HomeMy WebLinkAboutBuilding Permit #671 - 61 JOHNSON CIRCLE 5/4/2010TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
'f -One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
floodplain Wetlands
Watershed District ' <<
W4 Sewer
vw
utS(;KIP 11UN OF WORK TO BE PREFORMED:
Identification Please T e or Print Clearly)
OWNER: Name: o i Phone:, a�gJ VS--3ooZ
Address: Uh ��r�`,,
rzi
z
GO.N `I CTOR ?Marne: 't i p � >~ Phone: V 6
Address;
Supervisor's Construction License:,,
PExp Date: 1 °-
° II
Home�lm rovement Lrcense: l } 'p5 �O� Exa. Date: t t 10 R
ARCHITECT/ENGINEER 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: $_ 0 W
Check No.: 135-,- Receipt No.:_J �'i q
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature ofcontractor �'- '
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
I
Reviewed
DATE REJECTED DATE APPROVED
Sianature
Reviewed on Signature
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:,Signathre:
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
i
❑ 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
Li Building Permit Application
L3 Workers Comp Affidavit
o 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
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic y 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)
o 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)
o 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
t. 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
Locationz;5,/ 7dl7,-;JP"
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 131�-13—D
22992
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DAVID CASTRICONE O
CASTRICONE ROOFING & SIDING INC.
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 978-374-7314
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and ce the improvements according to the following specifications, terms and
conditions, on premises
below described:
y° zz.Owner's Name........L...................................... Telep e#......Job Address...... j ..........ELI,
tGt 1 'Crxx......�4.City ..... �.Cls....� ......... State—MA .......
Specifications:
.......................................................................................:............................ ..
............................................................................................
--Strip existing shingles ^*Pply new drip edge to all edges (,1% � g ��
L
,Apply _6 feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane
in valleys and bottom edges of any unheated areas of house.
..........pply ............
�felt pa
......................
Reroof using
......................
°Counterfiash chimney. --New vent pipe flashing. -egal disposal of all debris.
............................................A........ .c 3... .............. ........
... ........ .
Area(s) to be worked on: % /
_ .yz.In%...... L?• ...(11..0.14.la..,1�.............................
.....................///� .r
.�1.r..G...l.... .............k......%.....4.�..Z....w..l....•.•..................................................................... ...... ..
................... i .
................................................................... t�..li. ... .'
® 1....7.. .
.e ..................... .oma /-........... ct.w.yt ...�...........
Roof board replacement if necessary @ �Q /sheet or�Y--/toot.
.................................................................................................................................................................... ................... .. ....................
Two Year Workmanship Warranty (Not Transferable) Wanufacturer's Warranty as specifi y manufacturer
The coytTactor agrees to perform the work gnd� materials specified above for the SUM o S ...... ls,.�.. i�.........
payable ...J' (�....... on ...5.. ..............
Payable ............................. on ......... '................QBalance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability whilejob is Tin
Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed "nails) or
conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living
spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon
completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by
contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is
agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by
contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warant(s) that he is (they are)
the owners(s) of the above mentioned premises and that legal title thereto stands of record in his_ (their) names(s). There are no representations, guaranties or
wan -antics, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not
herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties.
All Home Improvement Contractors shall be registered and any, inquiries about a contractor or subcontractor relating to a registration
should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108
Tel: 617-727-8598
Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -
related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A.
Approximate starting date of work ................................................ Completion date ........................................................
Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation). /
IN WITNESS WHEREOF, the parties have hereunto signed their names this .y y . day of . j �?.1^)..)..... 20...6. t1..
Accepted:
)OSi .............. ............... Owner
Signed..................................:.......................................... Owner
.. ............. .............1
David Castricone President
Town. of North Andover
Buildlllg Dep.11'jYl nt
27 Charles Street
North Andover, Nlassachusells 01845
(978) 688-9545 Fax (978) 688-9542
DEDIUS DISPOSAL FORM
coanam w¢„ �.
s�HeFiu5�4
In accordance with the provisions of v1GL c 40 s 54, and a condition of.
Building permit. # the debris re:.;ILing from the work shill be disposed
of in a 6roperly licensed solid waste disposal facilit as defined by MGL cl 1, s150a.
The debris will be disposed of in /at:
Ndfacility lc>�<<kion ��
Signature of Applicant
Date
NOTE: A demolition permit fi-om the Town ofNarth Andover must be. obtainedfor this
project tluottgh the Office of the Building Inspector.
I he Uommonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
+vrvw mass.gov/dia
pensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name(13nsiness/Organization/lndividual): -DAV I) e MTq I LO p& QF I Nc,- I S IA) N 6- 1 N L
Address: Zcoca Su -VT -t tJ S"v 2 -E -E --r So 1-2e
City/State/Zip: h. AN DO 46 (L "A 6104Phone #: )-) 3 `4 20
Are you an employer? Check the appropriate box:
1. ® I wn a employer with `ti 4. ❑ I am a general contractor and I
employees (:full and/or part-time).* have hired the sub -contractors
❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I air a homeowner doing all work-
myself.
orkmyself. [No workers' comp.
insurance required.] t
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.$
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.9 Roof repairs
13. F1 011ier
*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.
lContractors that check this box must attached 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 7\�) e— MD 6-lly G� S�ZL
Policy # or Self -ins. Lie. #: jN C 9 9 S a. 19 � Expiration Date: q - d, 3 20 ► o
Job Site Address: _ U �o �Ms m 1,(. d"i•Q` u City/State/Zip:N0 ht &A
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 cruninal penalties of a
rine 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 $250.00 a day against the violator. Be advised that a copy. of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under thepains and penalties of perjury that the information provided above is true and correct.
Signature: CK �. 0..�. Date: _
use only. Do not write in this area, to be completed by, city or gown official
City or Town: Permit/License #
Issuing Authority (circle one).
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
DRID CERTIFICATE OF LIABILITY INSURANCE
09/28'%2009'
PRODUCER (506)651-7700 FAX 508-653-51D89
Eastern Insurance Group LLC - Commercial
233 West Central Street
Natick, MA 01760
Select Ext -53389
THIS CERTIFICATE IS ISSUED AS A MATTER OF INrORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INgURED ]David Castricone Roofing & Siding Inc
,ZOO Sutton St
Suite 226
North And9Yer, MA 0184$
INSURERA: The Insurance Co of State PA
INSURER B:
INSURER G;
INSURER D:
INSURER E.
C0VFRjkGFS
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY RE;0UIREM6NT, TERM OR CONDITION OK ANY CONTRACT OIC OTHER bOCUMEN'r 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.
INBR
-Lm
OD'L
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
-
I-.ACH OCCURRENC[: $
COMMERCIAL GENERAL LIABILITY
DAMAGE- TO RL -NT ED S !�
P r"11 rc IF-' �'r=su
CLAIMS MADE El OCCUR
MCD CXP (Any One Portion) $
PGRSONAL & ADV INJURY $
r31:N1-HAI AGrREGArL $
GtN'L AOCHEGATE LIMIT API'LIES PER.
F'KUUUC II: - COMP/OV A06 $
POLICY PRO-
JECT F7 LOC
AUTOMOBILE
UABIUYY
ANY ALTO
COMBINED SINGLE LIMIT $
(1-;3Pcndem)
ALL OWNEP AVt OS
SCHEDULED AUTOS
BODILY INJURY $
(Per person)
HIRED AUTOS
NON-DWNEDAUTOS
BODILY INJURY
(Por—cidcnl) I
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY
AUTO ONLY, EA ACCIDENT $
EA ACG $ ,—
07HERTHAN
ANYAUTO
AUTO ONLY: AGG $
EXCPSSIUMBRELLA LIABILITY
CACI I OCCURRENCE I
OCCUR CLAIMS MADE
AGGHLGATE $
S
� T y
IitVVC I'IBLk
g
RETENTION $
WORKERS COMPENSATION AND
WC9752746
09/23/2009
09/23/2010
x T U� DTH
A
EMPLOYERS' LIABILITY
ANY PRUPRIF,TURIPARTNERIESSECUfIVE
E.L. EACH ACCIDENT $ 100, 000
EL. DISEASE - EA EMPLOYEE I 100, 000
OFFICERWEMBER EXCLUDED?
11r� a', dannbc undo
SPEGIAI. PROVISIONS below
E.L, DISFASF - POIJCYLIMIT $ 500,000
OTHER
OESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Alt "ULLJLK CANCELLATION
SHOULD ANY OF YHE AflOVE DESCRIBED POLICIES 0E CANCELLED 9EFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, IYS AGENTS OR RpPRESENYATn'E5.
AUTHORIZED REPRESENTATIVE �y� �
5tace B'6b-"
�
rice PKG I6 1�-C��V••K+'•—
ACORD 26 (2001108) nACORD CORPORATION 1988
�r Board of, Buildin" Re-ulutions and titnndurtl�
- construction Supervisor
5pectaliy License
License: CS SL 99350
Restricted to: RE,WS.i°4
DAVID CASTRICONE
31 COURT STREET
NORTH ANDOVER, MA 01845
Expiration: 1'2/1612011
l ninii..iun,r
Tr.: 99358
._-iu; Lr:ytrr6Ytfa/l.cut:cr.r//t. n/..',,,,/.(,rucac,/uidellJ
k Board of Building KegulatioiSs and St:unl;u-ds
HOME IMPROVEMENT" CONTRACTOR
Registration: 104569
Exp •afion:7/14/010 Tril 270265
Type: Private Corporation
DAVID CASTRICONE ROOFING, SIDING &
David Castricone .
200 SUTTON ST SUITE 226 7"
NORTH ANDOVER, MA 01845 Administrator
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