HomeMy WebLinkAboutBuilding Permit #84 - 625 GREAT POND ROAD 8/1/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: OQ Date Received
Date Issued: -9' 1 —
IMPORTANT: Applicant must complete all items on this page
LOCATION 6I"y
not
PROPERTY OWNER t CYL O i
.-
Pant -
MAP NO: (0 �) PARCEL: ZONING DISTRICT: 'Historic District
Machine Shop Village
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yes no
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
_AJIetEgion
No. of units:
Commercial
(;Re:,Jair'i,,,replacement
Assessory Bldg
Others:
on
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
OWNER: Name:
Address: WS
tion Please Type or Print Clearly)
i IBJ
10 04 qm� 0,
Phone: � �1 - (094- oo)..-3
F
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CONTRACTOR Name: �1��-�� .� Phone:
Address:
JII l IPS'"
j
Supervisor's Construction License: Exp. iDate:i� t `
Home .Improvement License Exp. 'Date:
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: $ 000 FEE: $
Check No.: 7- 3 k Receipt No.: l 3
NOTE: Persons contracting with unregistered contractors do not have access to thgguaray4fund
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 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
❑ 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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
IHEALTH , Reviewed on Signature
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 signatureldate
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
MGL Chapter 166 Section 21A --F and G min.$100-$1000 fine
IM
NOTES and DATA — (For department use
❑ Notified for pickup - Date
. ........... . . . ........... . . ......... . . . . . ........ . ...... . ......... . ..... . ........... . .. . .. . ....... . ............... . . ................... . ..................... . . . .................. . ............. . ..... . . . . .............. . ............ . . . . .. . .......... . .............
Doc.Building Permit Revised 2008
Location zoec-?r 44e-pt7— A4W 7,11"
No. Date
e-) -z n -
Check # 1�14T
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Buildi ng/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
2 1 380 �CBuilding �Inspector
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Mr Vince Rubin
625 Great Pond Rd
North Andover MA, 01845
(978) 697-2023
ROOFING ESTIMATE
carpentry I painting; roofing igutters
203 WASHINGTON ST. #256
a SALEM, MA 01970
PHONE: 978.745.8745
FAx: 978.745.3476
SALES@ PRESERVESERVICES.COM
Date Bid: 5/6/2008
Estimator: Sean O'Connor
Keep the existing copper valley if possible.
PRIOR PREPARATION
PERMITTING: All permits will be obtained in accordance with the law as required.
DISPOSAL: A dumpster will be placed in a area designated by the homeowner.
ROOFING PREPARATION
COVERING: Tarp the exterior of the house so as not to damage the siding.
SHINGLE REMOVAL: Remove all layer(s) of old shingles
NAILING: Re -nail roof decking as necessary.
CARPENTRY*
Replace 1 board butting up against the roof on the rear of the home.
On the front of the house on the wall to the right of the front door. Install 1 wall length hard at the base
of the stucco. Replace 3 vertical boards off this pieces. Pine/spruce 2 x 8.
Patch stucco in the front of the house with a patch. It is not a long term solution. Paint the effected
areas.
Replace upto 6 pieces of plywood
Re -attach gutter on the rear of the house that fell down. The crease will be notieiable when it is done.
UNDERLAYMENT
FELT: Install 15 lb felt on all areas not covered by ice and water shield.
n
ICE AND WATER SHIELD: Install 3 feet of ice and water shield on eves and valleys. Install as
necessary on other areas.
DRIP EDGE: Install drip edge on all perimeters.
WALL JUNCTION: Install or rework flashing where the roof meets the wall.
VENT PIPES: Install new boot or flange around vent pipes.
CBDO NEY(S): Install or rework the flashing around all chimney(s).
VENTILATION
RIDGE VENT: Install ridge vents.
ROOFING MATERIALS
ASPHAULT SHINGLES: Install architectural shingle.
PRICE $10000 including Labor & Material
Payment Terms: 20% deposit (day of start); 30% progress; 50% end of job McNisa/Amex
Sean O'Connor r
Customer Signature
Additional to above estimate:
Patch all the stucco not specified above. Bondo rotten wood. Prime patched areas. Paint the stucco and
all brown boards butting up against the stucco 1 full coat.
Price $2600 Price including Labor & Materials
0
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£6
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The Commonwealth of Massachusetts
Department of Industrial Accidents
�a``" ;• !
Office. of Investigations
600 Washington Street
Boston, MA 02111
c_' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
pplicant Information dl_*� Please Print Legibl,
Naive (Business/Organization/Individual): 11 �
Address: 02x) 2) W 041�N
City/State/Zip
0
-�-
',J J-YICI �
Phone #: 4 l _ -AAS_
— P -4S
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4/1?;—Lam a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
required,]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
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
8. ❑ Demolition
9. ❑ Building addition
10. [1 Electrical repairs or additions
11.❑ Plumbing repairs or additions
1 Roof repairs
13.❑ Other
'Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
+ Homeowners who submit !'his aiidavii indicaiing they are duiug ail work aiid then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached 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 Name: \J �^ /
Policy # or Self -ins. Lie. #: 3 10'000 301 Expiration Date: � 0 az I ��
Job Site Address: 6a-� 1 Ld 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 required under Section 25A of MGL c. 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify u er the pains pe !ties of perjury that the information provided
above is true and correct.
Signature: _ Date: P v" 6 6 0 1` 0 0
Phone
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 Clerk 4. Electrical 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, 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 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' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) 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 cavy workers' compensation insurance. If an LLC .or LLP does have
employees, a policy is required. Be advised that this affidavit may 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 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 burn leaves etc.) 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
t7J/ J1/ Lt3ut1 LL: t7ts bl /J54U4b11
t'UNIL 1N5URANUL PAGE 02
4/1/2008 9:11:50 AM
876a ® 03/03
ISSUS DATE 04/012008
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06/10/2008
PROBER (781)449-6786 FAX (781)"9-4269
BOYNTON INSURANCE AGENCY
72 RIVER PARK STREET
NEEDHAR, NA 02494
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLIC BELOW.
INSURERS AFFORDING COVERAGE NAIL I
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DBA Preserve Services
Z03 Washington Street,PZS6
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INSURER A; Max Specialty
INSURER& Hartford Insurance
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THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
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10 DAYS N mmw N0710E TO THE CERTIFICATE HOLDER NAMED ThTM M LOT.
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