HomeMy WebLinkAboutBuilding Permit #118 - 476 WAVERLY ROAD 8/14/2008 L
BUILDING PERMIToNo DTN qti
TOWN OF NORTH ANDOVER 0� ': '° °°A
APPLICATION FOR PLAN EXAMINATION
Permit NO: ,/ '
Date Received 7 °gArim A�'`•�
Date Issued: �SSACHU
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
2i' OtYZ�I ^oa Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
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:
F3
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: c 1 6"\ ,
O�A v) 212742-1 G- Phone:
Address:3
Supervisor's Construction License: (2 6 Exp. Date: y
Home Improvement License: d S� l z- a
P 3
Exp. Date: � / Y
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: $ S 6d, y FEE:
Check No.: Z-- Receipt No.: o)_ 1,a
NOTE: Persons contracting with unregistered co tractors do not have access to the uaranty fund
signature of Agent/Own� --Signature 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
HEAL�H Reviewed on Sig nature
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:
Located 384 Osgood Street
FIRE 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
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o 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)
o Mass check Energy Compliance ance Re
ort (If Applicable)
L3 Engineering Affidavits for Engineered products
NOTE: All er dum ster
p 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
o. Engineering in
eerin Affidavits for
En i
neered P roducts
NOTE: All dum ster permits require sign off from Fire Department partmen
t rior 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 j
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location ! G
No. Date
NORTH TOWN OF NORTH ANDOVER
a Certificate of Occupancy $
�'�J''•°;<�
HU s Building/Frame Permit Fee $
wC
Foundation Permit Fee $ '
Other Permit Fee $
TOTAL $
Check #
2 1 4 Building Inspector
NORTH
o of
And
over
No.
* =-7
dover, Mass.,
O LAK
COCMICMEWICK
V
' S RATED p` �5
l! BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING.INSPECTOR
THIS CERTIFIES THAT �'� �''� t �-
'�-.... ............................�. .... .............................................................................. ...... Foundation
has permission to erect........................................ buildings on.................................................Ct.cl.... ....... ........! ... Rough
Chi
t0 b8 OCCUpled as........... s, ...:: :.:..." ....... . .. .............
Chimney
e
provided that the person accepti g 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
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO TS Rough
.................. ....................................................................................... Service
BUILDING INSPECTOR
Final
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 .J1 smoke Det.
rl,
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): Au_ U/-o L--4
Address: c
City/State/Zip: L--r(kd-(:f0 Phone.#: TV- SIS_'2 3 I
Areyou an employer?Check the appropriate boa: Type of project(required):
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 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
com insurance.$ 9. E]Building addition
[No workers' comp. insurance p.
required.] 5. ❑ We are a corporation and its 10..❑ Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their
k 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12. oof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.F-1 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 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
j I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
j
information.
Insurance Company Name: ° h Mi -(VM
Policy#or Self-ins. Lic. 'Z'i 1 I
Expiration Date:_ (I (g/ op
Job Site Address:_ � �
� � 2� City/State/Zip: lU /�1 iJoJZ�
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 verification
I do hereby certify under thepa' sand penalties of perjury that the information provided above is true and correct.
r
Si ature: Date:
Phone#: 9 '2V- 1 S 125 Y�
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 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,opera'te!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 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 maybe 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
that must submit multiple permittlicense 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 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. #6.17-727-4900 ext.4.06 or 1-877-MASSAFE
Revised 11822-06 Fax# 617-727-7749
www.mass.gov{dia
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Chimneys Residential & Commercial Roofing All Types Of
Siding CHIMNEYS POINTED-REBUILT-CAPPED Expert Masonry Work
Mass Toll Free >f Roof Leaks Experts Licensed& Insured
Locally Owned& Operated Since 1976 y""
1-800-WAIT-4-US 0 _ I License#034200
(924-8487) I KO Caf 'hams oe.,gvAff 'psi We Work Year Round
.4978-975-7531
4 Jeffersone s • ' 1 1 Temple Dr., Methuen, 01844
Proposal Submitted To Phone
Date
2
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:
4, 41--w chi r.?,;A C,.ML/,.,171,-6 IJ Dollars ($ �/did, a �•
•All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized
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 prop al 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 withinJ'f days.
We hereby submit specifications and estimates for:
Znstall feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley.#f roof is stripped, we will apply conventional ice and water shield
( 6 )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 { 22s' ) per linear ft.
or ( .54'�v ) per sheet of plywood.
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Install heavy gauge aluminum drip edges along every edge surface of each roofline.&4'1r�;�
t,.drCover entire roof(s)with I -fiberglass, premium grade shingles
(Color of choice)_Wic_t _ .Fjc:Loial 1111Ki e ,
U Replace all pipe boots where possible. s` ` - �I+� � j � �
4J Seal all flashings with clear Geo-Cel sealant. No black tar unless previously applied.
U Remove all work-related debris.
Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under
_normal circumstances.
Qd Local current references and proof of workman's compensation insurance gladly given_
U Remarks: 01 CST GQr% Cam /?,Vf-cS;a 1A`7-3
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Acceptance of Proposal - The above prices, specifications �tIZI /OP-9W? ��
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment Signature:
will be made as outlined above.
Date of Acceptance: Signature: