HomeMy WebLinkAboutBuilding Permit #785 - 50 LINDEN AVENUE 6/4/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued:
Date Received
I IMPORTANT: Applicant must complete all items on this nage
LOCATION J6 k-/A(b4 /V Ay8bftJ
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RROP.ERTYOWNER W&NbY � lJl
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VIAP 210 _PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Villaae ves
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:
,5-,x Ls // IA(6- c F- 14 L-<- lecib ir 4t,�&lj er 4w
1
Identification Please Type or Print Clearly)
OWNER: Name: %/1 t AjA V /`/ A 6-6)1/<,- Phone:
Address: 3D L I Al b�V A-Ve CJUE �)O, 4iJ&)L c1- >Lt, 4- C)1 g- yd -
CONTRACTOR Na e: �L t s%X/C(Y J£ "6r/1J� Phone: 946 i, 32YLo
Address: 206 T UJ -/"DX3 S i Y c` 15-U /` z-, Z 2 h� 4 f c�U h M/1 O IHS`
Supervisor's Construction License: q 3 Y E5 Exp. Date: l'o),
Home lmorovement.
10gS6
Date: / 1,� lzot o
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �d FEE: $ 2—
Check No.: OC� Receipt No.: a3 -6,,3
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owner Si natur a
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: Building Permit Revised 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
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THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
£ INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
a
HEALTHReviewed on Signature
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:
s' Located 384 Osgood Street
FIRE DEPARTMENT ---Temp Dumpster on site yes � t 90
Located at 12
# Mairi treet:'i �� • ,. 7
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 2010
Location (,M1&
No. %; Date —w
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee • $
Other Permit Fee $
TOTAL �$
Check # 3
232:x;
Building Inspector
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DAVID CASTRICONE S// 11D
CASTRICONE ROOFING & SIDING INC.
ROOFING, SIDING & REMODELING REPLACEMENT WINDOW§1n
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 t l
200 SUTTON STREET, SUITE 226, NO. ANDOVER MA 01845u'
In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill/ 978-374-7314
BY: .......................
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises be]oNv described:
Owner's Name ...... rk� r
...........
ti d t?.L� .............................. �.........t....... State Address...�o..... Z... ............... city .... 1FG,t. ...".l.l.Jl...!�L..'..
....
Specifrcalions:
..................................................................................................................................
tttrip existing shingles(i) 4pply new drip edge to all edges. klLl l Y I'
............................................. ........................................................................................................................... I.........................
v Apply _feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane
in valleys and bottom edges of any unheated areas of house.
......................
;� ppIy felt pa
......................
t4eroof using
�Counterflash chimney. Mew vent pipe flashing. al disposal of all debris.
............................................................................................... ..................... .................................. ....................
..... ()
✓�{rea s to be worked on: J %
/ / G t
............LL...i�.�:.✓.Y.1:L: ..........R..:P. sT.........I Xl..t,t.i.Ff...i...........................1..[iML.-r...1.1.5a�1i.'.Q a'].utY.�.... �....I.LaGCO/.......
.......................................... I......................... ....................,A............................................................................................
Roof board replacement if necessary @ �00 /sheet or'� "/foot. ,b,� o :/e1-" S S .
..................................................................................................................................................................... ...............................
Two Year Workmanship Warranty (Not Transferable) Nlitnufacturer's Warranty as specificAl manufacture
The contractor agrees to perform the work and furnish the materials specified above for the SUM o $...r'a1go...............
Payable............................. on .................................
Payable ............................. on .................................. Balance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e, water stains, crumbling plaster, exposed nails) or
conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic orother living
spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon
completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by
contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is
agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by
contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are)
the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There are no representations, guaranties or
warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not
herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration
should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108
Tel: 617-727-8598
Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -
related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A.
Approximate starting date of work ................................................ Completion date .........................................................
Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation).
IN WITNESS WHEREOF, the parties have hereunto signed their e is... . day of .. r,.t............ 20.. .01.
6666
Accepted:
'ySigne!(l l
. ............. `' ..................... Owner
Signed........................................................................ Owner
David Castricone, President /1
1 he Commonwealth oj*Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
lrwwv. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busitless/organizatiot>/Individual): e Am i CO N�_ R06 EINL,- 15 ID I N (T I N 1.
Address:- -2OCa SU::1 t-r,t3 S--V2t--E..-r Su �- e_ Z2
City/State/Zip: h . ANDO 49 k NA 01 S LAS Phone #: °I-) � (p t 3 3 42-0
Are you an employer? Check the appropriate box:
I. ® 1 a1n a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work-
myself.
orkmyself [No workers' comp.
insurance required.] I
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.1
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
10. ❑ Electrical repairs or additions
11.❑ Plumbmg repairs or additions
12.0 Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomtution.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contractors that check this boa must attached an additional sheet showing the name of the sub -contractors a,td state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I ant an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Compviy Name: Mn e— OA u face Co Mp �t a f- SIa:b _V -6
Policy # or Self -ins. Lie. #: yN r_ q 9rj a, I y (p Expiration Date: q -
Job Site Address: 5_6 Linde.., Avcnc. City/State/Zip: �J0,-ti, A rtiouez blit of iy1
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 the pains and penalties oj'perjury that the information provided above is true and correct.
Signature: :)-:,) L lJ C..,+� Date: , � /', //
use
City or Town:
10
not write in this area, to be completed by city or Yawn official
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
Town. of North Andover 'aIV
Building Depal-tment
27 Charles Street a
North Andover, Massachuseas 01845
(978) 688-9545 Fax (978) 688-9542
S'SAC[ItJ5�t
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL e 40 s 54, and a condition of.
Building permit # the debris re�zi.!Iting from the work sh::111 be disposed
of in a uroperly licensed solid waste disposal faeilit.; as defined by MGL cl 1, sl 50a.
The debris will be disposed of in /at:
Facility lo�:Iil10n
Signanure of Applicant
� I, O
Date
NOTA: A demolition permit from the Town ofNdrth .And.over must be obtained Cor t:ltis
project tluoligh the Office of the Building Inspector,
