HomeMy WebLinkAboutBuilding Permit #142-12 - 54 MAIN STREET 8/18/2012 C
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION `
Permit NO:� . Date Received
Date Issued:
LWORTANT:Applicant must complete all items on this page
LOCATION S:!!57 `r
Prin
PROPERTY OWNER 8. Unit#
Print
MAP
MAP NO: PARCEL ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units:
11 Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
� ®�Se't c t �Welly � ''��`�`��`` `;�❑Flood�`lain`�'� � �''
DESCRIPTION OF WORK TO BE PERFORMED:
(Identifiention Pleasea or Print Clearly)
y)
OWNER: Name: Q
Phone:
Address:
CONTRACTOR Name: e"7
Phone:
3! )
Address:
Supervisor's Construction License: Exp.,Date:
Home Improvement License: Exp. Date:
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.
Total Project Cost: $_ 40 ,<-C�D FEE: $ s�
Check No.: R/
' eceipt Nb',:
NOTE: Pers c racting with unregistered contractors do ccess to the guaranty fund k
nature.o Aaent/Owner:_ ---_ ----- - - -- - •--
Stq._.ate
- -�- r—
i
I;
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
I
Public Sewer ❑ Swimming Pools ❑ `
Tanning/MassageBody Art ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Privatese tic tank etc. ❑
� P � 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
�I
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
I
(n Water & Sewer Conn eGtion/Signature&Date DrivewaV Permit
th
M1 DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -TemDum er on site yes no
Located at 124 Main Street
Fire Deparhnent signature/dat "/(/2- Ut�-FD
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, roast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES
and DATA d For department use
li t
i
® Notified for pickup - Date
DomBuilding Permit Revised 2011 June/mi
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y
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
i
❑ 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
MOTE: 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
a Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
i ❑ 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
o 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: Doc.Buildiag Permit Revised 2008mi
Location T )ogln I
No. Date
NpRTh TOWN OF NORTH ANDOVER
►p. w
` 9
� y
�o ; , Certificate of Occupancy $
sACHU t<� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 3J�7
244b6
Building Inspector
LG
EIN#51-050-3313 Haverhill MA.978.374.9224
MA Reg.HIC#149221 e Lawrence MA 978.687.7339
MA Lic.UCS#78130 Hampton NH 603.929.9224.
BBB. Single-Ply License#1711 frog Hampstead NH 603.329.8200
S..nc'.e�2932ambCo. Toll Free 1.888.SOS.ROOF
265 Winter Street
Haverhill MA 01830
f— 1rLicensed },-Insured ,,-Factory Trained *Factory Certified
Name: r UG. ; , , Date:
Telephone: Alt.Tel ho ew E-Mail:
Billing Address: /1 ., -/ r ; Job Address:
Scope of Work [].Strip and Re-roof ❑Re-roof Approximate Roof Area:
❑ Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected.
❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site.
❑,Inspect wood deck, if we discover any rotted wood, replacement will will performed at*$ -`a ;y> per LF for roof deck boards. If
substantial deck rot is discovered, re-sheathing of roof deck can be performed at*$ per SF. If individual sheets are found to be
rotted/or de-laminated, removal,disposal and replacement will be performed at*$ "`" _ per sheet. If any trim boards are rotted,
replacement will be performed at*$ per LF for new pre-primed pine. Inspect siding at roof line and all flashing behind siding, if
we discover any damaged flashing or siding at the roof line,replacement will be performed at*$ _ If wood deck,siding, and
flashing is sound,we will re-nail any loose wood to rafters,sweep deck, and prepare for roofing.
0-Install 8"drip edge to all rakes and eaves. Color
❑ Apply ice&water shield(UNDERLAYMENT)as per manufacturers'specifications and/or
El Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck.
El Re-flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness.
0 If upon inspection,we discover chimney lead to be worn or deteriorated,replacement will beperformed at *$
Install a new: Year ❑ Traditional D-Aritbitectural ❑ Designer
11 Furnish and Install a new shingle over style ridge vent system ❑Soffit vent system*$
0...All-debris generated by Lambert Roofing Co., Inc.will be cleaned up.and disposed of from the job site in a legal fashion.Under no
circumstances will the watertight integrity of the building be compromised.
Special Notes f
t
JV
UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FORA PERIOD OF
YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND-_- .- YEARS HONORED AND ISSUED BY THE
SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$
*Denotes potential additional costs above the total estimated price.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the materials and.labor specified above for the total sum of: $�/J�/ (*)
(Dollars)
Payment will be made according to the following work schedule:
$ deposit upon signing contract
$ by_/ /_or upon completion of
$ upon completion of contract.
(Law forbids demanding full payment until contract is completed to both party's satisfaction)
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram or by delivery,not later than midnight of the
third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
Acceptance of the Contract Proposal
r^ .
Home Owner(s)Signature(s): Date: L
Contractor's Signature: Date:
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construction Supervisor License
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B-MPSTEAD, NH 03841
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Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute an employee °°
ee is defined as"...every e
P y person in the service of a
,�
rY P pother under any contract of hire,
express or implied,p ped,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 o
. f such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall 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, §25C(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 certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to cavy 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 confirmation 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 bum 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 Coin,-nor-wealth of rVIassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass_gov/dia
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Le�><bly
Name(Business/Organization/Individual): �7
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: _
L❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
[No workers' comp.insurance 5. El We are a corporation and its 9. E]Building addition
required.] officers have exercised their 10.[1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp,insurance required.] 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 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:
Policy#or Self-ins.Lic.#: Expiration Date: �--
Job Site Address: t�- City/State/Zip:
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 certi nde sins and penalties of perjury that the information provided above is true and correct.
Si nature: ✓-
Date:
Phone#:
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.Plum31nspector
6.Other
Contact Person: Phone#:
-K"_u TF 04,05 Pik ALLAN INS AGNCY FAX NO, 978174515483 P Ul
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