HomeMy WebLinkAboutBuilding Permit #708 - 604 ALDER WAY 5/13/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �� Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
OVAT�O 1U
cii�T�en ib• ti�
�' \,�*7K...,%
E�lAP1A PARCEL ZON1fG D1STR1C1 ` 4 Historic Dtstnct yes=, -o
Machine' Shop 111llage F" 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
Others:
acement
Assessory Bldg
Demolition
Other
ptc ll�/ell
t Floodplain 1fetlands # '
Valatershed7Di r
st ict -
WaterlSea�er
�
---� DESCRIPTION
OF WORK TO -BE PREFnRMFn-
rel
Identification Please Te or Print Clearly)
OWNER: Name: r' / Phone:
Arlrlracc•
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: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guar fu
1pd-
Signature of Agent/Owner �Signature:of contrac r
.
Locatio, (-epa/ , j
No. -70 Date ' �j
TOWN OF NORTH ANDOVER
Check #2
23'i 54
Building Inspector
i
A
Certificate of Occupancy $
' sACM usE`�
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #2
23'i 54
Building Inspector
i
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
v
COMMENTS
Reviewed on Signature
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
DPW Town Engineer: Signature:
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 Pian
❑ 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)
a 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
The Commonweizlth of Alassachusetts
Department ofTndustiial Accidents
Office Of Investigations
600 Washington Street
Uf Boston, AIA 0 111
Workers' CompensationInsurance Affidavit Builders/Con
Dyltcant Information tractors/Electriclans/Plumbers
Name (BusinesslOrganization/Individual) :
K
e JO 0
. ac.aac r Elul Legibly
Address: -PC &K 3 2
City/State/Zip: L q W l'• C n C
M a 6l &,one
,ee You an employer? Check the appropriate
box:[Ar
• Ll I am a employer with 2, L
4. ❑ I am a o contractor
Typ7Remaod(-,hg t (required):
employees (full and/orpart-time)*
2. ❑ I am a sole
general and I
have hired the sub -contractors
6. constructionu
on
proprietor or partner-
and have no employees
listed on the attached sheet =
7• ingship
for me in any capacity.
These mob—contractors have
workers'cam
�working
g• 1on[No
workers' comp. insurance
.ins
5. P urance.
We are a corporation
9,addition❑
3 • ❑ am a homeowner doing
and itsrequired] officershave exercised their
10•l repairs or additions
.I all work
myself: [No workers' comp.
right of exemption per MGL
c. 152§ I (4); and we have no
11. ❑ Plumbing repairs or additions
insurance required.] t
employees. [No workers'
12.7 Roof repairs
•,�..v ji�nt that n..j.1G^kE k,ny.�i must .0.190 Ml out
iFlomeownets who submit oris affidavit indicating the},
comp. insurance required.]
art loin aL' work
13.[] Other
and th—
Contractors that check this box must attached an additional sheet showing th e ® outside connactars must. submit a new affidavit indicating such,
name of the sub -contactors and thec wmi—, ,.,...... __:__. I
I am an employer that is proviafing workers' compensation
tnfOTmattO/1, insurance for My employees. Below, is the policy and job site
insurance Company Name: � tap (- �'� l0 � S IC �G t (• C1',- (Q �, G �'O � �
Policy # or Self -ins. Lic. #.. 66 q
Sob Site Address:
GO,`'� I Ver WCw Expiration Date: j —1 " l 1
Attach a copy of the workers' compensation policy declaration page (showing City/State/Zip: �1p An do ve( m, .
Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the �poolicy II�oo f criminal
n�� expiration date).
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form imposition
a STOP WORK ORDER and a fa
Penalties a
of up to $250.00 a day against the violator. Be advised that a copy of statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
1 do hereby
Pa= ftfd penalties
.� �AM
the information provided above is true an
d Correct
Dclal use only. Do not write in this area, to be completed by cam, or town official
City or Town:
Permit/License #
issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. plumb
6. Other iad Inspector
Contact Person:
Phone #:
Information an -d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "._.every peon in the service of another under any contract of hire
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise; and including the legal representatives of adeceased employer, or the
receiver or trustee of an individual partriership, association o$ other legal entity, employing employees. However the
owner of a dwelling house having not morethan three spar mLents and who resides therein, or the occupant of the
dvvelIing house of a>iother who employs Pe to do tnainte�ce, construction or repair work an such dwelling house
or on the grounds or building appurtenant thereto shall not because of such. employment be'd6emed to'bean employer."
MGL chapter .152., §25C(6) also staies,that "every state ,or, local licensing avency.shalt•withhold the issuance or
renewal of a license or'pei mit to"operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=npliance 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 unitil acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority"
Applicants 1*
Please fill out the workers' compensation affidavit complei:ely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), addresses) 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 carry workers' comp easation 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 r'vtuiaed t0 the city 4r town ilia—, the auk tiCnur3n for the pM720it or license :s being r eq=3*-zd, not the Depa---ant of
Industrial Accidents, Should you have any ouestioms regardin'`g the law or if you are r.t:ired to cbtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number m the appropriate line.
City or Town Officials
Please be sure that the affidavif is complete and printed legibly. The Deparifneni 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 permMicense number which will be used as a mfc,rence Inumber. In addition; an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
mation if necessary) policy- infor( 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 Irlce 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 Fndusizial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 4 617-72.7-4900 e -%t 406 or 1-877-M.ASSAFE
Revised 5-26-05 Fan. # 617-727-7749
urwu,.mass._gov/dia
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-CIZy •'` - SERVPRO of Lawrence
PO Box 328
Lawrence, MA 01842
800 535-6322
Client: Dand, Darpan
Property: 604 Alder Way
N. Andover, MA 01845
Operator Info:
Operator: MMORIN
Type of Estimate:
Date Entered: 5/12/2010 Date Assigned:
Price List: MAEM5B MAR10
Restoration/Service/Remodel
Estimate: DAND
SERVPRO®
Fire & Water - Cleanup & RestorationTM
Like it never even happened.
Home: (617) 633-0454
SERVPRO of Lawrence
PO Box 328
Lawrence, MA 01842
800 535-6322
L/R
DAND
Main Level
621.33 SF Walls
998.28 SF Walls & Ceiling
41.88 SY Flooring
77.67 LF Ceil. Perimeter
Height: 8'
376.94 SF Ceiling
376.94 SF Floor
77.67 LF Floor Perimeter
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
1. Baseboard - Detach 40.00 LF
0.91 36.40 (0.00) 36.40
3. Remove Laminate - simulated wood 376.94 SF
1.36 512.64 (0.00) 512.64
flooring
4. Tear out wet drywall, cleanup, bag 376.94 SF
0.75 282.71 (0.00) 282.71
for disposal
Totals: L/R 831.75 0.00 831.75
Total: Main Level 831.75 0.00 831.75
�' g$ T Bedroom
h U
I ss
Hb
131f
DESCRIPTION
2ND Floor
506.67 SF Walls
695.71 SF Walls & Ceiling
21.00 SY Flooring
63.33 LF Ceil. Perimeter
QUANTITY UNIT COST
Height: 8'
189.04 SF Ceiling
189.04 SF Floor
63.33 LF Floor Perimeter
RCV DEPREC. ACV
9. Baseboard - Detach 21.00 LF 0.91 19.11 (0.00) 19.11
11. Remove Laminate - simulated 189.04 SF 1.36 257.09 (0.00) 257.09
wood flooring
Totals: Bedroom 276.20 0.00 276.20
DAND 5/12/2010 Page:2
• _ SERVPRO of Lawrence
PO Box 328
Lawrence, MA 01842
800 535-6322
T
15' 2" o
iV X10'4 m.
O � 1
4,,0„ L
Hall
341.33 SF Walls
403.86 SF Walls & Ceiling
6.95 SY Flooring
42.67 LF Ceil. Perimeter
Height: 8'
62.53 SF Ceiling
62.53 SF Floor
42.67 LF Floor Perimeter
DESCRIPTION QUANTITY
UNIT COST RCV
DEPREC.
ACV
14. Baseboard - Detach 6.00 LF
0.91 5.46
(0.00)
5.46
16. Remove Laminate -simulated 31.26 SF
1.36 42.51
(0.00)
42.51
wood flooring
Totals: Hall
47.97
0.00
47.97
Total: 2ND Floor
324.17
0.00
324.17
Line Item Totals: DAND
1,155.92
0.00
1,155.92
Grand Total Areas:
1,469.33 SF Walls
628.51 SF Floor
0.00 SF Long Wall
628.51 Floor Area
1,609.50 Exterior Wall Area
0.00 Surface Area
0.00 Total Ridge Length
628.51 SF Ceiling
69.83 SY Flooring
0.00 SF Short Wall
689.04 Total Area
178.83 Exterior Perimeter of
Walls
0.00 Number of Squares
0.00 Total Hip Length
2,097.85 SF Walls and Ceiling
183.67 LF Floor Perimeter
183.67 LF Ceil. Perimeter
1,469.33 Interior Wall Area
0.00 Total Perimeter Length
DAND 5/12/2010 Page:3
,u - - - a- SERVPRO of Lawrence
PO Box 328
Lawrence, MA 01842
800 535-6322
Line Item Total
Material Sales Tax
Replacement Cost Value
Net Claim
Summary
1,155.92
@ 6.250% x 60.31 3.77
$1,159.69
$1,159.69
DAND 5/12/2010 Page:4
SERVPRO of Lawrence
PO Box 328
Lawrence, MA 01842
800 535-6322
Recap by Room
Estimate: DAND
Area: Main Level
L/R 831.75 71.96%
Area Subtotal: Main Level
Area: 2ND Floor
Bedroom
Hall
Area Subtotal: 2ND Floor
Subtotal of Areas
Total
831.75 71.96%
276.20
23.89%
47.97
4.15%
324.17
28.04%
1,155.92
100.00%
1,155.92 100.00%
DAND 5/12/2010 Page:5
SERVPRO of Lawrence
PO Box 328
Lawrence, MA 01842
800 535-6322
Items
GENERAL DEMOLITION
WATER EXTRACTION & REMEDIATION
Subtotal
Material Sales Tax
Total
Recap by Category
@ 6.250%
Total
%
1,094.95
94.42%
60.97
5.26%
1,155.92
99.67%
3.77
0.33%
1,159.69
100.00%
DAND 5/12/2010 Page:6
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91te eommoww"
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvemento Yactor Registration
KEJO CORPORATION
GREGG WHITE
P.O. BOX 328
LAWRENCE, MA 01842
'S-CA1 0 50M -04104-G10/12166
V 1LG Tp09?7gYto92[! p����LCIGP.�%
Office of Consumer Affairs & Business Regulation
HOME IMPRO.VEMENTCONTRACTOR
Registrations -1,58271
Expiration12/3112011 Tr# 291205
Type;i_I, ataorpqration
KEJO CORPORAT(O1,
GREGG WHITE � cW` ,`
8 BLAKELIN STREET
LAWRENCE, MA 01841 Undersecretary
Reqistration: 158271
Type: Private Corporation
Expiration: 12/31/2011 Tr# 291205
late Address and return card. Mark reason for change.
u Address L Renewal Lj Employment [] Lost Card
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Not va ,thousignatur
VIa',s.ichuset,ts - Departntrnt of PuhliC Sufcn
Board of Building Re�uL•ltiorts and 'St;InlLutls
Construction Supervisor License I
License: CS 67690
Restricted to; 00
GREGG M WHITE
4 CHATBURN RD
WINDHAM, NH 03087
Jam'
Expiration: 2/20/2012