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HomeMy WebLinkAboutBuilding Permit #526-2016 - 75 FRENCH FARM ROAD 10/29/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 'err Permit No#: ✓ �t� l Date Issued: l: IMPORTANT: LOCATION Date Received must complete all items on this -C^a 4 Print �p PROPllll� R Y OWNER N 4' A -t �S' �'' Print MAP PARCEL: ZONING DISTRICT 100 Year Structure yes Historic District YE Machine Shop Village YE TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building A'One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watersheds District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: /,J e4( S h�,%.�t Phone: Address: leo Contractor Name:TJ U4 Phone:__- Email Jnn)- 00 cc,A '1 Address: J 0 e!21*7 ,V1- / Supervisor's Construction License: ©�°j (2 o Exp. Date: Home Imarovement License: b S '7 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. yy L) Total Project Cost: $ FEE: $ %._. Check No.: 5B5� Receipt No.: 9h2� NOTE: Persons contracting with un gisteredyontractors do not have access to the uaraA fund 1 rj: � � 4 ,�-, Locationjrvlr,� r N — Date J Check # TOWN OF NORTH ANDOVER%% t � Certificate of Occupancy $ Building/Frame Permit Fee $�✓� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS ,a HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comm Comments Wafter & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: - _ _ Located 384 Osgood Street FIRE DEPARaTiMENT - Temp Dumpster on site eyes no., Located,at 124iMain,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 21A—F and G min.$1o0-$1000 fine Doc.Building Pennit Revised 2014 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 ,4.. Workers Comp Affidavit 4 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 OTE: 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 .rR Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/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 E: 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 ,ar Workers Comp Affidavit .re Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code .� Engineering Affidavits for Engineered products TOTE: 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 2014 O J S LL C ' m Nco U i _0 LL v 'ten N v N O LU N Z Z 0 C O v LLL t toY d' U U- O N z z m c J C t OC LL Q N Z V W W t � d' � i N LL O LU Z N s D C Ci LL 2 a W LU LU LL v CO z c v N v ai O V7 C) w CL M z m Cl) O �O Z U Cl) x z UJ O � U W LLI —j G.. Z A c4� ti ry 11 z rmi, 0o O CL CL �a J � O Z v CL U) Proposal To: Neal shapley Date 8/13/2015 Street: 75 French Farm rd. 978-973-7585 N. Andover MA Roof proposal nealshap@comcast.net Certainteed Landmark 1. Extra caution will be taken to protect house and 12. Removal of all work related debris. Planks will be landscaping as best as possible. (tarps etc.) placed under dumpster to prevent any damage to Magnets run at final clean up. driveway. 2. Remove all shingles from entire main house and 13. Building permit included. garage. Not rear low addition 14.Contractor workmanship warranty: 10 years under 3. Inspect and re -nail any loose or lifted plywood normal wind and rain conditions. Any compromised plywood will be replaced at an additional cost of $65.00 per sheet of 1/2" CDX Total roof cost: $11,000.00 fir. 4. Install heavy gauge 8" aluminum drip edge to all Certainteed 3Star extended direct MFG warranty eaves and rakes. (white, brown or mill finish) A fully transferable 100% coverage against 5. Install 6' of Certainteed Winter Guard ice and material defects for a fully non pro rated period of water shield along all eaves. 20 years. Offered to our existing customers and 6. Install Certainteed Diamond Deck synthetic included in this proposal at no additional cost. underlayment to remaining sheathing up to ridge. 7. Install all new pipe boots. 8. Install Certainteed Swift Start starter shingles to Balance due upon completion all eaves. 9. Counter flash chimney lead and all roof References available upon request protrusions with ice and water shield and seal. Highly rated member of the accredited BBB and 10. Install Certainteed Landmark Limited Lifetime Angie's List architectural shingles to entire house. 10 year material MFG. warranty. (See extended Thank you. warranty) All shingles will be installed and fastened according to mfg. specs. 11. Install new Cobra ridge vent and cap with color matched Certainteed Shadow hip and ridge shingles. Acceptance of Proposal—The above prices, specifical ions and conditions are satisfactory and are herby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature: CERTIFICATE OF LIABILITY DATE (MM/DD/YYYY) MW69E'RTIFICATE IS ISSUER AS A MATTER OF DIFdR AMON ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICA'T'E HOLDER. T11, HIS IFICATE DOES NOT AFFIRMA-TIVELY OR NEGATMELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. URTIFICATE OF INSUR=E DOES NOT CONS IME A COM'RACT BMWEEMTHE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE T M�'i3RTANT: If the certificate holder Is an ADDITIONAL MURED, the poi g1tes) must be endorsed. If SUBROGATION IS WAIVED, subject to the `=r—'5 and Condititms of the palicy, certain policies may require and endorsement_ A statement on this certificate does not canter eights to the "tet ?Tsai t¢� h�sl� Tn l€ess such endorsementfs). r-1tUDUCER CONTACT NAMM DAV IIJ E ZEL LER INS AGC'x .17I) T„ YNNWAY ftme (A/C, #a, Ext): FAX (AIC, No): LYNN, MA 0001 E-MAIL ADDRESS: ` D INSURER(S) AFFOROING COVERAGE NAIC 8 INSURER A: ACE AMERICAN WSURANCE COMPAM, BERRY, FRANK & BERRY. JAMBES DBA FR.,k K & SONS INSURER a, INSURER C, 43 VJI;rBROOIC DRIVE INSURER D. INSURER E:: EPPING,Ati3 03042 INSURER F: ' IicRAGES CER'nFICA'MMUM110 , REVISION NUMBER; O IFfATT#M Q>3aw"Ayr;sowiSSU-to SmviSltR KAMEDABOVE >FWTHE FOLCYFEWI)NOICATEA. EtQIYV 9TANDVG 41zIstl AE=tREMENT, TERM OR CiDHDY'M OF ANY COMMACT OR ! 1HM vocukt IT WM RE3FECT TD "WH TNS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THF INSURANCE AFFORDED BY THE. POILIMES DESCMVED HEREIN M 0WECT TO ALLTM TER&%EXCLUSMA AND CONAITIMS OF SUM POLICIES, LIMB SHOWN MAY HAVE BEEN REDUCED BY E'�eSt ilAf�A9. > I 43R TYPE OF INSURANCE AmoSUR L R POLCY NUMBER POL1CY£FFOATE (ltlAlDDIYYYY) POL00YEVONM (/At.DO1YYYY) Laws GENERAL LUMI17Y CCWAEPCtAL ,ENERA•_ L tABILITY H OCCURRENCE FFMt ;s AGETO RENTEDMISES (EA occurren.e) C Ath!S {t9AflE � CCCCUR. IED EXP (Any one per on) _ '. g GENT AGGREGATE- ,-M1IT APPLIES PER: ERSONAL & ADV GIJURY S ENERAL AGGREGATE $ POLICYI'fJECT �_�LOC RODUCTS-GOMPIOPAGG I; AUTOMOBILE LIAMLITY ANY AJM COMBINED ^al3IGLE LIMIT (Fa acckiw) iS ALL OV4NED ALMOS BODILY INJURY g SCHEDULE AUTQS ;Per person) HIRED AUTOS BODILY INLIURY ;$ NON -OWNED AUTOS (Pet occident) PP.GPERTYDAMAGE (P,ir BL«dsa) �S UMBRELLA LKS 0(:;,.;JR EACi4OCCURRENCE $ EXCESS LAS C:.;`:(f1S-MARE GGREGATE --.F DEDUCTIBLE RETEPtMN $ $ A i1tORKER'S COMPENSATION XVIDk* EMPLOYEWS LIABILITY Y174 nrsv sgCnEra!tORaARataEr�r xECL rIVE OF�iCcFi1A1 !ITER EXCLUDEC? {Linr�lmeryatcroll 0FSCR!PTiO3OF- OPERATIONS rie:3w fVJA US tgML434-14 A� pp L I l ``� �'C" ! 1110514014 11/0512015 uIC STATUTORY OTHER LIPiMTS E. L EACH ACCIDENT i 5 100,Qfi0 E.L. DISEASE - EA EMPLOYE Es 100,000 EL. DGEASE - POLICY LQultr S 500,000 VMCRIf TION OFL2P TTATIONSILCCA71ONSIVEIgCL=F-S3RlCTi;ZN SIPECtALITEM +91M REPIACPw ANY PRIOR CPRT1FICATE ISSUED 110 THE C RYMCXTE )JOI.DER ,SML7NG WORMS COMP COVMACM NO PAMMPS ARE C.011EtED EIV IW! INORkEPT CONVENSAITON MLIC.Y. CERTIFICATE HOLDERCANCELLATION ALL, UNDER CSNF, ROOF t 111 Tl: AADI r. Ili) RIOULD ANY OF 7HE ARM DESCftMED POLICIES BE CANCELLED 1 88:0111! Tl3E EXPteRAnnN nATF THMPnA lunl.rnr gine . n S m1. •Mt.�f�t��. �lw,�,ew _�• � ••� Yi.liyy'L.L •*u �.nav� �n� u�v nMaaaevnun J,yr �\ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Yorkers' Compensation insurance Affidavit: Buflders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ADulicaut Information Please Print Leeibly Name (Business/OrganizationtlMividual): G� kin �2 Address: City/State/Zip: h1 t`� `�'e� /M Phone #: c� Are you as employer? Caeck the appropriate Wit: 1.0 1 am a employer with employees (full and/or pan -lime).• 2.O 1 am a sole proprietor or partnership and have Do employees working for me in any capacity. [No workers' comp. insurance required.] 301 am a homoovvoer doing all work myself. f No workers' comp. insurance required.] r 4131 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance or are sok proprietors with Do employers. 5iam a general contractor and I have hired the sub -contractors listed on the attached sheet. eeerrr--- These sub -contractors have employees and have workers' comp. insurance.t 6.O We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § I (4), and we have Do employees. [No workers' comp. insurance required.) Type of project (required): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 Q Building addition 11.[] Electrical repairs or additions 12. []Plumbing repairs or additions 13QRoof repairs 14. UkM 'Any applicant that checks box ff 1 must also fill out the section below showing their workers' compensation policy information- ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a Dew affidavit indicating such. tComractors that check this box must attached an additional sheet showing the name of the subcontractors 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. #: Expiration Date: r Job Site Address: !�" City/Statc/Zip: 14n Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. 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 theme and etalties of perjury that the information provided above is due and correct _. V- P -,,�..n,��,�-t .,_.__ f 4121 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 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 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 -contractors) name(s), addresses) and phone number(s) along with their certificates) 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 arc 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 4u 4 ae Massachusetts - Depaftent of Public SafatV Board of BuildIng Regulations and Standards CkInritTSEfilin License: CS --M120 10A 30 -1 rjvwxx OR MTfWW MA EfFf F-Itpiration OMX2047 D 6 Click on Bie registration number to view complgitit history, You can also view arbitrate nand V Fund history, The list idcurrent as of Wednesday, October 8, 2014, REG WT 'RESPONSIBLE INDIVIDUAL R001- LANZAFAME, JOHN Search Results REGISTRATION ADDRESS EXPIRATION HUMBER DATE STATUNI 137057 '166- A MERRIMACK ST 10/0212016 METHEUN. MA 01844 V ZOI z Commonwealth of Massachusetts. mass-GovO Is a registered service mark of the COMMonwealth of Messaohusqtts.