HomeMy WebLinkAboutBuilding Permit #643 - 5 MAGNOLIA DRIVE 5/26/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 3 Date Received
Date Issued:s
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
- - . - -
MAP s
Print
L: ZONING DISTRICT: Historic District
Machine Shop
yes 1 n
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
WatershedDistrict
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: �1ACK ioA/-MIW7 Phone: ct Il"
Address: .S� /IA e/,� 6LI/q
CONTRACTOR Name: �(NVN 11+Y Phone: 1'
Address: (9 T" C -&A f. l t O - (-�
Supervisor's Construction License: (2 Exp. Date: 4,15 kcI l
p % Exp. Date: Z `�/ 0
Home Improvement License:
---J
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: $ %f 166, o FEE: $ qq-,0e-
Check
No.: P,� I Receipt No.: Q( a: -(D S
NOTE: Persons contracting h -unregistered contractors do not have access to the zParanty fund
Signature of co
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
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,
i
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Commen
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osaood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 MainStreet
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
Locatlon6— t,,4 /-94 t/
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
3 CHUS Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 7-
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Building Inspector
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GERTIFICATE OF LIMILITY INSURANCE —NA 1-f— i —*� n, T,
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s� The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
- Boston, MA 02111
-- www•mass.gov/dia
Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Legibiv
Name (Business/Organization/Individual): n(L tf n ✓�G= )/( �/S C �� 0�
Address:
City/State/Zip: tA :�_kS(A-, ttsj Phone #:
Are you an employer? Check the appropriate box:
1.21 an a employer with `f 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. workers' comp. insurance
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No. workers' comp.
insurance required.] t
5. ❑ We are a corporation and its
officers have exercised.their
right of exemption per MGL
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
i 0:❑ Electrical repairs or additions
I I .❑ Plumbing repairs or additions
12.[ oof repairs
13.❑ Other
--- - - -- •- -�^ • a,� .. ��. wc sconun vumw snowing their workers' compensation policy information.
+ homeowners who submil.this affidavit indicating L'ie, are doing E.! .cue:,; a_Fu then hire outside contraciorb roust submit anew atiidavii indicating such.
$Contractors 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 ny employees. Below is the policy and job site
information.
Insurance Company Name: A
Policy # or Self -ins. Lic. ' Expiration Date: /I 19 � D
Job Site Address: s /-lAG N Oti A ,%�a City/State/Zip: AJA
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 undep�the pgfns ¢nd penalties of perjury that the information provided above is true and correct
kk n V D
-91)S-153 j
Official use only. Do not write in this area, to be completed by city or town offccia!
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phone k
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 includin.g 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, §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 comps etely, 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 cant' workers' compensation insurance. If an LLC .or LLP does have ..
employees, a policy is required. Be 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 laxv 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 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 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 # 617-727-7719
Revised 5-26=05 www.mass.gov/dia
ChiIlnneays
Siding
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Residential & Commercial hoofing
CHIMNEYS POINTED -REBUILT -CAPPED
1. Strip all shingles from entire roof
2. Re– nail any loose plywood or boards
3. Any compromised plywood or boards will be re-
placed at an additional cost of $50.00 per sheet or
$2,25.00 per linear foot of roof boards.
4. Install heavy gauge 8" aluminum drip edge to all
eaves and rakes.
S. Install 6" WR Grace premium ice and water
shield along all eaves and top to bottom in the val-
leys for extreme winter protection. MA state code.
6. Install all new pipe boots.
7: Above the ice and water, install heavy 301b felt
base sheet to the ridge.
8. Install IKO Cambridge style 30 year architectural
shingles to entire roof
9. Cut and install GAF Cobra ridge vent to improve
attic ventilation. ( MA state code)
10. Counter -flash and seal chimney
11. 'Building permit included.
12. Removal of all work related debris.
13. Shingles are covered by the manufacturer up to
30yrs.
14. Contractor workmanship warranty =1.0 years un-
der normal conditions.
ptance of Proposal—The above prices, specifics
d. You are authorized to do the work as specified.
of Acceptance: 5-k1/11
All Types Of
Expert Masonry Work
Licensed & Insured
Total co. 7,700.00
* Install 3" white ventilation but-
tons on rearqffu
Balance due upon completion
Referrals available upon request
Hiahiy rated, member of the BBB
Than u v
and conditions are satisfactory and are herby ac-
nent will be made as Atlined. above.
CJ
'
la=of Boit ing Regul ons and=�i s
O
Ashburton Place- Room 1301 ne
Boston. Mas chusetts 02108
Home Improvement Contractor Registration
Registration, 137057
Type: DBA
Expiration: 10t 2/201 o
ALL UNDER ONROOF
JOHN LANZAFAME
166 A MERRIMACK ST.
METHEUN, MA 01844
:/lic C'vk..r,..,.•�,-�.�.r+� yy., /1.�aa,�rrAcrartis�
hoard of saitdtft Regatattz'sad Standards
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Update Address and return card. Mark reabon for ch?jj)gr
Address Renewal Employment Lcst C and
t=efte or r"t:ait" vattd fw i Idtwidaf nae ttatr
tte#ore the espike = tate. if t"Wo to:
9OW4 of Ruth PAGWb#D= aad Standards
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04 LmzAr-AME
A WRRIMACK ST i 11
\la..<nllu.etta - Depa.11111cnt of public safelN
9 Board tit Buildin!- RcmdationN and Standards
Construction Supervisor License
License: CS 69120
Restricted to. 00
JOHN W LANZAFAME
30 TEMPLE DR
METHUEN, MA 01844 x }j
�—�- --y—` Expiration: 4/3!2011
( .�unii. i nn•r Tri: 1344.9
\Ia..achis.rth Dcliiirtiricltt of Public �afrte
9-11rd est' Bt&i1din;! Rr,;utatiwn% and titandaril�
Construction Supervisor License
License: CS 69120
Restricted to; 00