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HomeMy WebLinkAboutBuilding Permit #374 - 46 WINTERGREEN DRIVE 11/13/2009 BUILDING PERMIT c� "ORTil q TOWN OF NORTH ANDOVER �? �`tt�eD"6'°�0 APPLICATION FOR PLAN-EXAMINATION s ry 12�q "o e" Permit N0: Date Received Date Issued: " 6 � SACHUS IM ORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER ~- Prin MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no _ Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE -- i Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: rAddress: Identification Please Type or Print Clearly) R: Name: lIX ahyl' ��ts� LCPhone �� � ko G2 �/I'���-� �ee­1 ���`I'Ve-, II CONTRACTOR flame: CW Phone: Address: �7 Supervisor's Construction License: i� j Exp. Date: Home Improvement License: t1cc Exp. Date: ARCHITECT/ENGINEER Phone: r 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: $ )c) / 70-- FEE: $ �.�(o, 0 Q �T. Check No.: 9 kReceipt No.:��, NOTE: Persons contracting with unregistered contractors do not have access t`oVthe guaranty fund Signature of Agent/©wne Signature of contract �--- ---- Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools WellTobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site i 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 Signature COMVENTS 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: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate I 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 i ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 -- r` 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 L 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 o 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 o 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: Doc.Building Permit Revised 2008 LocationAu/ y4e'zgce./7 � F No. �1z - Date NORTy TOWN OF NORTH ANDOVER � S i » Certificate of Occupancy $ '•� }�7b'••°'''<�' Building/Frame Permit Fee $ sJgCMUSE Building /Frame Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22620 Building Inspector NORTH Town of : _ 4 over . No.031 l A E - dover, Mass., • • C T D C I� COC MIC KEWICK y %d 00 RATED PPS\ SCC S BOARD OF HEALTH Food/Kitchen PERM . IT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... 4 7..#'R.'*_11&W. .......... Foundation has permission to erect........................................ buildings on ...... ►.1 ............. ........................................... Rough to be occupied as............ ....................... .............. . /��. „ himn y .. ........ . . .. . ..................................... C e provided that the person acceptin this permit shall in every respect rm to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to 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 �d • PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTR ST TS ELECTRICAL INSPECTOR Rough Service MINIM, ................................................................. BUILDING INSPEC inal Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove 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 Smoke Det. Page No. of Pages x � Builders License # 58443 Home Construction Reg. # 109288 066unm 0, mo (781)944-1994 (978)664-2557 "The Areas Oldest Roofing Company" P.O. Box 637, North Reading, MA 01864 SAL S W11TTE � �� DAT�,y STREET JOBNAME G> CITY,STATE AD ZIP CODS \J JOB LOCATION !/f tie We hereby submit specifications and estimates for: Recommended Optional 17 4t (' Noof (Included in price) (Not included in price) 11 Rip& Remove all shingle debris from roof&job site: 1 layer ❑2 layers ' ❑3 layers or more Repair/or epl `ce any roof decking;•`not to exceed 50sq.ft. (additional at$1.70 per ft.) Install 8"aluminum drip-edge/and rake-edge along entire perimeter. Choice of mill;"whit or brown W Install ICE&WATER underlayment along horizontal eaves,valleys,sidewalls,sky-lights and chimneys r/ Install premium base sheet underlayment between roof deck and roofing shingles Y Install 30yr CertainTeed/GAF/Tamko or IKO architectural roof shingles LJ 40 year �❑50 year ❑60 year ` ❑ Lifetime See manufacturer warranty policy for more details ✓ Install new aluminum vent-pipe flange(s) rr Chimney(s)-counter-flash and re-step existing flashing ❑Cut& Install new lead flashingM Ridge-vent/exhaust vent with low profile,design, hidden b `shingle caps ❑Soffit-ventilation ❑ Roof louver-vents • Seamless style aluminum gutters-custom fabricated at job site'py our own gutter machine ❑Downspouts t ( ❑Leaf gutter guards .� Pe Other 4 LL / IrQJ5 46aw - 71014pil r -Pili P l( -.7rfvre v P +IA 1 `�' .t i 1�'� z P k .�r 471,(M 1 ,w M rG I ,% �f G-A G - -150 , 'Please Note:All items in roof attic should be removed or covered due to falling roof particles,at time of roof tear-off Price includes all items above that are checked only/others may be priced separately upon request.' We jJrapase hereby to furnish material and labor-complete in accordance with above specificationsAor the sum of: �IC�Q Total price not including options. dollars($ Payment to be made as follows: 30%deposit required before ordering materials. Balance due in full upon day of completion. .Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 ` Late charges of$50 per week for all outstanding bills due upon day of Authorized 20�6 completion. Signature {l.Uta -Accepting proposal means agreeing to the terms of the enclosed binder Note:This proposal may be ?� contract.Please sign contract&return top copy(white)with deposit. withdrawn by us if not accepted within 36 days f Comm nwea k ofMassachusetts k1 i Departrnertt of industrial Accident c • ' Dice of Investigations ii`i��.' 600 lVashin n Street ,.; Boston, MA 02111 r� www.nzass.gov/dia Workers' Compensation Irasitrance Affidavit: Builders/Contractors/Eieatricians/Pitzmbe A licant Iaformation rs Name Business/ Duval Roofing, LLC ox 97 Please Print Le�ibl t}t'ganitafion/lndividual): Address: No. Reading, MA 01 64 City/State/zip: Phone#:! 7- emPloyew mployer?Cbeek.the ap.mpriate box: mployer with_ 4. ❑ 1 am a eneral ca F7. 0 ot�(�tuireo: (fun and/or part-time).* have bired the cont:ac orm construction.❑ I am.a.sole proprietor or partner- listed on the attached sheet 3 odeling ship and have no employees . These sub-contractors have working for me in any capacity. workers' Comp.insurance. o[No worers'comp. insuran 5. ❑ VJe are a corporation and its additionrequired.] offrce:rs have exercised their rical1 am a homeowner doing all work right of exemption per MGL TeP s or additions my [No•warkers com , c bin snit p 2, §l(4),and we have no g Tepairs or additions insurance required.]t employees [No workers' 12• oof repairs comp. insurancerequirr4j I3.❑.pth `/iny applicant time mxics bhis fff most also fi[i out thz section below showing their;work='4orrX; csetiCM Polley infbrmatioa. t homeowners who submit this aficdavit indicating they ars floing an work and then hhe onside tort IConhacfnrs that check this box mastatsaeked art additioasl sheoi show' o�nwst au6mit a.neiv afndavit irtdi m the name of the sub.contractom and the• 6 such v worlaxs•CO— an . I�•••an eWioyer that is tau erT »r p" ,irtnrnorioa infomiadom p i►tg word �trrpersa csri tnsuranee�or my etnpjoye= Befow.ir else _ Pam' job site .. . Insurance Company Name: ff Expiratio>1 Date: Job Site Address: l9 Misch a copry of the workers'.compensation deC�rntion page(showia thzitye � � ' P liry Dumber and expiration dale}. . Failure to semre coverage as required,under Section 25A of MGL c. 152 can lead to the imposition of criminal fine up to$1,50o.00 and/or one-year imprisonm penalties of a Of up to$254.00 a i e�as weir as civil penalties m the form of a SMp WORK ORDER and a fine say aga nst the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby cenk nder the pains and eearliies o e ' P .l rP *y rim the information provided above is true and cord Date: Fic d ase only. Do not write in this area,to be compjered orowno cial Town: Permit/License Au,&orify(circle one): d of Health 2. Building De rtment 3.C' 1TP$ n3' own Cferft4. Eiectrir cal Inspector 5. Pfntnbiirg fasp�r Person: Phone#: Information a nd In's4ructions i Massachusetts General Laws.chapter 152 requires all emp Icy=to provide workers' compensation for their employees. Pursuant to this statute,an enrpMyee is defined as"..:every person in the service of another under any contract Aim, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or UW two Or More, of theforegoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,bribe receiver ortnrstm-of an individual,partnership,associatioin or other legal entity,empioying employe.'Howe=the owner of a dwelling house having not more than three apa tnerds 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 dwelfthouse or on the grounds or building appurtenant thereto shall not because of sucb employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state oa-local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or ito construct buildings in the commonwealth for any applicant whe has not produced acceptable evidence Ar comprrance with the insurance coverage required." Additionally, MOL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic worse until•acceptable evidence of compliance with the insurenc e requimmcn s.of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation.affidavit compicn-tely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es):mind 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 r equiredlo carry workws'compensation insurance. Van LLC or LLP does have empioyees,a policy is required. Be advised that this afficlavit 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,notthe Doparimpm of Industrial Accidents. Should you have any Questions regal.ding the law or if you are rmpimd to obtain a workers' compensation policy,please call the Deparlment at the nurnber.fished below, Self-insured companies should enter their self-inswu rcic-licanso nurnbw an d='appropiiate iine. City or Town O mials Please be sure that the afndavit is complete and printed legibly. The Department hes provided a space at the bottom of the affidavit for you to fill out in the event the.Office of lnvestigatioris has to contact you regarding the applicmt Please be sum to fell in the permit/license nurnber whicb will be used as a reference number. in addition,an a0pikant that must submit multiple permit/hexose 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 cagy of•fhe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid afrrdavk is on n-re for futare 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 too bum leaves etc.)said parson is NOT.mquired to complete this affrdaviL 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 Commonwcadth of Massachusetts DepartmOnf of�d�astrW Accidents Office of Envsstiggifions 600 Washington Sheet Basten, MA M 111 TeL #617-7274900 ext 406 or 1-9.77-MASSAFE Fax#617-727-7744 1Lvised 5-26-45 www.mass.gov/dia .` '1'' ✓lie�omvireaiuuealClC o ✓�,aaaac�ivaeClQ � ' Board of Building Regulations and Standards J Construction Supervisor License J Li c n'se: CS 58443 I i i Expiration 1 /1,0/2009 Tr# 9949 I KENNETH P DUUAL`r...' i PO BOX 190/72 NORT4H#ST �J N READING,MA 01864 Commissioner ,p� lie 1°anv�non.,uea,�i o�✓�iaaaclzuQella j \ Board of Building Regulations and Standards License or registration valid for individul use only HOME_IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ° Board of Building Regulations and Standards Registration: 109288 One Ashburton Place Rm 1301 Expiration `g/9/2010 Tr# 273490 Boston,Ma.02108 .Type _DBA K DUVAL ROOFING* y' Kenneth Duval . 72 NORTH ST �gu� N.READING,MA 01864 Administrator Not valid without signature NOTICE N NOTICE W TO a TO EMPLOYEES EMPLOYEES y� �W / v a�M S-4 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91-9-09) 03-11 -09 TO 03-11-10 POLICY NUMBER EFFECTIVE DATES d� GILBERT INS AGCY 137 MAIN ST READING MA 01867 NAME OF INSURANCE AGENT ADDRESS PHONE# DUVAL ROOFING LLC 184 PARK STREET NORTH READING MA 01864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of o_ employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 002624 W20PIG02 TO BE POSTED BY EMPLOYER