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HomeMy WebLinkAboutBuilding Permit #537 - 522 CHICKERING ROAD 4/14/2009TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: <iommercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: x � s�ti � i2 af' s)7 , %� 4AJ �ti s : �— r» G L, AL /= /y/i rev Identification Please Type or Print Clearly) OWNER: TName: Phone: Address: CONTRACTOR Name:—D - - J' C a:, J1z" r Phone: Address 4, l��..t�r rr, n v j,9 7e Supervisor's Construction License: .2-3211 Exp. Date: Home Improvement License: /,0 7 5- 3 S-- Exp. Date: 15' It ARCH ITECT/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. �J Total Project Cost: $ � c�o1 S FEE: $ Check No.: 3 --- Receipt No.: CQ (� � NOTE: i Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location 5dg— C 41 L /Yt- - No. Jr3 Date t �aRTM TOWN OF NORTH ANDOVER Certificate Occupancy + , , of $ s�CHU Building/Frame Permit Fee $ Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ Check # 21914,6 . I Building Inspector 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 COMMENTS Reviewed on Signature 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 Ton 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 i i ❑ 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 ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 ❑ BBuilding 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 El 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 I Revised 2.2008 �fte �r a�xmzo9u h+. and Standards Board of Building jtegulah ns aad AcTO rds HOME IMPROVEMENT CONTRACTOR 1141stradon: 107538 Expiration: 81412010 TO 272916 Type; DBA D & J CONSTRUCTION Daniel Ingersoll 9 McKenzie Circle Administrator Tewksbury, MA 01876 a 1<t�s.tchu ctts -. Department of Public safet" Board.of Building Rclgul.ttst?ils and Standards Construction Supervisor License License: CS 23711 Restricted to: 00 DANIEL N INGERSOLL 9 MCKENZIE CIR �= TEWKSBURY, MA 01876 Expiration: 12N7I2009 2328 comm sioner 1 O A q?�. w W ,7a. a a U O ��•• �¢ w w o w°& .a a or. mv a�' U w w w r� cn c w a coo w w 0.4O cn cn C w O r Q W Y= O lj <u W 44 Iu O A'' Q r 0Nclo 0 z COO LUW F- W LIMV COO c ■- f O O C z �_ V CL c W W = O O � L y.+ 0 0 CL �0 m cc •_-. O O ocm c ago L L c 3 CR CIO 0 J m mc � .rte �u •Ccc : = Vl A C40 m Eo at,2 y m m ' C O Q •� � r C Z _O C1•yZ R O 0 CL O ` m c o ;ago wCD " y m •0.. ~ •y d.= W c O y .� O O V O) FE CL O�OA Vl J y z CL m O U O co ■ L O � v Z °D 0. O y C C ww`` � W i O CD.CO3 CD g m m CD 0 CD CL_~ Z O� �3 O � OD 0 0 CD L cc O d CL Om< S CO) �= c O V CL O CD Z ts cO 0 CL C.3 CO) c C c ■� C c CLH C ZONSTRUCF] ON V,,G_w_e_ .. PROPOSAL SUBMITTED TO : De Lu PHONE: 978-475-2404 cell 978-257-3268 DATE: 3-24- 09 STREET :40 Sunset Rock Road CITY, STATE, and ZIP CODE: Andover, MA 01810 Road, N. Andover, MA ARCHITECT DATE OF PLANS JOB NAME JOB LOCATION: 522 Chickering JOB PHONE We propose hereby to furnish material and labor - complete in accordance with specifications below, for the sum of: $6,325.00 Payment to be made as follows: All material is guaranteed to be as specified All work to be completed in a workmanlike manner according to standard practiced Any alterations or deviation from specifications below 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, or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. m Authorized Signature , Office Manager Note: We may withdraw this proposal if not accepted within 60 days. We hereby'submit specifications and estimates for: Remove existing roof shingles and install new 30 year archetectual roof shingles, to include ice and water shield on 1 st 3' of roof. Acceptance of proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of acceptance: - - 0 i Signature: Signature: FROM : SCHAFFiER INSURANCE PHONE NO. : 9786499375 i•CC�Ri�" CERTIFICATE OF LIABILITY INSURANCE PRODUCEit .Seha%m iAsummoe AgWy 1147 Main St Tewksbury. MA O1876 INSURED D&J CONSTRUCTION 9 Mckenzie, Cirde Tewksbury: Ma 01t378 - Feb. 24 2009 03:09PM P1 DATE INWOWY) 021241 THIS CERTIFICATE 13 ISSUED AS A MATTER OF W 0101ATION ONLY AM CONftRS no RIGHTS UP01i THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMM. EXTEND OR ALTER THE GAGE AFFOROED_0-11_THE POLI M i r. I= (978)840-9375 WSURERS AFFOROINti-COVERAGE _ 1 NAIL s - i INStNRERA, HERIIMTAGE INS CO ' 94SURER It LIBERTY MUTUAL RNSURER C:.._... - .... INSURER D: INSURER E.* _COHHRAGES ; rrSURtcR F. 1 THE POLCM Oi WWMjNCE UpW HAVE OEM ISSUED7Q THE DISURED KAWD PAM FOR THE POM PERIOD ga01CATED. MpTVYR1t81'ANDWG , ANY REOUtASMLVT. TERMOR CONDITION OF ANY CONTRACT OR OTNI:R DOtV Elff v 11M RF,SPECT TO VOUCH THIS CERTMANE MAY DE WJED Ott Ii MAY PERTAK THE OMPIM CEAFFOROED BYiHE POLMS DESCRIBED HEREM 6 SUBJECT TO ALL THE TMS. S CLUs10N5 AND COpDTRONS OF SUCH POLICIES. AGORM47E Mn SMWJN WY HAVE BEEN REOUCEO BY PAID CLAWS. TSR' 1N58tL! _ .. TYPl: OF ii6TlRtAlICE ... i p0! ICY NU —.' DA1I_.rX L LtA� to EACH Of 'NM . . FACOMMER04tGEMEMIJAmm ;HGL 154554748 11/3= 100,00D MED EXP V" one price) jQ,0_00jj' 1 0 J CL www OCCUR , ` :p 1lILSADVIMUIIttY 1000,0001 :GENEWAGME"'fE t,000,OQO; i I IO YPriaotHcrs-caMProPiIin..1;0�000 lGENTAGGREGATEUWAMESMEW W I IM ao=I pAOJ m I.. I LOC : COIMBDHEO SOME LI MT _ C AAUTO ! ; ice... -F-- •• AIIOYYNk7TAUi'OS i : GODLY NAM � ! 3 ri NY�'• SCAEDUUMAUTQS it �I HIRBDAVTOS9MY INJURY i Irl NON OWkWAUTOS PRO .0 _ _._ .. - - - _ . _ � . _ ...__ € . _ice T�aGE .. � _--•--• • j 1 - AUTO ONLY -FAADCKWNTGARAGE t NBIIiY OTHER THAN "ACC L; i02 ANYAW-Q 1 -AUTO ONLY' A 1 - -'�iI-�J EACHOCCURRENCEi ; I ICLA - _ ....:. _ __..�.....1 AGGREGATE !i. J ocxxRN L CtAIN S W ADE +� RETENTIM Orw -yy 6%►Ti�fANO----T-• ._ _. 174-03 02121!09 -' 0212111D t 5 _ --- I &MMOVER>: LVMNi.RY =VdC1 318-3Z6 j t B (ICER iMEMPERI PAM" H aECUTnrE i ' e�F-L i ._. 00.400` 100A00 ' ay8s, do b9 w10e[ ' E L. NkSEASE : POUCT UMIT 1 _ 500.0001 OTHER OsscRlaTlmm- LocaTloiasrvttsllclM+exexUstoriADM ej6s0iO ; t .. J CERTIFICATE HOLDER _ _._.. __ CANCELLATION 8NtDIRDANYOF W E ADORE t M POIJCHF.S 69 CANCE LED 8WVRE THE i = k'�IRATiOIIPATETtEREOF.TfE16SWG wiLL ENDEAVOR TO NAI. � DAYSVNW17113v NOTM TO NNE CERiFIC►1>E HOLOW NAUMTO 1 YHE Lt3T. DUT FAttJI M TO DO SO SMALL D MO OBLIGATION OR LIAHIJTY ! = OF ANY KIND NPON THE II.SURER, ITS OR REPRESENTAWA& AUTNIORIZ� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Z� i- T7 con/ s-7.2, L Z7 -'o,,-, o'er Address: 9 � m c ! f- A.7 o:- C. 2 6 A;Z City/State/Zip: ---6—y.zn* ©,,y? Phone #: 5 7 S- Are you an employer? Check the appropriate box: 1. []tel am a employer'with 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. I: 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. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 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.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit 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 my employees. Below is the policy and job site information. Insurance Company Name: a,% Policy # or Self -ins. Lic.'#: cvc. / •- 3%S' 11 Zi 7 y - ® 3 Expiration Date: A Job Site Address:,3oZ1 G , L,2R a City/State/Zip: 0& 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 ms and p�ltjrs of perjury that the information provided above is true and correct. �it nature: A Date: v Phone #: Official use only. Do not write in this area, to be completed by city or town official i 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 #: cn G m D -4 m T z D C') 0 z Cn m D CD z C c o m = O �• N 0 Q y §_G0 C 0CCDL- CD Cl) 423 C2 .0 y v O y�aC 3 m z S -O H CA 0=..• CD ..• C G 0 T Co C .0 CD —� c m y o P-* —. o CD CD 2 m: y Cl) o H• n Loo. 'O O oo 0 CD O c =G3 r C) Z CA _L n o CD rCL CD d •O•r O cc o• W O CO) CD CO) W • Q C7 C cc) �_ O CD o a CL 94 O CDO H CL CA CD CD Cr CD: .0=CD jC C) : • :p.3 CCD O CD ,� S �.: s Tl CID 14 co CO) CDN . •► CA i O� S C CD cc co CO) O =+ cn G� CD o CSD o ?: � r K• o co O -t CD Cl) Ocm 0 �Z CD rfl ci y c = 0: 0 0 rt Orb 7z,= n m �o c n m O -n C Cl) M �go O n n c .0 Z n