HomeMy WebLinkAboutBuilding Permit #724-11 - 66 MARIAN DRIVE 4/29/2011BUILDING -PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: I 2�Ef / Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
`One family
Addition '
Two or more.family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement-
Assessory Bldg
Others:
Demolition
Other
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DESCRIPTION OF WORK TO BE PREFORMED:
010P -01 n* d f ataf dr¢ Aeu f t.
OWNER: Name:
PIease Type or Print Clearly)
ert-4 Phone: 17F 377 0 J'J
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: $ :Z;_b
Check No.: Receipt No.:.0
NOTE: Persons co tr acting with unregistered contractors do not have acce 0 t ar ani
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
o 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
o Workers Comp Affidavit
a 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 Gonstruction (Single and Two Family)
❑ Building Permit Application
❑ Ce llfled 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)
❑ 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: Building Permit Revised 2008
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/MassageBodyArt 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 Sigriature
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals; 'Variance, Petition No: Zoning Decision/receipt submitted yes
Plannirig Board Decision:
Comm
Conservation Decision: Comments
Wafer & Sewer Connection/Signature & bate 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 lnspecor Yes . ' No
DANGER ZONE LITERATURE: Yes No
MGL Chapter. 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Permit Revised 2010
LocationG� lll�/yh�
No. Date
NORTq TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check # /U {
24103
P
Building Inspector
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www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): .DAV i li CA3TC1(ONC ROO F i NE- 1 SI bll%i(r IN t-,
Address: ZO (j Su -TT -0,3 STR E L -T S ; T& 2 Zto
City/State/Zip: No. Am ao�ieK: NA d 1145 Phone #: 9? � 0 33 4 2- Q.
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
4. ❑ I am a general contractor and I
Department of Industrial Accidents
M YL- k
Office of Investigations
listed on the attached sheet.
600 Washington Street
:,w =
v`
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): .DAV i li CA3TC1(ONC ROO F i NE- 1 SI bll%i(r IN t-,
Address: ZO (j Su -TT -0,3 STR E L -T S ; T& 2 Zto
City/State/Zip: No. Am ao�ieK: NA d 1145 Phone #: 9? � 0 33 4 2- Q.
Are you an employer? Check the appropriate box:
1. ® I am a employer with e
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.
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.❑ Electrical repairs or additions
I 1.❑ Plumbing repairs or additions
12.M Roof repairs
13.❑ Other
'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,
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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: f i A RTA s
Policy # or Self -ins. Lic. #: Expiration Date: q a j
r
Job Site Addressk1 111 City/State/Zip: 1' 1 1 nr 4 Ai('✓ I `r 1 O)E y f
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: 2:/.3 cj-.- C Date:
Phone #: q r] % U 3Phone #: 3 J4ao
Official use only. Do not write in this area, to be completed by city or town offrciaL
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 Perso
Phone #:
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
O
6'X
Q
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V.
LA
SACHUs���y
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL c.11, s150a.
The debris will be disposed of in /at:
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector,
ACORD,. CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDIYYYY)
11/3/2010
PRODUCER Phone: 508-651-7700 Fax: 508-653-8089
Eastern Insurance Group LLC -Commercial Lines
233 West Central Street
Natick MA 01760
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 POLICIES BELOW.
SR
TR
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Citation Insurance 0274
David Castricone Roofing & Siding Inc
200 Sutton St
INSURER B: CHART IS
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Suite 226
INSURER C:
INSURER D:
North Andover MA 01845
INSURER E:
EACHOCCURRENCE $
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR. THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 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.
SR
TR
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
1600 Osgood Street
POLICYNUMBER
POLICYEFFECTIVE
POLICY EXPIRATION
LIMITS
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
GENERAL LIABILITY
EACHOCCURRENCE $
COMMERCIAL GENERAL LIABILITY
fDAMA D
PREMISES Eaoccurence $
CLAIMSMADE FIOCCUR
MED EXP (Anyone person) $
PERSONAL& ADV INJURY $
GENERALAGGREGATE $
GENLAGGREGATE LIMITAPPLIESPER:
PRODUCTS -COMPIOPAGG $
POLICY jE'COT- 7LOC
A
AUTOMOBILE
LIABILITY
ANYAUTO
BCNGCV
8/1/2010
8/1/2011
COMBINED SINGLE LIMIT
(Eaacciderd) $1r000,000
BODILY INJURY
(Per person) $
X
ALLOWNEDAUTOS
SCHEDULEDAUTOS
BODILY INJURY
(Persocidenl) $
X
X
HIREDAUTOS
NONO'WNEDAUTOS
PROPERTY DAMAGE $
(Per aecldenl)
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT $
OTHERTHAN EAACC $
ANYAUTO
AUTOONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACHOCCURRENCE $
AGGREGATE $
OCCUR F1 CLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
B
WORKERS COMPENSATION AND
WC003989723
9/23/2010
9/23/2011
X I WCSTA IU- OTRH -
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.LEACH ACCIDENT $100,000
E.L. DISEASE - EA EMPLOYEE $100,000
OFFICERIMEMBEREXCLUDED?
lips 6describeunder
SC IAL PROVISIONS below
E.LDISEASE - POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT! SP ECTAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2001 /08) m ACORD CORPORATION 1988
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
Town of North Andover
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
1600 Osgood Street
CERTIFICATE HOLDER. NAMED TO THE LEFT, BUT FAILURE TO DO SO
North Andover MA 01895
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ,
ACORD 25 (2001 /08) m ACORD CORPORATION 1988
DAVID CASTRICONE Mej.2,y1416,i
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 Baxford 978-887-6147 In HaperhiII 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,lo install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below de cribed:
(92!)
Owner's Name...... �..a 1` ..........1....1. �, f7.e 1. ... elephone #....iU2-.. Lam? 2.
Job Address ...... L.lca......
t."..Lux • ('_1�s n......... ............ City...a ../../.0 .1!e ................... State .... l.:.I/..7.'........
Specifications
Strip existing shingles. ripply new drip edge to all edges. (1�,c;rr
.........................................::............................................................................................................................................................
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.
............................................................................................
✓Apply felt paper underlayment. ri•6stall ridge vent to 1 . r . ,. �s—r21`t° .,,, o �„� . � �71 �
-Re roof using shingles with a _la_ year warranty.
......................................................................................................................................................................................................................
-Counterflash chimney. -New vent pipe flashing. -Legal disposal of all debris.
Area(s) to be worked on: /
...................................��..jl.......ii.1••......j u............. .................................................
:.....
......... ..... ..?..(..a.t.."-:........................................I................................................ .
k.. < ... .. r:»_rc........S .i .�.r ........... r......�� d.G,e7 .... % 5.... t; .�...1.
S�
6......�'............. c> 3'fi.....�....& ...........................................
Roof board replacement if necessary @ GO /sheet or r/ --/foot.
.................................. ..........................:.................. :.......................................................
........................... ....-.:,...::...............................
Two Year Workmanship Warrapty (Not Transferable) 11 knufacturer's Warranty as speck by ma��n'uffact���ur
The c ctor agrees to perform th„ work d ish the materials specified above for the SUMO .... d. L)..CJ.............
o/ ayable ... off,.,2 ?......... on . �� .......... __
Payable ...... ::::= ............. on .......... alance parable on completion of iob
Owner or Owners arc not responsible for Property Damage or Liability whir�n is in operation.
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 wails, crumbling plaster, exposed nails, dust in attic or other living
spaces). Items in attic may need to be cover; 1 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
Weed that, if permitted by law, contractor s ;all be paid by the owners) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that
shall be incurred in enforcing the terms and :auditions 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 warrant(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
warranties, 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..,.✓ :.....�,p..% .......:. Completion date..... ..... .............
Receipt of a copy of this contact is hefeby aclrnowledged, and it is further acknowledged by thc-4ndersigned 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 alli 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 ...r day of ..]V:�%a........, 20....{.d...
Accepted:
Signed ........ku i�'.
............. \ ........Owner
Signed............................................................................. Owner
David Castricone, President