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Home My WebLink AboutBuilding Permit #819 - 53 SECOND STREET 6/21/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: J4 Date Received Date Issued: �'O-/ a IMPORTANT: Applicant must complete all items on this naize LOCATION PROPERTY OWNER `.Jf�i�n , ,��_ Psdrlxa Vr /Ctlo �f Print MAP 210 0/ PARCEL:' -6W /ZONING DISTRICT: Historic District yes Machine Shop Village yes no no TYPE OF IMPROVEMENT PROPOSED USE Residential q_ c no no 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: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: 9 CONTRACTOR Name: U Phone: 6J � Address: Supervisor's Construction License:. j e"ylcl(3 Exp. Da#e: Home Improvement License: lolz?gle Exp. Date: ARCHITECT/ENGINEER Address: Phone: 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.: �er Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Z*D.�Signature of contract��_ Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody 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 PLANNING & DEVELOPMENT F9101TARTAM0,10 CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature 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 DPW Town Engineer: Signature: Locateo 3134 FIRE DEPARTMENT - Temp_ Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 NOTES and DATA — For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 .. 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 Location <3 -- 5;:�e"Oh4d No. f� Date MORTh TOWN OF NORTH ANDOVER Y Certificate of Occupancy $ �'Ss�cMusE`� Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #5�?1211 230,1 Building Inspector City/State/Zip: The Commonwealth of Massachusetts -~ Department of Industrial Accidents Type of project (required): Office of Investigations have hired the sub -contractors 600 IVashington Sheet ' Boston, A11A 02111 y , ivurw.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LelZibly Name (Business/Organization/Individual): PO Box 687 9. E] Building addition OWN, MA 01864 Address: 10. El Electrical repairs or additions City/State/Zip: Phone M % / & & y 5,5 Are you an employer'! Check the appropriate box: 1. �m a employer with 4• ❑ I am a general contractor and 1 Type of project (required): employees (full and/or part-time). have hired the sub -contractors 6. E] New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have $ r_1 Demolition working for me in any capacity. employees and have workers' comp. insurance.$ 9. E] Building addition [Na workers' comp, insurance required.] P• 5. ❑ We are a corporation and its 10. El Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.[ oof repairs insurance required.] t c. 152, § 1(4), and we have no 13.0 Other employees. [No workers' comp. insurance required.] "Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatine such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I ani an carployer tlrnt is providing rvorkers' compensation iiisurance for my employees. Below is the policy and job site information. _ Insurance Company Name: / —��1z Policy # or Self -ins. Lie. #: A. -TU a � � 3U IVy1V Expiration Date: Job Site Address: City/State/Zip: t,�t% 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 ora 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 of perjury that the information provided above iis° true and correct. Sianature: Date- % Official use only. Do not write in this area, to be completed by city or town official. 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 #: 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 including 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 sliall 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, y25C(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 completely, 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry 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 confinmation 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 law 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 # 617-727-7749 Revised 4-24-07 www.mass.gov/dia n Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 109288 Expiration:. 9/9/2010 Tr# 273490 Type:. DSA DUVAL ROOFING Kenneth Duval 72 NORTH ST N. READING, MA 01864 Administrator - Massachusetts - Department of Public SafetN Board of Building, Regulations and Standards Construction Supervisor License License: CS 58443 Restricted to: 00 KENNETH P DUVAL PO BOX 190172 NORTH ST N READING, MA 01864 ( nnunissipile r Expiration: 12/10/2011 Tr#: 10475 NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91 -9-10 ) POLICY NUMBER GILBERT INS AGCY 137 MAIN ST READING 03-11-10 TO 03-11-11 EFFECTIVE DATES MA 01867 NAME OF INSURANCE AGENT ADDRESS DUVAL ROOFING LLC 184 PARK STREET NORTH READING MA 01 864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) MEDICAL TREATMENT PHONE # DATE The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 002991 W20P1G02 TO BE POSTED BY EMPLOYER Page No. of Pages Builders License # 58443 Home Construction Reg. # 109288 DU W Age K00fing,LLC (781) 944-1994 (978) 664-2557 "The Areas Oldest Roofing Company" P.O. Box 637, North Reading, MA 01864 PRO ,(S Lu 00 ' DATE STREET f 3 i N �v�/ v� / ` J ! / l7 ) CITY, STATEN ZIP CODE . JOB LOCATION We hereby submit specifications and estimates for: Recommended A Optional r, r t _rG— —_ (Included in price) (Not included in price) Rip & Remove all shingle debris from roof & job site: Ldrl layer ❑ 2 layers ❑ 3 layers or more V Repair/or Replace any roof decking; not to exceed 50sq. ft. (additional at $1.70 per ft.) Install 8" aluminum drip-edge/and rake -edge along entire perimeter. Choice of millrwhit or brown Install ICE & WATER underlayment along horizontal eaves, valleys, sidewalls, sky -lights and chimneys t/Install premium base sheet underlayment between roof deck and roofing shingles V/ Install 30yr CertainTeed/GAF/Tamko or IKO architectural roof shingles ❑ 40 year ❑ year t ❑ 60 year ❑ L.ifetime See manufacturer warranty policy for more details V/ Install new aluminum vent -pipe flange (s) Y Chimney (s) -counter-flash and re -step existing flashing ❑ Cut & Install new lead flashing V Ridge-vent/exhaust vent with low profile design, hidden by shingle caps d ❑ Soffit -ventilation r!, )j Roof louver -vents • Seamless style aluminum gutters - custom fabricated at job site by our own gutter machine — ❑ Downspouts ❑ Leaf gutter guards V Other J- i 1, 'Please Note: All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear -off Price includes all items above that are checked only / others may be priced separately upon request. We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: ice-- Total price not including options. dollars ($ Payment to be made as follows: 30% deposit required before ordering materials. Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Late charges of $50 per week for all outstanding bills due upon day of Authorized / completion. Signature J n - Accepting proposal means agreeing to the terms of the enclosed binder Note: This proposal may be 2 r contract. 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