The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #375 - 72 LISA LANE 11/13/2007 NORTH BUILDING PERMIT 0 ,Lao 1 V6 TOWN OF NORTH ANDOVER * *' APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received "°�gArAD a gsSACHU`�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 12, _ t SA l elnt ' Print PROPERTY OWNER on�t Jr t I Z m Print MAP NO: PARCEL: ZONING DISTRICT:_ Historic District yes no Machine Shop Village Vires`" 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 r Water/Sewer f e r � DESCRIPTION OF WORK TO BE PREFORMED: j ►�c�v� F�STidtlGa�� S1�rne GLS t\ 1-y _ Identification Please Type or Print Clearly) OWNER: Name: COQ S M �� Phone: Address: 2 Li 519 E CONTRACTOR Name: 7`?c- Phone: ` e70 ` r Address: 1 hs ylletl y Supervisor's Construction License:_ exp. Date:VAOO Home Improvement License: Exp. Date:, £' ` 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: 000 . CO FEE: $ oc�✓ / Check No.: "I� Receipt No.: c J23 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund lgnature of Agent/Owner Signature of contractor J 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 2.2007 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 i INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS f DATE REJECTED DATE APPROVED HEALTH COMMENTS b Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT -`Temp Dumpster on site yes no Located at 124-Main Street Fire Department signature/date ` 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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Location No. +5' Date �,4 NORTH TOWN OF NORTH ANDOVER F n 9 Certificate of Occupancy $ MSS tBuilding/Frame Permit Fee $ Foundation Permit Fee $� Other Permit Fee $ TOTAL $ Check # `� 20790 Building Inspector \ The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations d 600 Washington Street A, Boston, MA 02111 w , M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): v L �Vlba9rv(riz-- Address: City/State/Zip: Phone.#: a^Z f3 ^ s7 ,-_>-1 J 3l3 Are,you an employer?Check the appropriate box: Type of project(required):, 1.&1 am a employer with 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' y p �'• 9. E]Building addition , [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:__ 3'bt c � n( �OrtU47 Policy#or Self-ins. Lic. #: VV(2 16 7_7 -7 Cl Expiration Date: Job Site Address: 2- 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 Investi ations of the DIA for insurance coverage verification. I do hereby erti under the ins d penalti s of perjury that the information provided above is true and correct. Signature: Date: 11/13/ep _ Phone#: 47l"; v 5- qv-313 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 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector - 6.Other i 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 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,opera'te�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 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 bum 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 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 1122-06 Fax# 617-727-7749 wv.mass.gov/dia 11/13/2007 10:18 FAX 9785572130 nicueLuu AVrro nuol— _ OP IDC DATE lxM/DorvrYYl 13 07 ORDa CERTIFICATE OF LIABILITYTHNSU FRANC A77—E—IS SUED A. AMATTER OF INFORMAtION IAC ONLY AND CONFERS NO RIGHT:I UPON THE CERTIFICATE PRODUCER HOLDER.THIS CERTIFICATE DE CS NGT AMEND,EXTEND OR Z+liohaud r Rose And Ruscak Ins. ALTER THE COVERAGE AFFORI IED BY THE POLICIES BELGW. 198 M,as;achusetts Ave EN, North Andover NA 01845 INSURERS AFFORDING COVERAt.E _Phone:979 688 8829 SaX:979 g57 2130 INSURER A: er.6""d Nutuol Ineus.nco Co. IN/URS INSURER& AIRezican Into',>na�nalCOS Dean L�Coftic �ldinq INSURER C; Acballa erotoatioa XV-4eo. tl19 Bo l r INSURER Haverhill al 01632 INSURER E: COVERAGES ISSUED TOTHE INSURED MAY 1 T46 POLICIES OF INSURANCE LISTEDBEL OF ANY CONTRACT OR OTHER DOCUMENT WITH ESo LIT.T E TERMS.EXTwisCERTIFICATE Ua O WH OHS AND CON I TIONS OF SUCH ANY REQUIREMENT,TERM OR CONDITION0 HEREIN 15 MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRY PAID CLAIMS,SUBJ UNITS RIBE POLICIES,AGOAGGATE LIMITS SHOWN MAY HAVE SEEN REDUCED DATE MPAf —POLICY NUMBER DAT E/.:"OCCURRENCE •1000000 EOf NSU L NS -w 1IIRNE Tv11ERTE�'� $50000 GENERAL LIABILITY PF I:MISES Ea xwrow COMMERCIAL.oENERLIAOITC8p0130513769 XP(MY sMI ) CLAIMS MADE ❑OCCUR 05/17/07 05/17/08 PI IISONALBADV INJURY 510 0000 A X Business Owners GI 4ERALAGGREGATE $2OUuUuw PI )DUCTS.coNmlop AGG x2000000 GEWL AGGREGATE LIMIT APPLIES PER: POLICY P O LIC g 100000 C:MBINED SINGLE LIMIT AufOMOML9LIAIMIT/ 02/18/07 02/18/06 l('=dderol C ANY AUTO 35033400002 B;OILY INJURY 6 ALL OWNED AUTOS (I`Q Person) X SCHEDULEDAUTOS S OILY INJURY $300000 HIRED AUTO$ (I-,recddem) NON4WNED AUTOS F OPERTY DAMAGE $100000 / RO ONLY-EA ACCOENT f i GARAGE LLWUTYEA ACC i ( 'HER THAN AGG 3 TO ONLY: _ ANY AUTO : I"CH OCCURRENCE EXCESSNMBRELLA LIABILm i A;ORGGATE 3 OCCUR CLAIMS MADE E I $ 1 DEDUCTIBLE t i RETENTION S TORY LIMITS ER I yy0WjRSCOpPENSAT10NAND L.EACH ACC[DENT S* B E pLOYERW UABIUTY ...ID 06 feeUED DI'MC'IDY ANY PROPRIETORIPARTNER/EXECUYIVE L.DISEASE•EA EMPLOYEE 4 BY A.t.G• OFFICER/MEMBER EXCLUDED? L.DISEASE-POLICY LIMIT S 11e9 doaWbe andel SMIAL PROVISIONS Delow OTHER PROPERTY 1000 I { pEgCRIPTION OF OP TIONS/LOCATIONS/VEHICLES/EXCLU810NS AODED ENDORSEMENT I'sPE01A4 PROVISIONS Project Location: 72 Lisa Lane North Andover, Ilial CANCELLATION �. i CER nFICATE HOLDER NORTHA9 SHOULD ANY OF THE ABOVE DESCRR L'D POLIGIEO at CANCELLED OEFORE THE E><RITTEN DATE THEREOF,THE ISSLNNG INSURE I WILL ENDEAVOR TO MAI DAYS WRITTEN Town of North Andover NOT 109 TO T"E CERTIFICATE KOLDEI NAMED TO TILE LEFT.BUT FAILURE TO oo SO SHALL Brian tjedthe IMPOSE NO OBLIGATION OR LIASIUr DF ANY KIND UPON THE INSURER,ITS AGENTS OR Attn. TIVES. 600 Osgood Street REPREBENtA 1 4 North Andover NA 01845 AUTN REpRESEN �ZZS ACORO CORPORATION 1988 I ' ACOIRD 25(2001108) I 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: 7 -A 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: �-ronl 0-0 i , � 6�5-0l C.L (Location of Facility) �-),67A.,44 Signature of Permit Applicant l� 13 ate i ` NORTH '9 0 of over 0' dover, Mass., • AC OC HIC HEWICK �d 0RATEO `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................. rop". ............ ...4.40 ............................................................. Foundation has permission to erect....... buildings on ........./-.2............t f,jar...........LA-e........ Rough to be occupied as............3Z � .......�.. .. .I.. It.......... .......h/.w.. �... Chimney thprovided that the arson accepting this ermit shall in every respect conform to eyri�i of the applical ono file in is office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final p� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS U TS Rough ... ........... ....................... .. Service BUILDING 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. T1 ell, W�-1-a� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registry;ion 114647 Expiration ~1'0/8/2009 Tr# 260601 �� # -Type LItd�Liability Corpor DEAN A. LACO �IC_LDGZ .REMOLDING DEAN LACOSTIQ 819 BROADWAY J HAVERHILL, MA 01832 } Administrator BOARD OF BUILDING REGULATIONS ` License: CONSTRUCTION SUPERVISOR Number CS, 060246 j •'f,Birthdate 07/29/169 I Expires A7(z9/200.8- Tr.no:. 2738.0 :' Restrict{,Oaf ' DEAN A LACOSTIE 819 BROADWAY ' ~ HAVERHILL, MA 0183,2 commi4ilpher f I Dean Lacostic Bldg &Remod, LLC Estimate 819 Broadway Haverhill, Massachusetts 01832 Date Phone# (978)521-9313 9/11/2007 E-mail lacosticbuilding@verizon.net Name/Address Mr&Mrs Smith 72 Lisa Lane North Andover,Ma 01845 978-975-7189 I Project Item Description Total Siding Quote Remove existing siding from entire house_. 21,000.00 Apply Tyvek house wrap to sidewalls. Install wide 5 1/2"Traditional Supercomers to outside corners. Install Triple 3"Smooth Beaded Soffit Panel. Install Certainteed,Monogram Double 4"vinyl siding. Custom Bend Aluminum for Windows,Doors and all Trim Work. Remove all debris from the premises. �I Total $21,000.00 Signature