HomeMy WebLinkAboutBuilding Permit #679-14 - 58 MAY STREET 4/3/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
�4-1-�
Permit NO. _ Date Received
Date Issued: L1 1:S 11 c4
'
'IMPORTANT: Applicant must complete all items on this page
LOCATION
.' P Print_
PROPER WNERd�Dt✓iN`� �o_ f1.N
Print" � � 100 Year Old Structure yes no
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes 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
11 Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
N STick t-�- S� UIN�JL- (7 1 FL -67a iPj w(Nbyy`'S
OWNER
A(lrirP-,q-
Identification Please Type or Print Clearly)
Name: M81>2t_INL Phone: 979 Q31
S M A y S�-, 3
CONTRACTOR Name: (.)05,--�P,4 t c- [4 P ro Phone: i 7 ?2-`i �,S- Z `3
Address:
-767 -7 U�Un�c.�rr.r� Si"', l,J i �v�,��-,
Supervisor's Construction License: C �_ 917-7Y Exp. DateJ /('//4
Home Improvement License: i_ -)T 6 -7 _ _ Exp. Date: t ll %
ARCHITECT/ENGINE
Phone:
Address: Reg. No
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $� FEE: $
Check No.:_ 5R2- Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have ams o14e gfiaranty fund
_ .
Signature of Agent%Owner.._W�__ -�_._ M -Sig=nature of contractor
Plans Submitted FL -J-' Plans Waived ❑ Certified Plot Plan ❑ Stam d Plans ❑
Plans Submitted ❑ PlansWaived-0-
""Certified Plot Plan ❑ Stamped Plans ❑
-TYPE OF{ SEWERA:GE.DISP_OSAL- `
Public Sewer ❑
Ta nning/MassageBody Art ❑ ..
Swimming Pools ❑
Well ❑
Tobacco Sales
-Food Packaging/Sales ❑
Private {septic tank, etc. ❑..-- ;
Permanent Dempster on Site El
THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED: DATE APPROVED
PLANNING & DEVELOPMFNI' ❑ ❑
COMMENTS
.CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature .
A
COMMENTS
t
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ,
Planning Board Decision:
Comments
Conservation Decision: Commen
Wates' & Sewer Connection/signature & Date Driveway Permit
DPW To` o Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTW.L-NT .Temp Dumpster on site yes no
Located-at'124,Mair Street,, `' - �•,:,
Fire Departure►it',sig'riatureldat6" !
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-, mast -or service drop requires approval of
Electrical Inspector YeS No
DANDER.Z®NE LITERATURE: =Yes No
MGL-Chapter-166.Section 21A -F and G min.$100=$1000 fine
N®TES and DA I A — (t -or cle
Ll Notified for pickup - Date
Doc.Building Permit Revised 2010
ent use
Building Department
The fol -,awing"is"a-list of,the required forms to be filled out -for.: the appropriate. permit to be obtained.
Roofiv,g, Siding, Interior Rehabilitation Permits
❑ ' Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L Licenses
o 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 _Affldav_its 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
a 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 apw?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm:tted with the building application
Doc: Doc.Buiiding permit Revised 2012
Location J P '
No. �( Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # <kz '
Building Inspector
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2014-03-18 13:17 Lowes #2382 ISO 6036814226 >> P 3/4
Bak to Quote
Date: 03/18/,x,014
LOWE'S HOME CENTERS, LLC 92382
541 SOUTH BROADWAY
SALEM, NH 03079-0000
USA
(603)681-4218
Project #: 404880777
Customer Name: MADELIN , FONTAINE
Customer Phone: (978) 258-1231
Customer Address: 58 MAY ST
NORTH ANDOVER,
MA 01845
USA
Line Item
Frame Size
Size = 32" W x 45 3/8" H
me Size = 313/4" W x 45
,H
Description: PSE Window Quote
Product Code
Description Unit Price Quantity Total Price
Manufacturer: ThermaStar by Pella (R)
t 314" x 45 1/8"
roduct: Windows
ype: Double Hungs
lanufacturer: ThcrmaStar by Pella (R)
nergy Star(R) Qualified Products Only: Ycs - I would like to
icw only the units that are qualified for Energy Star (R),
nergy Star(R) Zone: Northern
oom Location: Other I
laterial: Vinyl
rame Type(Overall Width): Replacement Frame (3 1/4"
SAW - No Fin)
loped Sill Adaptor: Yes - Included
cad Expander: Yes - Included
onfiguration: Ono Wide
rams Size Width: 313/4"
rame Sizc Height: 45 1/8"
on( Size: 1/2 Vent
xterior Finish: White
iterior Finish: White
lazing: Advanced Low -E
rgon Gas Filled IG: Yes - Argon Gas
ompercd Glass: Annealed
rillcs Bctwccn Glass, Type: None
ardwarc; 2 Cam/Kccper Lock ScLs
ardware Color: White
:rcen: Half Unit Fiberglass Screen
esign Performance: Standard
;ad Time: 16
20 Order Typo; No
$197.11 5
2014-03-18 13:17 Lowes #2382 ISO 6036814226 >> P 4/4
Salesperson:
Accepted by:
Project Total: $985.55
Date; 03/18/2014
Print this Page
This Millwork Quote is valid until 3/2412014. This is an estimate only. This estimate does not include tax or delivery charges. Delivery
of all materials contained in this cstirrmate are subject to availability from the manufacturer or supplier. All the above quantities,
dimensions, specifications and acccuories have been verificd and accepted,
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The Commonwealth of Massachusetts -
Department of Industrral Accidents
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Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractor�/Electr cian;s/Plumbers
Auulicant Information / Please Print Legibly
Naive (Business/Orgadzationitndividual): ( bS`L��J (}". I ,✓�, c_- J LI
Address: / J d 3ulz_r+ S�
City/State/Zip: (rJ f l im 1.>7� Con Phone #: q 7 � ? Z ? - S
Are you an employer? Check the appropriate box:
Type of project (required):
1. D I am a employer with
4. ❑ I am a general contractor and 1
6, ❑ New construction
employees (fall. and/or part-time).*
2. I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet, I
`!• ❑Remodeling
shi and1ave no.employees,
p
These sub -contractors have
8. ❑ Demolition
-,
working forme in any capacity.
workers' comp. insurance.
9, ❑Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
ME] Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
1111 Plumbing repairs or additions
myself. [No worker s' comp.
c. 152, §1(4), and we have no
12.❑ Roofrepairs
insurance required.]
employees. [No workers'
13.[i Other
comp. insurance required.]
!Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensationpolicy information.
I Homeowners who submit this affidavit indicating they die. doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must affached 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
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 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 reguired.under Section 25A of MGL o. 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
-1do herebp-z!tKt&,under the pains and penalties of perjury that the information provided clbove is true and correct,
Phone #: � i 7S `% Z/ — V L 3 1 1
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 Cleric 4. EIectrical 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 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, MGI, 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' compensaiion affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) andphone 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 maybe 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 maybe 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 homeowner 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 eta) 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 COM
oxjwealtt.OfMassarhusetts -
Depaftentoflndu al,Accxdejats
(afce Qfwe'siigamin
6.00 Waki gkon Sere -t
Boston} MA 02111
T QJ. # 617-72,7-4900 W 406 ox 1-877•:I1�A��A��
Revised 5-26-05 Fax # RT727 774.E
wwwaass,govlclta
2014-03-18 13:18 Lowes #2382 ISO 6036814226 >> P 1/1
CONTRACT # 0 O
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MASSACHUSETTS EXTERIOR SOLUTIONS INSTALLED SALES CONTRACT
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dodumonL the Tons &-4Condlllorw Incuod with this document sad any other addenda and aapchmente hsible, shoe be mroned to "In as this Twm0,•
PLEASE READ ALL TE" AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING.
INGTALIAmON STREETADORCSS CITY STATE ZIP
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INSTALLED SALES SPECIALIST NUM9ER
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DATEh LOWE'S HOMO CENTERS, INC; 8 MANIC NO.:
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Are permits required for this installation?: DgYes ( )No
Contract Total
"applicable tax included
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FEIN: e6 -0748,75p
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CITYSTAT[ ZIP
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dodumonL the Tons &-4Condlllorw Incuod with this document sad any other addenda and aapchmente hsible, shoe be mroned to "In as this Twm0,•
PLEASE READ ALL TE" AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING.
INGTALIAmON STREETADORCSS CITY STATE ZIP
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INSTALLED SALES SPECIALIST NUM9ER
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DATEh LOWE'S HOMO CENTERS, INC; 8 MANIC NO.:
•w••••.o .. w y.vnraa yup wen uro parrI monovaro Rrgm, 15y signing this Contract, Customer
OCknowlodg09 having rocolvod a copy Of this Oamahlot betero work bacon Informina cuslmmnr et ph n rants mm A,i, .f ter.., r--. s. ...._-
m ronovatlon activl to bo rformed In Customer's dwollln unit.
- - -- - Q
WAIVER OF LIEN and ONE YEAR WARRANTY (TO BE SIGNED BY INSTALLER)
I, the undersigned Installarllndependent Contractor, having been employed by the Customer who signed the Certificate of Compfoton below do hereby certify that the work for this project
me
will be or has boon completed In a worknllko manner and to the Customer's satisfaction, In consideration of aro recolpt of ono dollar and other good and valuable consideration, and to the
exlerd ponntl0d by applicable law, I hereby waive and relinquish an Mons and all rights and claims of lions which 1, the undersigned, now have or may hereafter have for labor or materials
furnished, and further corbly that all work pedomlad and materials fumished, If any, by any other parry a parties upon the order of the undors ignod, have been fully paid for, Further, I the
undersigned, agree to cause the prompt release of any medhanlo's lien(s) which may be filed against the Customer's promises by any subcontractor, laborer, mechanic a material supplier
claiming the right to file such a lion through work related to the Customer's Conlrecr with Lowe's. In addition to any warranties provided by law or specified elsewhere, Including the Customer s
Contract with Lowe's. the undersigned, further warrants that all work fumished for this projod shall be free from defects either in material or workmanship. If any defects in material a
workmanship shall be discovered in the work fumishod Or material used during the cmrso of the work or within one year from the data of the Cerilficate of Completion, the undersigned agrees
to replace or correct such defective work or material, free from all expanse to Lowo's and the Customer in a manner satisfactory to the Customer.
I furter represent that I have given Customer Oise option of rotaining soma Of ell of the surplus motonals or having some or all of such surplus materials removed from the Customees
Premises,
If applicable to the poffommance of the work required for this project. I, the undoNgnod Inslallerlindependenl Contractor, do hereby comfy that I have complied with at requirements of the
Load Renovation, Repair, and Painting Program Rule ('LRRPP Rule'), 40 CAR, sec. 745,80 at seq., or any applkablo state laws a program regulating load based point safe work practices,
Including compliance with all Information distribution, notice roqulrements and work practice standards In perforating the work required for this project I comfy that I have provided the
Customer with all documentation required to be suppled under the LRRPP Rule or state program, shall retain all records required by low, and have attached to this document capias of all or
the records required to be retained by the LRRPP Rule or applicable state program.
Signed and delivered this day of
Installer loll
Print Name
CERTIFICATE OF COMPLETION
1. I, the Customer, certiry that the Installorsrindopondem Contractors or their sub-cahlmctors, have furnished all Goods and/or soMOea, that Inatallatbn, repairs and altoatons or tmprovomnols
(1119 01618118110n SaMcas7 have boon completed as set forth In mylour who with Lowe's, and that I have boon offered the opportunity to request that Law's allow me to retain come or all of
any unused, mcOlptod surplus materials rather than have such 9uT0115 materials remain the property of Lowe's,
2. Buyers InIII* (Buyer INITIAL ONE only)
Thargwero no such surplus materi9Lt
I accepted at surplus motarials I wanted, e
I declined to receive any surplus materials,
Date:
Owner's Signature Owner's Printed Name
(7tiacCti QUI
/ r1 -
#90981 (Rev.12/10)
a 7004 by LOwa'p,W Londa and Ilia aablo doslen
INSTALLER COPY am mpbtemd andWMTM or LF Corpor°aon.
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Are permits required for this installation?: DgYes ( )No
Contract Total
"applicable tax included
/,
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•w••••.o .. w y.vnraa yup wen uro parrI monovaro Rrgm, 15y signing this Contract, Customer
OCknowlodg09 having rocolvod a copy Of this Oamahlot betero work bacon Informina cuslmmnr et ph n rants mm A,i, .f ter.., r--. s. ...._-
m ronovatlon activl to bo rformed In Customer's dwollln unit.
- - -- - Q
WAIVER OF LIEN and ONE YEAR WARRANTY (TO BE SIGNED BY INSTALLER)
I, the undersigned Installarllndependent Contractor, having been employed by the Customer who signed the Certificate of Compfoton below do hereby certify that the work for this project
me
will be or has boon completed In a worknllko manner and to the Customer's satisfaction, In consideration of aro recolpt of ono dollar and other good and valuable consideration, and to the
exlerd ponntl0d by applicable law, I hereby waive and relinquish an Mons and all rights and claims of lions which 1, the undersigned, now have or may hereafter have for labor or materials
furnished, and further corbly that all work pedomlad and materials fumished, If any, by any other parry a parties upon the order of the undors ignod, have been fully paid for, Further, I the
undersigned, agree to cause the prompt release of any medhanlo's lien(s) which may be filed against the Customer's promises by any subcontractor, laborer, mechanic a material supplier
claiming the right to file such a lion through work related to the Customer's Conlrecr with Lowe's. In addition to any warranties provided by law or specified elsewhere, Including the Customer s
Contract with Lowe's. the undersigned, further warrants that all work fumished for this projod shall be free from defects either in material or workmanship. If any defects in material a
workmanship shall be discovered in the work fumishod Or material used during the cmrso of the work or within one year from the data of the Cerilficate of Completion, the undersigned agrees
to replace or correct such defective work or material, free from all expanse to Lowo's and the Customer in a manner satisfactory to the Customer.
I furter represent that I have given Customer Oise option of rotaining soma Of ell of the surplus motonals or having some or all of such surplus materials removed from the Customees
Premises,
If applicable to the poffommance of the work required for this project. I, the undoNgnod Inslallerlindependenl Contractor, do hereby comfy that I have complied with at requirements of the
Load Renovation, Repair, and Painting Program Rule ('LRRPP Rule'), 40 CAR, sec. 745,80 at seq., or any applkablo state laws a program regulating load based point safe work practices,
Including compliance with all Information distribution, notice roqulrements and work practice standards In perforating the work required for this project I comfy that I have provided the
Customer with all documentation required to be suppled under the LRRPP Rule or state program, shall retain all records required by low, and have attached to this document capias of all or
the records required to be retained by the LRRPP Rule or applicable state program.
Signed and delivered this day of
Installer loll
Print Name
CERTIFICATE OF COMPLETION
1. I, the Customer, certiry that the Installorsrindopondem Contractors or their sub-cahlmctors, have furnished all Goods and/or soMOea, that Inatallatbn, repairs and altoatons or tmprovomnols
(1119 01618118110n SaMcas7 have boon completed as set forth In mylour who with Lowe's, and that I have boon offered the opportunity to request that Law's allow me to retain come or all of
any unused, mcOlptod surplus materials rather than have such 9uT0115 materials remain the property of Lowe's,
2. Buyers InIII* (Buyer INITIAL ONE only)
Thargwero no such surplus materi9Lt
I accepted at surplus motarials I wanted, e
I declined to receive any surplus materials,
Date:
Owner's Signature Owner's Printed Name
(7tiacCti QUI
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#90981 (Rev.12/10)
a 7004 by LOwa'p,W Londa and Ilia aablo doslen
INSTALLER COPY am mpbtemd andWMTM or LF Corpor°aon.