HomeMy WebLinkAboutBuilding Permit #261-11 - 660 CHICKERING ROAD 9/27/2010 BUILDING-PERMIT
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION o
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Permit NO: Date Received
Date Issued: SgcHuse
IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition ' Two or more.family In rial
No, of units: Commercial
Re air re lacemenf Assessory Bldg Others:
Demolition _ Other
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ESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please T e or Print Clearly)
OWNER: Name: I - - �. Phone:
Address:
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`_'x-w•-.- rr
No. Z Dateof �v
NOR71y TOWN OF NORTH ANDOVER
10.?'• • Oj° '�M
S
a ; ; Certificate of Occupancy $
Mutt�'• Building/Frame Permit Fee $
s�cs
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
254 � 6
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISP7Tanning/Mas
Public Sewer sageBodyArt swimming Pools
WeIIacco 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 APPROVE -
D
PLANNING &:DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
C0IVI1v-1EN 1 S
HEALTH Reviewed on Signature
r'
COMMENTS
ti "
Zoning Board of Appeals:.'Variance, Petition No: Zoning Decision/receipt submitted yes
Plannirig, Board Decision: Comments
Conservation Decision: Comments
Wafer & Sewer Connection/Signature Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
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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 m1n.$100-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup- Date
Doc.Building Permit Revised 2010
Building Department
The following is*a fist of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Inferior 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
❑ 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
❑ 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:Building Permit Revised 2008
ORTH
TO'" of
Andover
_ LAKE �`- dover, Mass., ' a� •�� _ .
COCHICHEWICK
"meq A0 ATED
`S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT ,1,�I�4r ... ..............a.,
..................................... Foundation
has permission to erect.................................... buildings on ...4.0..0......... I�'/!!!. .... ............ .. �...... Rough
to be occupied as...... ''� ..................... ..... ............ A.A.AU. ....... ? �1 imney
h'
provided that the person ecce ting this permit shall in every pact conform to the terms of the application o file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
S
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTR O STARTS Rough
..... ....................................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected' and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Massachusetts - Department of Public S.tfetr
9 Board of Building Regulations and Standards .j
Construction Supervisor Specialty-License
License: CS SL 101787
Restricted to: RF,WS
DAVID VERONESI '
83 SUMNER STREET
BROCKTON, MA 02301 j
Expiration: 7/1'J2012
(unmrissiuner Tr#:•101787
i.—_—'..-__.._ . .� ✓� -C/JOOTI//9I0�/"LC!/cu'r^'�" O�.."".'"""CGC1' �tt
Office of consumer Affairs&Business Regulation 4
HOME IMPROVEMENT CONTRACTOR
Reg istration .
- :.-164867
Expiration::`;-=1-1[_1912011 Tr# 290797
Type . poration
t
COMPLETE COVERAGE INC_.;
DAVID VERONESI
83 SUMMNER ST'
BROCKTON, MA 02301: Undersecretary
d
COMPLETE COVERAGE, INC.
45 Robbins Ave Estimate
Abington, MA 02351
pit# 508-328-5780 Date Estimate#
fx# 781-857-2407
4/18/2010 100
Name/Addresb
PI,Squared,Inc
187 Page street,r3ldg N9
Stoughton,MA 02072
NV 781.297-9536
Description Total
.rob Location: McDonald Roof,,660 Chickering Road,N.Andover MA
1. We will strip/remove the entire shingle roof down to plywvud mid re-nail any loose wood. 12,595.00
2. We then will install Y ice water shield on bottom perimeter, balance of roof will be 15#felt paper.
3. Any trotted wood will be an extra charge of$3.00 per square foot.
4. Then we will install new 8"white alunihium drip edge on fuscia.a.nd rake boards.
5. After drip edge is installed,we will install 30-year Architectural shingles make by Certainteed,owner to pick color.
6. New ridge vent will be installed and capped over with Shingles.
7. Complete Covcragc will tarp house during cunstruction and will run magnet when finished.
B. We will supply dumpster,materials, labor,insurance and also permit,
9. 30-year warranty.
All material is guaranteed to be as specified, All work to be completed in a.workmanlike manner according to standard .
pinetk;cs. Any alteration or deviation from above specifications involving extra costs will be executed only upon written
orders and will become an extra charge over and above the estimate, All agreements contingent upon strikes,accidents or
delays beyond our control. Owner to carry fire,tomado and other necessary insurance. Our worker's arc fully covered by
workman's compensation insurance. The above prices,specifications and conditions arc satisfactory and are hereby
accepted. You are authorized to do the work as specified, We propose to furnish material and labor-complete in
accordance with above specification,for the sum of:
Thankyou for your business.PAYMENT DUE UPON COMPLETION. Total $12,595.00
Company Signature
Customer Signature
&Date V/1101
The Contmanivealth of Massackrtsetts
ter.- Department of Industrial Accidents
Office of Investigations
�•,,�' �' 600 Washington Street
Boston,/VIA 07111
may,'
w)Pw.mass.gov1dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Name (Bus iness/Organizaatntion/Individual): r•-, (� t--- ,
Address: q S t g&62 1 ,L V
City/State/Zip: L U Phone M — 3.2 — 3 �6
Are you an employer?Check the appropriate box: Type of project(required):
E9
1. am a employer with S 4• ❑ I am a general contractor and 1
employees(foil and/or part-time).*
have hired the sub-contractors f' ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plu ing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. oof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*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.
Contractors 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.
1 aur an employer that is provitling workers'contpettsation itrsttrtntce for niy ettployees. Belo►p is the policy attd job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M 1 ►4 Expiration Date: �f
Job Site Address:--(Q(o CLC. t P E f 9 City/State/Zip: a n < J
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 cert' raider the pains a eitalties fperjrtry that the iaforivatioa pr•opided above is r•tte acrd correct.
Sienature: Date: a 1
Phone#: 3 Z(i 3 S-0
Official ttse,only. Do not sprite in this area,to be completed by city or town offtciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health Z.Building Department 3.City/Town Cleric 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 eutployee 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-contractor(s)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 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 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 permitAicense 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.
Tile 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
09/1612010 12:05 5086953957 G: GILMORE INS PAGE 01/01
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