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HomeMy WebLinkAboutBuilding Permit #509 - 72 BLUE RIDGE ROAD 1/16/2007TOWN OF NORTH ANDOVER I►ORTIy APPLICATION FOR PLAN EXAMINATION 0E4.�■� �.1tia O Permit NO:50� Date Received +' Date Issued: — 0� 1Ss�CHUS�� IMPORTANT: Applicant must complete all items on this page LOCATION % 3 1 V C 2% J 21 to S Print PROPERTY OWNER S ��.t�v + Li S A L-, 3sZ: G, U Print MAP NO.: (IS PARCEL: 106 ZONING DISTRICT: It, —� TVPF. AND ITSF, OF RUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE 5+f -'/e- LC �Z � G4yt Phone: `-7%- 61W Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration 'One family ❑ Two or more'family No. of units: ❑ Industrial IkRepair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESnCRIPTION OF WORK TO BE PREFORMED 1`� ter ` q � 'L � i ✓`� �j yr '�` , S i 1 r .l al �1 1N � 1 2-' �h b� lrmo-/4r OF kovSf Identification Please Type or Print Clearly) OWNER: Name: 5+f -'/e- LC �Z � G4yt Phone: `-7%- 61W Address: Address: 5 'A P \ 4 ton/ J` CONTRACTOR Name: �t T� S -i- � Phone: Address: 5 'A P \ 4 ton/ J` yU �, 2 ►� A of c2 Supervisor's Construction License: C S o CH 71$ Exp. Date: (a / -6 1 -.) o o C? Home Improvement License: I ak o aq 6 Exp. Date: tI 111 I a 00-7 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost :$ 0, 50 FEE:$ 5�; �- Check No.:—3 0 5 I Receipt No.: 19 J? Page I of 4 Location�r�t•r�C No. Date % 9�- 40RTN TOWN OF NORTH ANDOVER L D Certificate of Occupancy $ 's • E�� cNus Building/Frame Permit Fee $ ~' s� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # , ! 119,967 Building Inspector TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art E] Swimming Pools 11Public Sewer �, Well F1Tobacco Sales ❑ Food Packaging/Sales ❑ F1 Permanent Permanent Dumpster on Site ElPrivate (septic tank, etc. Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor Pch� L�� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS X DATE REJECTED 0 DATE APPROVED DATE REJECTED DATE APPROVED ❑E DATE REJECTED DATE APPROVED FERE DEPARTMENT - Temp Dumpster on site Fire Department signature/date COMMENTS Q yes n --e Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Sienature & Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required 4— Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 1VUTLJ and VATA A — Wor department use Page 3 of 4 SERVICES Created JMC. Jan.2006 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 Dec: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 m m x m m m mm c CA d CA CM) 'O O n Z CA CCD O 'O. CL C CL _• y aCC2 v o v CD d� O c� CD CCD O CD C co CA �. co CZ 0 CO) —• O tt] C V J n O cn I C c m -4O -• ,)3v o Q N. rn go &a ,� O O C'! o yC2aC m Ma CD O O N p N O ?m O = to �p = O 0 .c: N CI• C09 1 O c ?y�:C um o = CD m O N CD 0 CD CL 10 °-• N O d N C=A Q H �q ,. i CD ' N CA + m d tONcm . = CD CDCD o ='• CD O ...► : � m co) r _ m o o� a'o_ o ^: � o c_VwAlb k.: O � � _ c cw o z 0 z C7k o x z n rt c gn] P O C ►s TESTA Building and Remodeling 5 Appleton Street North Andover, Ma 01845 (978) 682 2023 Proposal Submitted To: Lisa and Steve LaBrique 72 Blue Ridge Road North Andover ,MA 01845 Job: Install new windows and new Siding Proposal November 10, 2006 Home Phone: (978) 686-4023 Cell Phone: (978) Job Description: Obtain building permit Complete removal of all demolition and construction materials generated by Testa Building and Remodeling and its subcontractors. CONSTRUCTION: New Anderson windows for the front of the house only. Insulate with new trim for the inside of the windows. New Anderso rest —U a windowsIn the house . Strip and Tyvek the front of the house. Reside the front Of the house with new primed solid cedar clapboard. The comers will be P V C plastic wood and the facia and soffet will also be P V C plastic trim. P V C trim around the Windows with a sill. New P V C trim around the dormer And new siding on the dormers $15,050 —oft 9'r $ 15,200 A finance charge of 11/2% per month (18% per year) Ml apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection, including reasonable attometfs fees. I propose hereby to furnish material and labor complete in accordance with above specifications, $ Depends on options that you choose -Z - j O 7 S-0 One-half to start one-half upon completion. Authorized I reserve the right to cancel this contracted not accepted in -30— days Signatu Signature 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: -71 1& t jr- v -s .4 , (LA- 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 I OA. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit (Location of Facility) Signature of Permit Applicant Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:—57 A p p) {, k -o ^j S+- City/State/Zip: N© A ,.`J A o%t t2 Phone. #: R1<b-- Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I EXT (full and/or part-time).* have hired the sub -contractors r 2. Ib i am a soleproprietor or partner- listed on the attached sheet. ship and have no employees 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 These sub -contractors have employees and have 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. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.❑ 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 and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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. M Expiration Date: Job Site Address: 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. I do hereby certokunder the pains and penalties of perjury that the information provided above is true and correct Phone #: / x5— D-- O 3 use only. Do not write in this area, to City or Town: or town official Permit/License # I /')'-/0-T 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 l--------�_ - �__ ---- u, ung egu ati"o'iis au tanc ar s iJ 13o0'il ! op � HOME IMPROVEMENT CONTRAC70R �.. Registration' 120296 ra{ion 1.111912007 Expf TESTA BUILDING g REMbtSLiNG � 3 xtt i ,LAMES TESTA `- TREET �, ,� �, �✓ ':. 5 APPLETON Su_s Administrator j N.ANDOVER, MA 01845 `"' t �- BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR NumbeS:CS 054718 r' Birthdate ; 06%08/1965 i Expires 06/08/2008 Tr. no: 145.0 Restricted 6o JAMES M TESTA,. 5 APPLETON ST F N'ANDOVER_ , MA 01845 w" • Commissioner 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-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 carry 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 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 604 Washington Street Boston, MA 02111 Tel. # 617-727-4400 ext.406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.govldia