HomeMy WebLinkAboutBuilding Permit #902 - 60 WINDSOR LANE 6/25/2013TOW RTH ANDOVER
LICrN� LAN EXAMINATION
Permit NO: / J Date Received
Date Issued: �` V
IMPORTANT: cant must complete all items on this page
LOCATION �a 0 L0110J Sc9 I?
Print '
Print
MAP NO/ 6p Q PARCEL: ZONING DISTRICT:
- Historic District yes (IM�)
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
0 Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
0 Others:
0 Demolition
❑ Other
(] Septic (] Well:
❑Floodplain ❑ Wetlands
❑ Watersfied District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
M
(Identification Please Type or Print Clearly)
OWNER: Name: Z—;J 7 AA
Address: �O0 U-,71 r%dsOrf-
CONTRACTOR Name:
Address:
(03-3ZI—(oyy�
Phone:
T ST
Supervisor's Construction License: (S 3 7/ 7e9 Exp. Date: 2 pit-/
Home Improvement License: L 9 Exp. Date: af–/ /.-
ARCHITECT/ENGINEER Phone:
Address:
Reg. No. ---
FEE SCHEDULE. BULDING PERMIT. • $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASE ON $925.00 PER S.F.
Total Project Cost. $ FEE: $
v
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have a ess to the gua anty fund
;Signature:of,Agent/Qvvne Signature of'contractor "`�
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature A
COMMENTS
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:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories:_
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
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 2008mi
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
(VOTE: 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
o 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
MOTE: 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.Building Permit Revised 2008mi
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Location
No. Date
ANDOVER
Check #
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Building Inspector
Location �z'd 1,e-�
No.
Check #
� I t t
Date
TOW;NrOF
OcVCertificdte L paili
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TOTA
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516
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Building Inspector
, Office of Consumer Affairs & Business Regulation
r� -i�iF OME IMPROVEMENT CONTRACTOR
�tegistration: 108288 Type:
expiration: 8/14/2014 Individual
WILLIAM C. JARZYNKA
William Jarzynka
25 PEQUOT ST.
N. BILLERICA, MA 01862 Underseeretar;
Board w
i ;.•—i )T .e.ig '�Ud.'-9�v1V 1"i'wl ;.i''�".
-
Ulbehsa:. CS -037120
wii CJARZYNKA
25 PE+QUOT ST -
N BILLERICA MA 01362
04117/20/4 ..
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, Office of Consumer Affairs & Business Regulation
r� -i�iF OME IMPROVEMENT CONTRACTOR
�tegistration: 108288 Type:
expiration: 8/14/2014 Individual
WILLIAM C. JARZYNKA
William Jarzynka
25 PEQUOT ST.
N. BILLERICA, MA 01862 Underseeretar;
0
R [ Ff, CATEUR4NCEj
EnTHIS C=R-r
Kc r �a... I DATE
t'� 4A, TER f 1.T
} CERTtFfCFtTE DOES w1OT AFFIRMATIVELY F c,try FtTifaTiri� 4Lt AND CONFERS Eu0 t-�IGri3S ;F vId T{ E CERTIFICATE HOLDER. THIS
BELOW. THIS CERTIFECATE C`Y CR itc�raTtvcLY` klLrtENED EXTEND OR ALTER TETE COVERAGE AFFORDED SY THE POLICIES
OF INSURANCE DOES N ER. THIS
NOT CONSTITUTE A CONTRACT rsETWEEN THE ISSUING INSURER(S), AUTHORIZED
PRESENTATIVE OR PRODUCER, AND THE. CERTIFICATE NOT HOLDER.
theWPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollc les frills! ti
cer terms and condlt+ons s tt,e nntiri, t i„ 1 !'( )e endorsed. if SUBROGATION IS WAIVED, sut)jzct to
certirica[e hOit�er in Lieu Of s a C'icies I vy r2 lire 8,± el'uorseinet i- A sE
nCy cnderSament{s}. ate"Ll'i On flus certificate does nat eo^tsr rights to the
PROQUCEk
A James Lynch Insurance Agency Phone: i$1-598-4.?'L�0 CONTACF
297 Eroadtvay NAIAE:
Lynn, MA 0190,1 -aY: 73'i-505-058flIL
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25 PeigUot Street
Billerica, MA 01821
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'HIS 1S TO CERTIFY l -HAT THE Pp; I E iNliift�lcsER: ...... _..-_. ....
INDIC
OF,
CERTIFICATE
NOTWITHSTANDING S SU D 0 .ANYIREQUIREh REQUIREMENT TERM OR CON pHty pF ANY CON 12E4'ESIE3ili NUMBER:
CERTIFICATE MAI' E E ISSUED OR P, E i3_EN fSSUED TO THE INSURED NAMED TRAABOVE FOP, THE POLICY PERIU_t
MAY PERTAIN, THE INSURANCE AFFORDED N THE POLICIESEYA COCK 9EDTHER jiER� DOCUMENT SI SUBJECT PTO ALL THE PC FEI P,%S
EXCLUSIONS —TYPE
CONDI tS OF SUCH POLICIES. Ut1iTS SHOWN MAY HAVE BEEN REDUCED gy Po
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LTR I TYPE OF -WS URANCEID CLAIMS
GENERAL LIASILI, v 3N R ,r✓ , I ...- ..._ ._....
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::^_•c SCRIPTION OE OPERATIONS
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DISEASE - EA EPdPLOYEE F -.
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E.L. DISEASE -POLICY LIMIT g
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES Attae o
carpentry/ ( h ACORD 1R9, gdd!i�^23 Per.arlts Schc luie, if ntor- 5 ac is ream:od7
interior
CEP -IfFICATE
I�iayriiihan LutT der
154 Chestnut Street
N Reading, APIA 01864
,CORD 25 (2010105)
SHOULD ANY OF THE ABOVF DESCRIBED POLICIES E;E CANCELLED REFO F
THE EXPIRATION DATE THEREOF
ACG^vRDANCE t4{,NOTICE i`YILL BE DELIVERED IN
TH THE POLICY Pr, r';;Siw•I rc
AUTHORIZED REPRESENTATIVE
The ACORD name and log e registeredmarks 2010 O CORPORATION. SEI rights
o ACORD resenred.
rO $r
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BEVERLY
82 River Street
P.O. Box 509
Beverly, MA 01915
(978)927-0032
FAX: (978) 927-8201
Subcon
NORTH READING
164 Chestnut Street
P.O. Box 128
North Reading, MA 01864-01,28
(978) 664-3310 . (781) 944-8500
FAX: (978) 664.0872
Workers' C
PLAISTOW
12 Old Road
P.O. Box 1160
Plaistow, NH 03865
(603) 382-1535
FAX: (603) 382-1935
Lion Waiver
I,
William Jarzvnka hereby acknowledge that I, as an
independent contractor, have been asked by Moynihan Lumber
Company to provide it with a certificate of Worker's Compensation
Insurance coverage for myself. Based on the exemption provided b
the Worker's Compensation Insurance coverage for myself because I
am a sole proprietor without employees. Therefore, I hold Moynihan
Lumber Company and it's related organizations and the Arcadia
Insurance and or Self Insured Lumber Business Association, Inc.
totally harmless for any injuries or cost of injuries incurred by myself
because I have voluntarily chosen to exclude myself from coverage
by engaging the exemption provided under the Worker's
Compensation Laws.
I have taken this option Of 1T;y own free will.
`>:T: r-
Date: /p 7
Signature
"OU ALITV PACKED BY A DES ItEE TO PLEA.uErr
The Cora MOnwealth of Afassaellusetts
Department of Industrial Accidents
QfJz-ce of Investagati®ns
X CON9'ress Street,Suite 100
Boston, AM 02114-2017
Y®w>>� Mas,. g®V/dna
Workers' ®>�pe>�sa�t> on Insurance Affidavit.. Buflders/C®1rltractarsl
3Ecant InfOLMation
Name (Business/Orgauization/Individual):
Address:
Cl /state/z1
�3' v 2,
z2te,��2 ' Phone #
Are you anfl eMployer? Check the appropriate box: �
I . ® I am a employer with _
'loyees
4. ❑ I am a general contractor and I
(full and/or part-time).*
have hired the sub -contractors
2. am a sole proprietor or partner-
.listed on the attached sheet.
ship and have no employees
These sub -contractors have
working forme in any capacity,
employees and have workers'
[No workers' comp, insurance
comp. insurance.l
required.]
3. ❑ I am. a hoaneoNvlier doing all work
5. ❑ We are a corporation and its
officers have exercised their
myself. [No workers' comp.
right of exemption per MCL
insurance required.] t
c. 152, §1(4), and we have no.
employees. [No workers'
comp, insurance reauirPri 1
ra
Type of project (required):
6. ❑ New construction
7. [DRemodeling
$. ❑ Demolition
9. ❑ Building addition
10. F-1 EIectrical repairs or additions
11.11 Plumbing repairs or additions
12. ❑ Roof repairs
13 . ❑ Other
T.any apptFcant 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 attacbed 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.
a>Y v. ff "lut a provaazng w®rkers' c®rmpensation insurance
informatiof®r my e»apdoyees del®w is tlaep®dict' rrndj®b site
n.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/State/Zip:
attach a coley ® flee ®rkers' compeansation policy declaration page (showlaag the policy number and expiration date),
Failure to secure coverage as required under Section 25A ofl\/IGL c. 152 can lead to the imposition of criminal penalties of a
an_e up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK (jRIjEIt and a tine
of up to $250.00 a day against the violator. Be advised that a copy Of this statement may be forwarded to the Gffice of
investigations of the DIA for insurance coverage verification.
'rho hereby nerins azaeiperedalties of,�eriazay Haat the ir,�,znn ad
f:�,�U�derzhe
/ an provideci above is tame and correct
0 "al use ORZy.Do not write in this area, to he completed by city or town alicial
City or Town: Permit/L,icense #
Issuing Authority (circle one):
1. Board Of Health 2. Building Departnhent 3, City/'11 ORM Clerk 4. Electrical Inspector 5. Plumbing Inspector
ect®r
6.Ofler
Contact Person:
Ph®»e
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- 9A� 23i'
MOYNIHAN-NORTH READING LUMBER, INC.
"QUALITY BACKED BY DESIRE TO PLEASE"
164 Chestnut Street FEIN:04-2261995
North Reading, MA 01861 s Contractor Reg No.:
978-864-3310 / 781-944-8500 W Exp. Date: — / /-
Salesperson(s):
HOMEOWNER INFORMATION
,L-
Name Daytime Phone
(0 w')YtA' L c,w
Street Address (Not P.O. Box) Evening Phone
Al c)T'UX Avt" m4 o lys
City/Town State Zip Code Mailing Address (if different from Street Address)
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Moynihan -North Reading Lumber, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to
use such materials in connection therewith as set forth also in Exhibit A, attached hereto and made a part
hereof.
The following schedule shall be adhered to unless circumstances arise beyond Moynihan -North Reading
Lumber, Inc.'s control: Work scheduled to begin: _/ /— Expected date of completion:
May be based upon arrival of special order material
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
Moynihan- North Reading Lumber, Inc. agres to rf m the work, and furnish the material and labor set forth in
Exhibit A for the Total Contract Price of: $ �! + L.L,(which amount includes all finance charges).
Payment stlall be made by Homeowner according to the following payment schedule:
$11 S 9 2` initial deposit upon signing this Contract (the initial deposit shall not exceed the greater of
one-third (1/3) of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom
Ord rs as set forth below).
$ L #:2 by—/—/—or upon completion of delivery of materials
$ =, DD by—/—/—or upon completion of install
$ upon completion of the Contract
In order to meet the completion schedule set forth above, the following materials/equipment must be special
ordered before the Contract work begins, for a Total Cost of Special/Custom Orders of $.
$ to be paid for building permit
$ to be paid for
$ to be paid for
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Moynihan -North Reading Lumber Inc. 512111-3
H_gmeowner's Si Tlature Date Contractor Dat
K av: Dale Fuller
�oomeowner's Name (Printed) Installed Sales Coordinator
You may cancel this Contract if it has been signed by a party thereto at a place other than an address of
Contractor, which may be its main office or branch thereof, provided you notify Contractor in writing at
its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight
of the third business day following the signing of this Contract. See attached notice of cancellation for
an explanation of this right.
See reverse side for additional Homeowner Terms and Conditions
Incl ASO � / IA16;.. n";_.. v. _... O_.- ---.:-- n.-11 n--- . -t r