HomeMy WebLinkAboutBuilding Permit #738 - 54 LANCASTER ROAD 5/21/2010BUILDING PERMIT q;U91o ;6 q\
TOWN OF NORTH ANDOVER C
^ APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
�SSACHUS��
Date Issued:�
IMPORTANT: Applicant must complete all items on this page
LOCATION j q LA N (- A,)7Z- tk- % b
Print
PROPERTY OWNER yt r r 1/L
Print
MAP 210 PARCEL: / %, ZONING DISTRICT: Historic District yes
Machine ShOD Village ves 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:
�n d rrSNrvlo a wLi c4 'R
Identification Please Type or Print Clearly)
OWNER: Name: 3eR 11)e -h Imcr Phone: 17Y- 3Q03.
Address: 6H Lmi
CONTRACTOR Name: D. C!"+nLane KQu h nc Phone: 9 )1 ( a 3 3
Address: te- S , 'Z-2G� i c((,rY
Supervisor's Construction License: Ctcl 3 S Exp. Date: t )-- -/ t-, ' t
Home Improvement License: � 0 `{ V(01) Exp. Date: -? iI q - �-C / n
ARCHITECT/ENGINEER Phone:
lit
Address: Reg. No.
Js FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Ing
Total Project Cost: $ b 0 U. U 0 FEE: $ 1
Check No.: 1 3 yq O Receipt No.: 23 t W
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of rvAgent/0C Signature of contractor
r'
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
PLANNING & DEVELOPMENT
COMMENTS
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:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
yes.
uocatea St54 usgooa street
no
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''' S �+ l C1No. 3k _� k Date
NORTIy
TOWN OF NORTH ANDOVER
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Building/Frame Permit Fee
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
23,68
Building Inspector
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Town. of North Andover
BlAdding Depal-tme,lt
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 588-9542
DEBRIS DISPOSAL FORM
�y (a fit 7ly
UR1rc n f004 �h
C5AcF1 )l 5th
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Building permit: # the debris re. .iIting from the work shill be disposed
of in a properly licensed solid waste disposal faeilit ) as defined by MGL 01, s150a.
The debris will be disposed of in /at:
racility :lc>t<<lio�t --•
Signarure of Applicant
Date
NOTE: A. demolition permit fiom the Town ofN&th And.over must be obtained for this
project thiotigh the Office of the Bui[cling Inspector,
1 he Uommonwealth oj'Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
;tiwv>`v mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/lndividual): -DA\J 11 CMTR I CQ NL R OQ F I NC, `` S JD I N (- I N L
Address: 20p S0:1- cpt3 S -v CZ -s. -E ---r So
City/State/Zip: h - AN b0 J6. IC MA n 1 X NS _ Phone #: 9-) 9 (e 6 3 3 q3_0
Are you an employer? Check the appropriate box:
I . ® I atm a employer with 4. ❑ I am a general conductor and I
employees (.full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or par wer-
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
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.T
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.M Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill 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 indicating 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 am an employer that is providing workers' compensation insurance f6r my employees. Below is the policy and job site
information.
Insurance Company Name: M) e OA L i c"_ce, Cn("D&-6kf af 5a. -_.b 'm
Policy # or Self -ins. Lic. #: yN C q 9.rj 9,1 y (o Expiration Date: Cl - a, 6. 20 I a
Job Site Address: 5 4 LA, )C-6-3 / Lo -d City/State/Zip: N- Andogs W 6 1 J Yf—
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
foie up to $1,500.00 and/or one-year imprisotnnent, 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 DTA for insurance coverage verification.
1 do hereby certify under the ains andp nalties of perjury that the information provided above is true and correct.
.. � c
Sig�
nature: Date:
ane #: G7X (I X3 34.60
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 #:
ACRD,,,, CERTIFICATE OF LIABILITY INSURANCE
DATE 9'
PRODUCER (508)652-7700 FAX 508-653-8089
Eastern Insurance Group LLC - Commercial
233 West Central Street
Natick, MA 01760
Select Ext -53389
THIS CERTIFICATE IS ISSUED AS A MATTER OF INI ORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EKTEND OR
ALTER THE COVERAGE_ AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE MAIC #
INUURED David Castricone Roo Tng & Siding Ino
200 Sutton St
suite 226
North Andover. MA 01845
INSURER A: The Insurance Co of State PA
INSURER B:
INSURER o,
INSURER D:
INSURER E.
COVERAGES
THE POLIGIE5 OF IN5URANGE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIME POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY R5-OUIREMENT, TrQM OR CONDITION OK ANY CONTRACT OR OTHGR 66CUME,N'I' WIYH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED 013
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF $UCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE DEGN REDUCED BY PAID CLAIMS.
IN9ROD'
I To
TYPE OF INSURANCE
POLICY NUMBERDATE
POLICY EFFECTIVE
POLICY EXPIRATION
DBY> WM =
LIMITS
EACH OCCURRFN(;F
$
GENERAL LIABILITY
COMMERCIAL CFNERAL LIABILITY
DAMAGE TO HLNTEU
GGU[.CnGC
$
CLAIMS MADE 0 OCCUR
�J
MED EXT' (Any one parson)
$
PCRSONAL A ADV INJURY
$
3I:NI-RAI ACGRECATC
$
GtN'L AUGHEGATE LIMIT APPLIES PER.
1'N,000C 1 S - COMPfOP AOO
$
POLICY PRO LOC
JECT
AUTOMOBILE
LIABILITY
ANY AUTO
COAeBINE❑SINGLE LIMIT
(I -a pCadenQ
$
ALL OWN"I AVIOS
SCHEOULEDAUTOS
BODILY INJURY
(l'ai 0eT50n)
S
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY
(Pur mccidertQ
S
PROP,R'IY f5AMAL1
(Per acrldent)
GARAGE LIABILITY
AUTO ONLY, EA ACCIDENT
$
FA ACG
OTHER THAN
$
ANY AUTO
$
AUTO ONLY: AGO
EXCES31VMBRELLA LIABILITY
CACI I OCCURRENCE
$
OCCUR CLAIMS MADE
AGGREGATE
$
y
--r
S
17tVVC 1'IBLL
RETENTION 3
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WC9752746
09/23/2009
09/23/2010
X WC STATU- OTH
RMLT
E.L. EACH ACCIDENT
$ 100,000
A
ANY PROPRIFTOR/PARTNETLEKFCU-FIVE
OFFICERWEMBER txCLUDEO?
IIyYo�S, daicnbC Und¢r
8PECIAl. PROVISIONS below
E.L. DISEASE - ILA, EMPLOYEE
3 1010 , 000
F.I., DI$FA$F _ P(11 ICY LIMIT
$ 500,000
OTHER
OESCRIPYION OF OPERAYIONS I LOCATIONS) VEHICLE9 / EXCLU91ONS ADDED BY FNDORSEMENT I SPECIAL PROVISIONS
David Castricone Roofing & Siding
200 Sutton Street
Suite 226
North Andover, MA 01845
SHOULD ANY Or YHE ASOVE %''SGRIBEO POLICIES 8E CANCELLED SErOAC YHE
EXPIRATION DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN N07;111: TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH d0YICF SHALL IMPOST NO OnLIGAYION OR LIAeILfTY
OF ANY KINb UPON YHF INSL '(7R, IYS AGENTS OR RepRESEIOAYIYES.
AUTHORIZED REPRESENTATIVE - %4
�Stacey_ Brice/PKC ILt�>LK_
ACORD 25 (2001108) C�)ACORD CORPORATION 1988
Construction Supervisor Specially License
License: CS SL 99350
Restricted to: RI -,WS rAr; - "N
DAVID CASTRICONE
31 COURT STRE=ET
NORTH ANDOVER, MA 01845
C �unnri.�iiun•r --
q
Expiration: 1211612.011
f r 99358
a rn nunumt.; tccgnlatinr`Is :uul Sl:uulru ds
FIOME IMPROVEMENTCON TRACTOR
-J
Rec
-_. 1 istra 4on:104569
Expiration:
7/14/2010 1-rtt 270265
Type: Private Corporation
DAVID CASTRICONL- ROOFING, SIDING &
David Castricone
200 SUTTON ST SUITE 226
NORTH ANDOVER, MA 01845
�\Uwinisfretor
0
IMA
AW!
DAVID CASTRICONE BY: - - *
CASTRICONE ROOFING & SIDING INC.V/j �//,*0,...
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
In North Andover 978-683-3420 ]nBoxford 978-887-6147 InHaverhMI978-374-7314
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to famish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below described:
Owner's Name........ je.)�.p ... Ck 14..u............................................. Teleph ne #..........
Q ............ city ........ k
Job Address..... . .... 1.,AG C,,-. . .. ................. State.....
Specifications:
................................................................................................................................................
--Strip existing shingles.(/) -Apply new drip edge to all edges. F '/
......................................................................................................................................................................................................................
,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.
.......................................................................................................... ...................... ....................................
-Apply felt paper underlayment.,�•-Wstall ridge vent to LI,
1& -r -o-- .
of .. us -in -g -
shingles with a_- J&_ year warranty.
.......................................................................................................... I ...........................................................................................................
,Counterflash chimney. —A19W vent pipe flashing. --LEgal disposal of all debris.
........................................................................ 2 ..........................................................................................................................................
Area(s) to be worked on:
............................................. ..... ....... ...... ....
.. . ...... ........... P-) ........ koa� ..... I ..... e--
.............................................. �71VN ........ 1;6 ....... .......
.................................................................... ;0 .................... ................................................................................................................
Roof board replacement if necessary 40 /sheet o y /foot.
......................................................................................................................................................................... . ........... ; .................
Two Year Workmanship Warranty (Not Transferable) Minufacturer's Warranty as specjfitld�--
by an fac ore
The con actor agrees to perform the work do fu �ihh the.materials specified above for the S 00
... ... ......... ..............
con
..... .0 ... . on . ........ ...
Payable......... .............. on .......... :7= .............. (Okalance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability wbilcjobis 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 or other 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 tide 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 herein, 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 he 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: 617-727-8599
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 names this .... ........ day of JnQ 'I ............. 2012....
Accepted: Signed ... rte. ....................... Owner
Signed............................................................................. Owner
...................................................................
David Castricone, President