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Home My WebLink AboutBuilding Permit #825 - 53 HERRICK ROAD 6/12/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ""a '0 ., �e• N��i TYPE OF IMPROVEMENT PROPOSED USE Re idential Non- Residential ❑ New Building Y One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: 11 Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �*M^•t� �� P jaF Flood.�.i �� a G�tVo'ki��klMjal ll �yy�((f$[` {�> p r� �. i DESCRIPTION OF WORK TO BE PREFORMED: Identification Please T pe or Print Clearly) OWNER: Name: Phone: 998 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. t Total Project Cost: $__ 1 ► d �r FEE: $ 2 '� Check No.: ,� doh Receipt No.: 2�r 5-v a + NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature ofwAgOnt/Cl mer Sig> ature of contractor w ,. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL A 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 PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED 11 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS HEALTH f OMMENTS ❑1 DATE REJECTED DATE APPROVED Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservatid'n Decision: Comments Water & Sewer Con nection/sig nature & Date Drive Permit Located at 384 Osgood Street Z' Temp x umpser A a 1.24 Main �re�t � d air; �� rtrinentureldas , a F 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 i ............... ............... ............. ...... _....... .................. --- .................................... ... .......... _................... ................. .......................... ......... _............................. ..................... ............. .................................................................................................................................................................. ... ............ ..................................................... Doc.Building Permit Revised 2007 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 a Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks L3 Building Permit Application u Certified Surveyed Plot Plan o Workers Comp Affidavit L3 Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) u Building Permit Application Li Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Maass check Energy Compliance Report o 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 2.2007 Location �6'3 11C4-,L,,C4 i/1 No. i2 -5— Date (1 4P .2 TOWN OF NORTH ANDOVER + s + ; . Certificate of Occupancy $ Building/Frame Permit Fee $ ACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # S f) 0 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street U1 Boston, MA 02111 ` Workers' Compensation Insurance Affidavit: Builders/Cont 2211cant Informationrectors/Electricians/Plumbers Name (Business/Organization/Individual): Address: l� City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. Cl I am a employer with 4. ❑ I am a general contractor and I J employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These subcontractors have working for me in any capacity. workers' com [No workers' comp. p. insurance. p insurance 5. ❑ We are a corporation and its 3. ❑required.] officers have exercised their I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp, c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' coin Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs p. insurance required.] I 13 ❑ Other 'Any applicant that checks box #I must also fill out the section blow showing their wo�tcers' co t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating mpensation policy information. �Contractois that check this box must attached an additional sheet showing the name hi the outside c..t tra to �cating such. icy information. `2� am an employer that is providing workers' compensation insurance for my employee�„Below is the powul"Kers, comp. li l�nd'yob sit information. Insurance Company Name: Policy # or Self -ins. Lic. #: � e/ Expiration Date: ' Job Site Address: Attach a copy of the workers' compensation policy declaration page showin ttt�t the policy number Failure to secure coverage as required under Section 25A of MGL o 5the 2 can lead to e and expiration date). fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER imposition of criminal penalties of a of up to $250.00 a day against the violator. Be advised that a copy of this d a fine Investigations of the DIA for insurance coverage verification. statement may be forwarded to the Office of I do hereby .••«W• 1-apains ana peva/tieso of perjury that the information provided above is true and correct: Cl Dat Official use only. Do not write in this area, to be completed by city or town uJJ9ciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Ine.,e,...._ e 6. Other _ Contact Person: Phone #: • z CL a a � a o c ` O N C °o' w° cn U A as .8 m c w° U w w a w w U 6 CL C w Q UW M � w w q co 6 z L cn o cn z CL P% 2 W f 0 0 • �• L 0 5 Z I cm C C O■� y G � y 'E m m CD CL Cm CD OL e_m o �- d 0. C Q• y ♦_. C eeQ� ev v J 'p .a o CD C Z ts CD v ' COD c C C c CA LLI W ce W W C9 LLIW U) � o c ` O N C CJ V •d � CL C M ® co ;= ts O ts N = L ECFa r • O r.r o o: N E� 0 4 Ace. t' s0 c E O 4,00 oCD L OLD o 3 •' N C" m CO C CO 7 :,C C N O CO) 9 N m o _W O T O y 4D = 'zs o •'�'o CD C_ C O c �O • 'RIO= m 40 mor C3 h > Z O t+ W d _ H m m O :m�3 N m O� m y W � rpt ep ZMD •tNA IS O CZ ac �E O.= - � •N oCMLLI a ara m0�oy Q .� �m`� o a:4=-m� P% 2 W f 0 0 • �• L 0 5 Z I cm C C O■� y G � y 'E m m CD CL Cm CD OL e_m o �- d 0. C Q• y ♦_. C eeQ� ev v J 'p .a o CD C Z ts CD v ' COD c C C c CA LLI W ce W W C9 LLIW U) Board of Building Regulat ons and Standards e One Ashburton Place - Room 1301 " Boston. Massachusetts 02108 Home Improvement Contractor Registration CARL MALM CARL MALM 75 HEATH ST NEWTON, NH 03858 DPS-CA1 Co 50M-05/06-PC8490 �anznwmusea.�ii a�✓�/iaaaac/zuaeCla Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:' 154100 Expiration: 2/7/2009 Tr# 254154 Type: Individual CARL MALM CARL MALM 75 HEATH ST NEWTON, NH 03858 Administrator T� �u ,/Ci«aaar,�ivarlta Board of Building Regulation and Standards Registration: 154100 Type: Individual Expiration: 2/7/2009 Tr# 254154 Update Address and return card. Mark reason for change. F] Address [] Renewal [] Employment D Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 � c Not valid without signature 00 - 35,000 cf enclosed space IA - Masonry only 1G - 1 2 Family Homes i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Construction Supervisor License License; CS 96202 `* Birthdate:° 9/19/1960 Ezpiration:.91.19/2010 Tr# 96202 �r Restriction 00'' , CARL MALM 75 HEALTH STREET y ,k` NEWTON, NH 03858 Commissioner Registration: 154100 Type: Individual Expiration: 2/7/2009 Tr# 254154 Update Address and return card. Mark reason for change. F] Address [] Renewal [] Employment D Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 � c Not valid without signature 00 - 35,000 cf enclosed space IA - Masonry only 1G - 1 2 Family Homes i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. REQUIRED PERMITS The frIllowing building permits are required. It is the obligation of the contractor toe re such Secox- � 1 wrN permits as the homeowner's agent: +1i �dj ,�rlC'�,UT #1200 NOTE: NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded from the Guarwo Fund provisions of MGL c. 142A. Is an EXPRESS WARRANTY being provided by the contractor? NO YES Warrantee Provisions: U0AY— r1r� Unless i otherwise noted within this document, the contrset shall not imply, that any lien or other security interest has been placed on the residence. ARBITRATION The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may summit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be requiftd to su mit to such arbitration as r Wed in M.G.L. c.142A. Contractor: Homeowner: Date: Date: Z NOTICE: IM 910NATURES OF THE PARTIES A13OVE APPLY ONLY TO THE AGREEMENT OF TIM PARTIES TO ALTERNATIVE DISPTJI—h SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. THE CONTRACT MUST ALSO CONTAIN; 1) A Complete Description of any other documents which are part of the agreement; 2) A List and Description of other matters upon which the contractor and homeowner lawfully agree; 3) Any Other Provisions otherwise required by applicable laws of the Commonwealth. Remember, the Contract must be the Complete Agreemen between the contractor and the homeowner. Sem,",-0 16inal If you have general questions or need additional information about The Home Improvement Contractor Law, contact: Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulation 10 Park films, Room 5170 Boston, MA 02116 617-973-8787 If you have questions about Contractor Registration, contact: Director of Home Improvement Contractor Registration Board of Building Regulations and Siaudar+ds One Ashburton Place, Room 1301 Boston, MA 02108 617-727-3200, x25205 OO NOT SIGN THIS CONTRACT 1F THERE ARE ANY $LtaliK SPACES, Identical copies the contra should go to the h eowner and the coqntractol. H?rn wner's Signature Contractor's Signature�� G W-to�c added-(, �k,,� eoi11