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HomeMy WebLinkAboutBuilding Permit #008 - 57 GREEN HILL AVENUE 7/7/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o`"�oT 6 gtio o t Permit NO: co 13 Date Received ea Date Issued: — ��SSACHus�t�� IMPORTANT: Applicant must complete all items on this page LOCATION e) 7 /1 eevv 1-7// /9"✓--c- ® Print PROPERTY OWNER ,/� GLI ,4- _a `�1 T� ' Print MAP NO.: PARCEL: y ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ,tkepair, replacement ❑ Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED s s f C6 Jam. Identification Please/Type or Print Clearly) OWNER: Name: 2",414,d1J P Phone: Address: CONTRACTOR Name: I/ ta? �'�4 5 T�tc �� Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$10.00 PER$1200.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ %3,. , x12.00=FEE:$ Check No.: )7, Receipt No.: Page W4 4 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I i 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 Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo CopYH.I.C.of H 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) New Construction (Single and Two Family) i ❑ 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 ons (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report i 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:BPFORM05 Psoe 4 of 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ ❑ Tanning/Massage/Body Art ❑ Public Sewer ❑ Tobacco Sales Food Packaging/Sales ❑ Well ❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the g anty fund Signature of Agent/Own Signature of contractor , cN..�• Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS r DATE REJECTED DATE APPROVED r CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 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 Temp Dumpster on site yesno Fire Department signature/date Building Setback(ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area, sq.ft.: NOTES and DATA—(For department use) I i i 3 Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 i Location .16 ;J, v No. 008 Date ' -4 a �OR,M TOWN OF NORTH ANDOVER s i • ; : ; Certificate of Occupancy $ • o� ;�s�•~'•E<�' --Building/Frame Permit Fee $ s►cMus Foundation Permit Fee $ Other Permit Fee $ ct! TOTAL $ G • 1 Check # 7d 19015 Building Inspector v V40RTH Town o :.. Andover QL—i7, � l A E o dover, Mass. 007Wa COCMICMEWICK �ADRATED F`Pa�y '9S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • THIS CERTIFIES THAT..... BUILDING INSPECTOR R�. �!.r. ........... �... . .... .. /................................................. Foundation has permission to erect........................................ buildings on ... M. ................ ........... Rough to be occupied'as...Uisn-j- -L.....#►...iT'.�w. ........... . a.la....... .. .. ..w*.i �.. imn y h' eprovided that the person accing this permit shall in every respect conform to th terms application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS THS Final UNLESS--CONSTRUC TARTS ELECTRICAL INSPECTOR Rough .. .. Service BUILDING IN ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. DPS-CAI ii 5UM-U:1rGa-G IUt?lti --� rvtZZ� - .-- Buar d of Buildiug Rc9ulatioai and Stand rds HOME IMPROVEMENT CONTRACTOR Registration: 104569 Residential contractors and service ` —sU'� Expiration:Ex p 7/14/2006 providers doing business in Massachusetts Type; Private Corporation must be registered. If the contractor or DAVID CASTRICONE ROOFING,SIDING& subcontractor is not registered,you will not David Castricone be entitled to compensation from the state if. 7 Hillside Road something goes wrong with your job. 13 Oxford,MA 01921 Admiuisrraror 'this ae:tlfies u,et David Castricone Roofing&Siding Inc, GAF Authorized installer,one of a"small ,me,wsta,s,r number of professional contractors in your ' Aurriorized metropolitan area that has earned this special !!!l�....;.,. factory certified status." �„� , Narth,awkess � 7hyhMpleWtDbMndateach aest ffffr oeim +>x!r'batwd WWdWWm mofteraareare*"iaea m u&rthe&meet amw&yam,rats w wwTaW. WL Taw A. A44 ri This firm has met RPI's qualification criteriaf` for experience,reputation and dedication to !" 1 ;i;'- :t a :: S7fi� a :,.: professionalism. ' -- ` "ASTkTCONE R.0QFTJgQ.' .stjct+PrIITy° arrl`1ai„in$seminarian then` I �is ,•Pti� 1T�R .e• �..� �4. , . 1�. Rt�1Ns.tp,;b cQlt19A��of� -P�'Rd,N[' r'orlpi it•t.- .Iar1f;, r}roris .y. rtrre ani 75da Through special training programs available - exclusively to Alcoa Master Contractors, they learn how to be experts on quality installation and how to build and conduct business in a highly professional manner. aj ZL,yr DAVID CASTRICONE D CASTRICONE ROOFING&SIDING I.D,No.: A01921 D-A 1}er=Since ;� ACORU CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/05/2005 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAT11ON Internet Insurance Agency ONLY AND CONFERS NO RIGHTS UPON TFIE:-,,CERTIFICATE- 522 Chickering Road HOLDER.THIS CERTIFICATE DOES NOT AMEND;f=XTEND-QR: 9 ALTER THE COVERAGE AFFORDED BY'THE POLICIES BELOW. North Andover, MA 01845 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: NORFOLK&DEDHAM DAVID CASTRICONE INSURER B: NORFOLK&DEDHAM ROOFING AND SIDING INC. INSURERc: AIM 200 SUTTON STREET, STE. 226 INSURER D: NORTH ANDOVER, MA 01845 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AU FXP LTR INSRD TYPE OF INSURANCE POLICY NUMBER DA (MM/DD ) (M M/6MYN LIMITS A GENERAL LIABILITY ND-P-009867 8/12/2005 8/12/2006 EACH OCCURRENCE $ 1,000,000.00 ✓ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SO,OOG.00 PREMISES Ea occurence $ CLAIMS MADE OCCUR MED EXP(Any one person) $5,000.00 PERSONAL&ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1.000,000.00 POLICY PROJECT LOC B AUTOMOBILE LIABILITY 44506400001 08/01/2005 08/01/2006 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS ✓ SCHEDULED AUTOS BODILY INJURY $ 250,000.00 (Per person) HIRED AUTOS BODILY INJURY $ 500,000.00 NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ 100,000.00 (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ ' OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY VW C 6009480012004 09/23/2005 09/23/2006 7 TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT is 100,000.00 OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE' $ 500,000.00 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMI $ 100,000.00 OTHER CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) U ©ACORD CORPORATION 1988 SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of1bolgilding permit. Signed affidavit Attach es.......G o.......❑ SECTION 5 Description ro osed Work(check_all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS , Item Estimated Cost(Dollar)to be QFF L4 USE ONLY Completed by permit applicant g y r 1. Building (a) Building Permit Fee b d Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) X (b) 4 Mechanical(HVAC) 5 Fire.Protection 6 Total 1+2+3+4+5) b Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building Pe PP unit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I> 124 V L 7) C—A S 77'k L C.a/0 ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief DAV cD �, S7' ��nl Print Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRVIBERS 1 2No 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BtJU DING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T .5echm"ort is al Use fat77 BUILDING PERMIT NUMBER: DATE ISSUED. SIGNATURE: icic Building Commissioner/In ctor of Buildings Date Z SECTION I-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: V Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Propused Use Lot Areas Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required- Provided Required Provided 1.7 Water S 1.5. Flood Zone Information: upplyM.G.L.C.�10. 54) 1.8 Sewerage Disposal System: Public ❑ Private ❑ ZOIIe Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ -SECTION 2-PROPERTYaOWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record f Name(P� c) AR// W CTO�.t �—/V104 — Address for Service: NO 14lvvo Vic- A Signature Telephone 2.2 Owner of Record: Name Print Address for Service: J O Z Signature Telephone M SECTION 3-CONSTRUCTION SERVICES Q� 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 3 O License Number' ' Address mn Telephone Sig nature Expiration Date r 3.2 Registered Home Improvement Contractor. Not Applicable ❑ Company Name `b V ������--��0, 1 t�`� �ul + ,�4 Registration-Number �.. Signature Telephone Expiration Date Y^ .i q&Comm =eartfi of 911assachusetts Department of Indust=[,gc6dents Offue of Investigations 600 Washington Street Boston,.WA 02111 Workers'Compensation Insurance Affidavit APPLICANT INFORMATION Please PRINT Legiblyt. Name: -6-o--r� 1A) Location: � i• V `j/ GQE '/ ILL AVE City. Alt) Cm — ��t--� Telephone#: $"/ "[ ,(sfl em J ❑I am a homeowner performing all work myself. ❑ I am sole proprietor and have no one working in my capacity ❑ I am an employer providing workers'compensation for my employees working on this job Company Name: Ay Lb C,AST9l•COM L 20 J F INCe l /lU(r —7A/C' ' Address: _ Cl?U U Vy-r7—,o NyT (5V 2 , City: l V d , AAJD ey��- Telephone*: q71' 6 f331/Z0 0 3 U 1 z Q Insurance Company: // /h Policy#: V w C tO 0Q / T 0 Q 01 200 4 ❑I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following. workers' compensation policies: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'.imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that e copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certi under the pains and penalties of perjury that the information above is true and correct. Signature: Date: o y�. c Print Name: �} (/ /'� fni S T t-t-a iu IL Phone# 7 7 0 0� 7 _ Official Use ONLY-Do not write in this area ❑Building Department o Licensing Board Permit/License#: City or Town: ❑Selectmen's Office o Health Department c Check if Immediate response is required ❑Other iNFo CATION&INmucnONS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" 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 1152 section 25-also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit Woperate 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, neither the'commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpubli6 work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. .Applicants Please fill in the workers' compensation affidavit completely,by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. 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 Fax# (617) 727-7749 Telephone# (617) 727-4900 ext. 406, 409, or 375 Town of North Andover o� OO TH 4 vt � Building Department o 27 Charles Street North Andover, Massachusetts41 h (978) 688-9545 Fax(978) 688-9542 ,p 0R�°`�` \ J \ / 7 �RµTEa C H DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris resulting from the work shall be disposed 4 of in a properly licensed solid waste disposal facility as defined by MGL ell 1, s150a. The debris will be disposed of in/at: Z L S /ISG Facility location • � r 'P,.-,-D L A. Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector.