOVER Of� . o ,�,1•C 4 i Certificate of Occupancy $ CNustt Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1 : �? NkBuilding Inspector TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art Swimming Pools Public Sewer Well Tobacco Sales Food Packaging/Sales G Permanent Dumpster on Site Private(septic tank,etc. J Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarankfund Signature of Agent/Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ eaedPlans THE 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 ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ J COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision:receipt submitted yes Planning Board Decision: Comments Conservation Decision: Continents Water& Sewer connection,'Signature& Date Drivewav Permit Temp Dumpster on site yes_no Fire Department signature;date Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area, sq. ft.: No,r S and DA FA—(For department use) Page 3 44 Ur.e,I�51�L,Cl;I)N;\I.SI_b:.`�IC'L.S I)hP/�R'fVILN I',ISIFUR.`�t0i i'. ucd AIC .Lin_unn 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 ❑ 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:INSPECTIONALSEAN ICES UH;I'.\K'I'\IIiV'f:aPPOR\1115 1,,„ l ail•t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): JALL 0601-4 (Y� r ab Address:_c� ��t City/State/Zip: {LY✓I-c-�d-e v1 rwks) Phone #: 4`10 Are you an employer? Check the appropriate box: Type of project(required): 1.0I 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.❑ I am a sole proprietor or partner- listed on the attached sheet. EJ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 101-1 Electrical repairs or additions required.] officers have.exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ �'I inhing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. Roof repairs insurance required.] t employees. [No workers' 13.❑ 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 lContractors that check this box must attached an additional sheet showing the name of the sub-contractors 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 information. n ` Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: ��t(!l� ? r `� 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 fihe violat6r:-Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coveragri verification. I do hereby certify`under tlpains andpenalties ofpetjury that the information provided above •s true and correct Signature: Date: Phone# 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#: 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 6r 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 legalentity, 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, §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 numbers) 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 iequired. ae 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 Pfease 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 perrnit/liceuse 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. Anew 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 burn 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 5-26-05 www.mass.gov/dia d x., Chimneys Residential & Commercial Roofing All Types Of Siding CHIMNEYS POINTED-REBUILT-CAPPED Expert Masonry Work Mass Toll Free Roof Leaks Experts Licensed & Insured 1-800-WAIT-4-US Locally Owned do Operated Since 1976 g License#034200 (924-8487) IKO'o 'ylazw oe TvAf 'syr° We Work Year Round Proposal Submitted To � _ 1 Phone - ��� ..2� Date... C_ cT cf C(fly tc Street Job Name City,State&Zip Code Job Location Job Phone We Propose hereby to furnish and labor in accordance with specifications below, for the sum of: (.y 4���a c�s r ��� S t�T c�✓t Dollars ($ 1/•..26o, a �a 1. All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized q A0 manner according to standard practices.Any alteration or deviation from specifications be- Signature: low 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 NOTE:This proposal may be or delays beyond our control, Owner to carry fire,tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. We hereby submit specifications and estimates for: E , �- �t 4� E7CfC/Z-fl,4 /")% RJ Install 3 feet of special "Save Seal" ice and water barrier protection along all bottom edges of roof and top to bottom in each valley. OF roof is strip d, we will apply conventional ice and water shield ( )ft. high in the same locations previously described and tar paper will cover the remaining bare wood. Any rotted or damaged boards will be replaced at { — ) per linear ft. or ( Sz .6- ) per sheet of plywood. dinstall heavy gauge aluminum drip edges along every edge surface of each roofline.Y ���, ,j lidCover entire roof(s) with IKO 2fiqnmr ate asphalt, max-fiberglass, premium grade shingles (Color of choice). p?Tcc _ze?Q�scz-f sadr��o �,,,, �- /74/4, rc-cTV4 Replace all pipe boots where possible. Seal all flashings with clear Geo-Cel sealant. No black tar unless previously applied. VRemove all work-related debris. &Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. IdLocal current references and proof of workman's compensation insurance gladly given. "RemarksoT C 1�a5i7t�� fr/F/ c�Y?� l�,✓1�c tf<�1 �.� �+r.��i�: � �r/3'�✓�C-`c � Awn,r�'�s� /a►!C-�I'f 3!-�i T-c< -f-���+r�cn <'t�kr=,�, �_�7 _ (.3; ��C= l< -�c..,f/-t�c-�'t %a,�l���.- 3p �c�i'Lit �/:���y.��.�;��Jc✓i Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment Signature: will be made as outlined abo e Date of Acceptance: o{ Signature: �� IAORTH ' ooAndover Twn f No. 00 over, Mass. 7, /0 0 to A COCHIC EWICK 7�S ATE BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System F BUILDING INSPECTOR THIS CERTIFIES THAT W.........0.0 IV Ic ...... ................................................................... Foundation N---****... buildings on.. .... .4 has permission to erect........... ..... ... . ....... ...41AAkk Rough to be occupied as.....sre-! ......f.....0941100 ............................................................................................ Chimney provided that the person acce e6j this permit s'h­a­1*I*In'**a**v** respect conform to the terms of the application on file in tii 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 #000, PERMIT EXPIRES IN 6 MONTHS Final UELECTRICAL INSPECTOR UNLESS COCONSTRUC 'T Rough .... . ......... .............. ............ . .............. 1��DD17G�� Service Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE __Jj Smoke Det.