HomeMy WebLinkAboutBuilding Permit #850-12 - 667 FOREST STREET 5/31/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Q �v 1- Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this Daize
LOCATION 4,67 rover 6�_. Nd
Print
PROPERTY OWNER PPS114DIN,
Print -
MAP NO: / PARCEtQd ZONING DISTRICT: Historic .District yes no
Machine Shop Village ves - no
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
Septic 'Well
Floodplain Wetlands
Watershed 'District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
5772/i /wg D nob{ Lur rh'
Identification Please Type or Print Clearly)
OWNER: Name: Jost-pN pi-9!!r-� Di/vo Phone: 91 - G ems-
Address: 11417 Fo 2CST" 6r , NO 1*91y nO&/� /L
CONTRACTOR Name: RP I PA-- A- agn76 Phone: 6t7- 6 9'lO - Z 110
Address: 5-Y !'19`io17d C1r Alqvye '01elg1ear- . rrm. f G
Supervisor's Construction License. M/5/ Exp. Date: 7 -,3 -to 113`
Home Improvement License: !b 21" Exp.. Date: i -.z, - e2A1a0, ;
ARCHITECT/ENGINEER Phone:
n
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: $ !�� o0o, °O FEE: $ //00
Check No.: W' -,r Receipt No.: RS".3`,y
NOTE: Persons contracting with unregistered contractors do not have access t t e gu ,pvfund
reof
x
V.
Location
No
Check #
25344
Date. -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $—
Building/Frame Permit Fee $—Z��, 0,0
Foundation Permit Fee
Other Permit Fee
TOTAL
- A
/ Building Inspector
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
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
R Conservation Decision: Comments
a
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes
Located,at'24 MainStreet-
Fire Department si+gnatureTdate
COMMENTS
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
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RA:LPH-je BUR -KE
A Family Business Since 1941
Roofing - Gutters
Rubber Roofing
DANIEL X BURKE RALPH J. BURKE, JM
TELEPHONE 181-245-11-10 FULLY INSURED -.LICENSED 27 BYRON STREET, -WAKEFIELD, MA 01880
Estimated price for labor and material to:
remove all roof shingles
replace rotted/broken roof boards up to 10.0 square feet
re -hail loose boards.
install aluminum .drip ,edge.
3 feet of ice and water barrier
heavXwei.ght felt paper (30 lb.)
30 year CERTAINTEED LANDMARK Architectural
shingles, hand nailed
reflash all vent pipesand chimney
4z
e
V 'V
co
71
remove all roofing debris from the yard
Total-cos.t f12 mo.
All workmanship guaranteed twenty years.
Please remove or cover all items in attic., as
-----------------
dust and roof particles may settle on attic floor.
Thank you
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affrdawt
Name Please Print
Name: Jrise4A 19,911 d'I"ei
Location: G E02E5r 5T.
City Not -Py Phone # 9?k- 6
aI am a homeowner performing all work myself.
0 I am a sole proprietor and have no one working in any capacity
F71 I am an employer providing workers' compensation for my employees working on this job.
Company name: P01 112 H Li U 2 K C R®ofI 24
Address -.22 d gl?-ON 5ME,7'
City: W tWE Phone # 7R/ 02 VS -,l
insurance Co. ?-a 2/ C_// e- "9/y _Z/YS ale-NCG Policv # G Z Z Lee- U / 9L /`/ 41D - y'- /,2-,
Company name:
Address
City: Phone #:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00
andfor one years' imprisonmentas wettas _civil .penalties in She farm cf a STOP WORK ORDER_arid_a fine of .($100.0o) _a slay .against _me. I
understand that a copy of this stat nt may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify. �g penalties of pedury that the information provided above is true and correct.
Date
Print name( Q9 /.a f Gua K, Phone # 6 r 7 V,9 / //0
Official use only do not write in this area to be completed by city or town official'
vity or Town PermitlLlcensino
Building Dept
❑Check if immediate response is required E] Licensing Board
p Selectman's Office
Contact person: no #: ❑ Health Department
o Other
NORTH ANDOVER BUILDING DEPARTMENT
Tei: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at:
f_r r, 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: ROoG/i14 71Ti,�Sv T/Zuck
TD % P 3oyy �IZ/9rYsFF_/L <_-5maA /2r / , /i -I9Ij oy
(Location of Facility)
— 1,4ell, //,, //
ignature f Permit Applicant
Date
011te -C
Office of Consumer Affairs and Husiness Regulation
10 Park Plaza - Suite 5170
Boston, Massac setts 02116
Home Improvement r for Registration
Registration: 107146
Type: DBA
Q I ; Expiration: 7/29/2012
RALPH J. BURKE ROOFING
Ralph Burke
27 Byron St
Wakefield, MA 01880
DPS-CA1 0 50M -04/04-G101216
7/.
Office
(/J0lJLlYt012ClJeCLGUt B/
/!�(CIQQq�/tCI4e
Office of Consumer Affairs & Bi(siness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: x,,07146 Type:
Expiration: : QZ012 DBA
RA H J. BURKE amm/ t
Ralph Burk(
27 Byron St
Wakefield, R
.t
Tr# 200547
Update Address and return card. Mark reason for change.
E] Address [:] Renewal E] Employment 0 Lost Card
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Undersecretary Not valid without signature
Alaamachusems - +''Departmen=t of Public Sa et
Board of Building Re--lul:ttious and Standard
License: CS SL SM4 _
Restricted tm RE
RALPH BURKE
a
54 PADDMK LANE
DRACUT, MA 01825
cxpiratiEz.-E: 70=3
: +HOIAE>cl��flrF 18834
05/30/2012 21:49 17812462642 PAGE 01
AS -00. CERTIFICATE OF
LIABILITY INSURANCEDATE(MMA)OIYYYY)
PRODUCER (781) 245-3954
Wakefield Inaurance Agency, Inc
P -0 -Dox 557
63 Albion St
05/31/2012
THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
FALTER HE OVLDER. THISCERAGEICATE A FORDED BY HE POLICIDOES NOT ES BELOW, OR
Wakefield MA 01880-
INSURERS AFFORDING COVERAGE MAIC R
INSURED
Ralph Burke Roofing
UMITS
INSURER A.
1NSURER8:S&fet Indemnit
27 Byron Street
INSURER c: ZURICH
INSURER D:
Wakefield MA 01990-
[INSURER E�
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.
INSRADOL
Attn:
TYPE OFINSVRANCE
POLICY NUMBER
ODATF( MMSD mE
OATE DUCY m
UMITS
INSURE ITS AGENTS OR REPRESENTATIVES.
GENERAL UABILITY
/ /
/ /
EACH OCCURRENCE 6
COMMERCIAL GENERAL LIABILITY
CLANS MADE D OCCUR
/ /
/ /
OAMA S TO RENTED
P Mtle, aaurlen(:e 0
MED EXP one son 0
PERS NAL 6 ADV INJURY 0
GENERALAGGREGATE f
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY JECT Loc
PR T - p/OP AGO 1
AUTOMOBILE
UABIUTY
/ /
/ /
COMBINED SINGLE LIMIT
ANY AUTO
(Eaaeadex) 0
B
X
ALL OWNED AUTOS
SCHEDULED AUTOS
1614563
01/01/2012
01/01/2013
BODILY INJURY
(Per OerMM) s 250,000
HIRED AUTOS
NON -OWNED AUTOS
/ /
I I
BODILY INJURY a 500,000
(Per st=iOrK)
_H
PROPERTY DAMAGE 0 100,000
(Per occ"nl)
0ARAGE LWBIUTY
AUTO ONLY - EA ACCIDENT 0
ANY AUTO
F]
/ /
/ I
OTHER THAN EA ACC s
AUTO ONLY: AOG 0
EXCESBIUMBRELLA LIABILITY
EACH OCCURRENCE 0
AGGREGATE 0
OCCUR � CLAIMS MADE
f
DEDUCTIBLE
0
RETENTION
WORKERS COMPENSATION AND
EMPLOYERO' LIABIUTY
!
/
u(�
TORY UMffS 0 R
EACH ACCIDENT S 100,000
ANY PROPRIETORfPARTNERIEXECUTIVE
M
OFFICENEMBEREXCLUDED?
If ye., deearfe underSPECIALPROV1810NSDetav
GZZUD-132SCO2-3-09
03/01/2012
03/01/2013
[E.L.
L. DISEASE -EA EMPLOYEE O 500,000
A, DISEASE - POLICYLIMIT ! 100,000
OTHER
DESCRIPTION OF OPERATHNOSILOCATIONSNTWCLESIEKCLU610NS ADDED BY ENDORSEMENTISPECfAL PROVISIONS
CFRTIFICA.TF MOLnFR rwurCi I •rinU
/►wim? AD (AuuItua) a ACORD CORPORATION 1888
INS025 woe).De Paye I of 2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Attn:
EXPIRATION DATE THEREOF, THE ISSUING INSURER WALL ENDEAVOR TO MAIL
20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
North Andover Building Department
FAILURE TO 00 SO SMALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE
INSURE ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED R SENTA VE
/►wim? AD (AuuItua) a ACORD CORPORATION 1888
INS025 woe).De Paye I of 2