HomeMy WebLinkAboutBuilding Permit #7 - 50 JOHNNY CAKE STREET 7/3/2007BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
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
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nFscRiPTION OF WORK TO BE PREFORMED:
F1
Identification Please Type or Print Clearly)
OWNER: Name: Mc e P ' Phone: % -20S-
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: $ � FEE: $
Check No.: Ov-// Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Well ❑
Private (septic tank, etc. ❑
Q
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
Tanning/Massage/Body Art ❑ I Swimming Pools
Tobacco Sales ❑ Food Packaging/Sales
Permanent Dumpster on Site ❑
0
0
Zoning -,Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Located at 384 Osgood Street
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
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
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
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
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 2.2007
Location A, C'
No. Date d
NORTp TOWN OF NORTH ANDOVER
0:.ao :,yC
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� 9
+ ; ; Certificate of Occupancy $
;7s'•"' tilt' Building/Frame Permit Fee $
s�CHus rs
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2G��`'
Building Inspector
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ftgs Of
Free Estimates 105 Haverhill Street
Fully Insured Methuen, MA 01844
THOMPSON'S ROOFING (978) 691-1355
Shingles - Slate - Rubber Roof
Single Ply - Copper Work
PROPOSAL SUBMITTED TO
PHONE
DATE
John Mcelroy
17S - 20 - l 4-7
5-18-0
STREET
JOB NAME
50 Johnny Cake Street
CITY, STATE AND ZIP CODE
JOB LOCATION
North Andover Ma 01845
ARCHITECT DATE DF PLANS
JOB PHONE
We hereby submit moons and estimates for:
Strip off all roof shingles on house
Renail all loose plywood and if any needs to be replaced it will cost
$45.00 a sheet
Install .024 white aluminum drip edge around roof line
Apply ice and water shield 6 ft. up all along edge and in valleys
Apply 15 lb. felt paper on rest of roof area
Reshingle with a www.gaf.com timberline 30 shingle
Install new flanges around soil pipes No�5 �fb '�-(etar-
(Install -
ridge vent O�
7�
Seal around chimney flashing-�weEti
Remove all work related debris
• �n.�r• few-�<<d s�f%yf�s ,14 I -p- U NA
30 year warranty on material S"''t � S f t C-keice 4,% 6e pi'ovi�edC
5 year guarantee on labor Lie- vr&4' cftr q,Afe CSO
5
construction tic. #060112 • Gki'el pt -3 tie I-et(4te-k X&Ie-k
improvement #128612 • �cQ � �.+a..�e� S��Q(� � Fi���
&���1� N1&Aj— re air !k4 6,x)e
6..�t Aro.+ �C�' rr fCS V ct, W - &tow AW, �
4���
t"$4f-660k f6 `e P41t&4
WiR-Ne0O S.
Ut 111117OitOOC hereby to furnish material and labor — complete in accordance with above s peciftcations, for the sum of:
Nine thousand six hundred dollars ($-g-, ti n n n n
Paymem to be made as follows:
3,600.00 down balance upon completion
All material is auarardwd to be as soerifle 'AS work to ba oomnleted in a unkmerike m vw
ww d M to standard pror k me Any alteration or devladon from above spedeeatlorra kmwv
an costs wffl be eousr AW ony upon mitten orders, and wall become w Boma clwge aver and
above the estimate. AN agsertw><a contingo upon strikes, wcWwb or delays beyond as
control. Owner to carry fke, tornado and other rw omq kiauram* Our wwkn aro fully
covered by VNorkrrren's Compensation k+aitmwe.
fttVMW Of VrOpOgat- The abm Prices, specifications and
conations are satisfactory and are hereby accepted. You are a &sized to do the
work as specified. Payrnent MR be as outlined above.
Date of Acceptance: Z %
Nota P t propmol mq be
wf@%ft" by us N not aoceptad VVIO t dWs,
Ac
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
klip Boston, MA 02111
`
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
u deontr s/C
palicant Information actors/Electricians/Plumbers
Name (Business/Organization/Individual):
City/State/Zip:
ry
Are you an employer? Check the appropriate box:
1. ❑ I am a employer
with
4. ❑ I am a general contractor
2. ❑employees (full and/or part-time).*
1 am a sole proprietor or
and I
have hired the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet. ;
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We are a corporation
3. ❑required.]
I am a homeowner doing all
and its
officers have exercised their
work
myself. [No workers' comp,
right of exemptibti per MGL
c. 152, Q 1(4), and we have
insurance required.] t
no
employees. [No workers'
comp insuran
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.[] -Roof repairs
ce required.] I 13 0 Other
Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy mformauon.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating
tContractors that check this box must attached an additional sheet showing the name of the sub coOntrac O a., r .rtd-..._it
such.
- - - ��.��.a wmp. pol- Information.
i am
information,
n employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #: '' w- C
Expiration Date:_ _ 6"
Job Site Address:_
City/State/Zip: , u
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 civilpenalties in the form of a STOP WORT{ ORDER and a
of up to $250.00 a day against the violator. Be advised that a copy fine
Investigations of the DIA for insurance coverage verification. of this statement may be forwarded to the Office of
- . «qry U"er me pains and penalties of perjury that the information provided above is true and correct:
2nahrrr+• J A
Official use only. Do not write in this area, to be completed by city or town ufflciaL
- 5 ~ 6
City or Town:
Issuing Authority circle one): Permit/License #
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
1 OA.
The debris will be disposed of in:
Fire Department Sign off:
Dumpster Permit
(Location of Facility)
Signature of Permit Applicant
2- 3 -
Date
ACORD� CERTIFICATE
OF LIABILITY INSURANCE :j:DATE(MM/DDlYYYY)
PRODUCER
04/26/2007
Pelham Insurance Services, Inc.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS
P.O. Box 960
NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
122 Bridge Street
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Pelham NH 03076
INSURED
INSURERS AFFORDING COVERAGE NAIL #
;;;
Thomas Doyle dba
INSURERA Nautilus
—
Thompson's Construction �
INSURER B Associated Ind of MA
8 west St
INSURER
Salem NH 03079
INSURER D
COVERAGES
INSURER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR
THE INSURANCE AFFORDED BY THE FOLICtES_ E^rtT��HER€lN
ANY
OTHER DOCUMENT WITH RESPECT TO WHIC}iTF11SCE&Tilp,TE-µAY--S-ORy p�RTAIN,
IS gQBU
-L YE LIMITS SHOWN MAY HAVE BEEN REDUCED BY
AR
TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
PAID CLAIMS.
ADD
NSR ADD'L
.TR INSRD
TYPE OF INSURANCE POLICY NUMBER -
POLICY EFFECTIVE
DATE (MMIDDIYY)
POLICY EXPIRATION
DATE (MM/DD/YY)
A
GENERAL LIABILITY
NC 644138
04/15/2007
LIMITS
04/15/2008
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS MADE E OCCUR
DAMAGE TOREN) D
PREMISES Ea occurrence
$ 50,000
MED EXP (Any one person)
S 1 000
GEN'L AGGREGATE LIMIT APPLIES PER.
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULEDAUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE LIABILITY
IANY AUTO
EXCESSIUMBRELLA LIABILITY
7 OCCUR ❑ CLAIMS MAUL
DEDUCTIBLE
B WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROP RIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
It yes. describe under
SPECIAL PROVISIONS t>elc�
OTHER
r
PERSONAL 8 ADVINJURY $� 1,000,000
GENERAL AGGREGATE $ 2, 000, 000
PRODUCTS-COMP/OPAGG $ 1,000,000
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person) $
BODILY INJURY
(Per accident) $
PROPERTY DAMAGE
(Per accident) $
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
AUTO ONLY
AGG $
UU tl
It $
$
AWC 7012214012007 04/21/2007 04/21/2008
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENDSPECIAL PROVISIONS
roofing e 17 Knollcrest Dr., Andover, MA for. Judith Brasseur
ICATE HOLDER
978 623-8320
Town of Andover
36 Bartlett St
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE 100,000
E.L. DISEASE -POLICY LIMIT $ 500,000
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
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