HomeMy WebLinkAboutBuilding Permit #690 - 66 HAY MEADOW ROAD 5/1/2006of N� oTM 7b
,SgACHUSEt
Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received:
IMPORTANT: Applicant must complete all items on this pale
LOCATION (�C� l ��� Ka
Pri nt
PROPERTY OWNER c5' -T UG le U gx, () �--
Print
MAP NO.: PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
die family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
epair, replacement
❑ Assessory Bldg
10.
❑ Commercial
❑ Demolition
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Please Type or Print Clearly)
OWNER: Name: 's -TL u Phone3�g
/Signature
Address:
31,V\ �� ��-! G� Phone:
CONTRACTOR Name: �
Address: c3 � ` �GC g55� -,W ,4 S S
Supervisor's Construction License: 0G�/2 � Exp. Date:
Home Improvement License: [,� b / Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: Q0.00 PER SI000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost :$ &,764 00 x10.00=FEE:$46 2. ga
Check No.: rZ % Receipt No.: A16 `z -
Pal >e I of 4
TYPE OF SEWARGE DISPOSAL
Tanning/Massage/Body Art ❑
Swimming Pools
Public Sewer
n
Tobacco Sales
Food Packaging/Sales
Well
❑
Permanent Dumpster on Site ❑
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with un gisterec contractors do not have access to the guaranty and
Signature of Agent/Owner . Signature of ContractoYamip'ed
S z.�
Plans Submitted Ellans Waived Certified Plot Plan ❑ ars ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT - ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
DATE REJECTED
M1
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
DATE REJECTED
11
DATE REJECTED
HE
Comments
Comments
Water & Sewer connection signature & date
Temp Dumpster on site yesno Fire Department signature/date
r
Building Permit Approved and Issued by: L 1
Page 2 of 4
107
701
DATE APPROVED
DATE APPROVED
DATE APPROVED
Building Setback (ft.)
Front Yard Side Yard
Rear Yard
Required
Provided Required
Provides
Required
Provided
DIMENSION
Number of Stories:
Total land area, sq. ft.:
NVIt15and UA1A—
Page 3
Created 1MC. hn2006
Total square feet of floor area, based on Exterior dimensions.
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
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
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 DEPARTN'IENT:13PEORM05
Page 4 of 4
Location
Y P
No. 61f O ` Date S-116
TOWN OF NORTH ANDOVER
A
Certificate of Occupancy $
'7 b' •°''<�' Building/Frame Permit Fee $_
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ / 7'
Check # 1,2,7t-
19
,27t -
19 162 1 A
l3ililding Inspector
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work, shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
j l) 1 Y% 0
✓&J5 (--t^
Fire Department Sign off:
Dumpster Permit
of Facility)
Slign#Q of Permit Applicant
Date
- Restricteds 00 ���#
JOHN -W LANZAFAMFz� ,
30.TEMPLE DR`,%` /
METHU.EN MA
Commissioner
Boa_ s ` �72cg itt`t%ons an.' Stand trds
F HOME IMPROVEMENT CONTRACTOR
4
Re
gtstratioiF ,137C57
t �rvExpirafran� tD1212006
iYp DBC
ALL UNDERL>tiROOF '
OHN
�T- p --C o���iaaaacleuoei1a
!
BOARD OF BUILDING. REGULATIONS j
CONSTRUCTION SU
IL j
u,
ILtcensa
"Number069120
f
Othdate� 04J03/1959
!
Ezpires.'..04/fl3/Q 7 Tr. n'o: 1'0500,
- Restricteds 00 ���#
JOHN -W LANZAFAMFz� ,
30.TEMPLE DR`,%` /
METHU.EN MA
Commissioner
Boa_ s ` �72cg itt`t%ons an.' Stand trds
F HOME IMPROVEMENT CONTRACTOR
4
Re
gtstratioiF ,137C57
t �rvExpirafran� tD1212006
iYp DBC
ALL UNDERL>tiROOF '
OHN
an+1 Standarus
lugHUME_IMPROVEMENT CONTRACTOR .
Registratio:, 137057
Expiration::. 101212000
Typp DBD:
i'.
ALL UNDER,---,,.Ir- ROOF 1...
NAPE a'-.
JOHN
166 A IMERVRACK ST:; � .
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El ectricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual): Au_ V4 /JLz�4 GSI C IF6 Qhs
Address:_ ,-_'�c>
City/State/Zip: 8 ,�= V.% cJ OJ 4144 . Phone #:
Are you an employer? Check the appropriate bog:
1 O`Iam a employer with
4. ❑ I am 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.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
'--j -rt ....... .;, ���«�, oox s► must also nit out uie 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.
tContractors 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:
Policy # or Self -ins. Lic. #:-4w C 1?() l> Co (4 U ( ZJ u 3 Expiration Date: I i 9 1 Q b
Job Site Address: �*oi k) City/StatelZip:_/� �-
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
3f 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.
l do hereby certify under the ins and penalties ofperjury that the information provided above is true and correct
3i ature: ZA
/ Date: L/ %ZYA
'hone #: °l 7,.1 .13
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
6. Other
Contact Person:
3. City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phone #:
BUILDING CHECKLIST
Instructions: This form is used to verify that all necessary approval/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law,
regulations or requirements. ALL SIGNATURES ON SAME CHECKLIST -we will not accept separate forms.
BUILDING ADDRESS: l�� l>Gf(i Map Lot
OWNER'S NAME:_
OWNER'S ADDRESS:'~`°'
APPLICANT'S SIGNATURE: PHONE: � -� I J - IJ
TAX DEPARTMENT (62 Arlington Street):
Authorized Signature:
TREASURER'S OFFICE (62 Arlington Street):
Authorized Signature:
HEALTH DEPARTMENT (11 Spring Park Ave.)
DESIGN APPROVAL:
DISPOSAL WORKS PERMIT
Date:
Date:
Auth. Signature: Date:
SEWER DEPARTMENT (1196 Lakeview Ave.) Sewer Available: =Yes _ No
1196 Lakeview Ave.
Sewer Entrance Permit: Auth. Signature: Date:
WATER DEPARTMENT (47 Hopkins Street) Water Available: =Yes _ No
(Kenwood -Town Hall, Clerk)
Connection Permit: Auth. Signature: Date:
FIRE DEPARTMENT (488 Pleasant Street):
:Authorized Signature:
ENGINEERING/PLANNING (11 Spring Park Ave):
Date Lots Released
Authorized Signature:
Date:
Comments: Date:
CONSERVATION COMMISSION (11 Spring Park Ave): Order of Conditions:
Necessary permits filed and appropriate erosion controls proposed
for earthwork or topsoil removal greater than one (1) acre. _ Yes _ Not Applicable
Authorized Signature:
Comments: Date:
DEPARTMENT OF PUBLIC WORKS (833 Hildreth Street):
Auth. Signature: Date:
CERMFIC A TE OF UAMLITY INSU-ltAN%W-E
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Chi=uneys Residential & Commercial Roofing
CHIMNEYS POINTED -REBUILT -CAPPED
Siding,f Roof Leaks Ex erta '
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1 -800 -WAIT -4 -US IKOm �� wacm ve —CvAAs
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Job Name
Job Location
All Types Of
Expert Masonry Work
Licensed & Insured
License #034200
We {Nark year Round
�Date
/
Job Phone
City, State &Zip Cone„ ,J g T � A
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of.
Dollars ($ d'/2'4" J )
All material is guaranteed to P as specified. All work to be completed in workmanlike
rkmi e
manner according to standard practices. Any alteration or deviation from specifications
ome an
low involving extra costs will be executed only upon tint gent upon strikon orders, and will s, arc dents
extra charge over and above the estimate. All agreements
or delays beyond our control, Owner to Our workers are fully covered by Workmen's carry
rCompensation Insurance. e, tomao other necessary insurance.
We hereby submit specifications and estimates for: S1VV 1
Authorized
Signature:
NOTE: This prWsal may be
withdrawn by us if not accepted within_ days.
Ol Install 3 feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley. if roof is gagRo, we will apply conventional ice and water shield
( ) ft. high in the same locations previously described and tar paper will cover the
remaining bare wood. Any rotted or damaged boards will be replaced at ( ) per linear ft.
/or ( ) per sheet of plywood.
O/ Install heavy gauge aluminum drip edges along every edge surface of each roofline. J14- .rz,�,
►d Cover entire roof (s}vriik year all asphalt, non -fiberglass, premium grade shingles
(Color of choice).P?TCC:5-S,1au0C'S 3s4/1
Replace all pipe boots where possible.
O'Seal all flashings with clear Geo -Cel sealant. No black tar unless previously applied.
Remove all work-related debris.
Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under j
normal circumstances.
Local current references and proof of workman's compensation insurance gladly given.
j
�Remarks:
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Acceptance of Proposal -The above prices, specifications
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment Signature:
will be made as outlined abov . Q n
V , � 7, / , — Signature: —
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