HomeMy WebLinkAboutBuilding Permit #401 - 82 LISA LANE 11/8/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: o Date Received
Date Issued:
I
MPORT
1ANT.Applicant must complete all items on this age
LOCATION �� I.�S� ►^Ck NC
Print
PROPERTY OWNER SIna kr Unit#
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yeOno
Machine Shop Village ye
100 year-old structure ye
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Ane family
❑Addition ❑Two or more family ❑ Industrial
❑8iteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
i®'Sep°tie Well ® oodplain , ®Wetlands ®Waters �d ict
i w i
DFSCRIPTION OF WORK T BE ERFO D•
(Identificat" Please Type or Print Clearly)
OWNER: Name: C\ _�r, Phone: g7k-5 k-130
Address:�`a 1_ �a �khL
CONTRACTOR Name:Dom Phone: Cj 2x-3 4,0 -- Q
Address: l �' v� } G �G� g16i�
Supervisor's Construction License: C5 G K� Exp. Date:
Home Improvement License: 1 �/�(� Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST 8E $125.00 PER S.F.
Total Project Cost: $ 1 n� 0 0 1 V
� FEE: $ i
Check No.
3 Receipt No.: �,
NOTE: Persons contracting with unregistered contractors do not have access t e guarantyfund
:1__= - gnature of"cont�acto k «`
I
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
o 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
VOTE: 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
IIOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
a all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
trust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Swimming Pools El
Art ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. El 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 Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Siqnature& Date Driveway Permit
DPW Town Engineer: Signature:i fi r" i
Located 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 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
J
Doc:.Building Permit Revised 2011 June/mi
1
Location 3-2— L is
No. b Date
i
P
NORTM TOWN OF NORTH ANDOVER '
Certificate of Occupancy $
SACMUSES� Building/Frame Permit Fee $
Foundation Permit Fee $
c
Other Permit Fee $
TOTAL $
Check #
Building Inspector
V4ORTH
TONM Of
O Andover ..
0 Fo. k.
No. 6� - MR x
over, Mass.,
LAKE
COC MIC ME WICK ^
ORATED C2
BOARD OF HEALTH
Food/Kitchen
Septic System
. ..P E R M IT T . D
BUILDING.INSPECTOR
THIS CERTIFIES THAT.................. �.•
••••• Foundation
has permission to erect........................................ buildings on .........$.?.►.........(1.,,s ......... arm....................... Rough
Chimney
to be occupied as.. "�.. 6.... ch' eY
...... .. . .l Q:.. .
provided that the person accepting this ermit shall in every respect conform to the terms oft application on 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
Final
PERMIT' EXPIRES IN 6 MO ELECTRICAL INSPECTOR
UNLESS V LESS C®NSTRUCTI S� � Rough
....................... .......... ...........................................................
Service
BUILDING INSPECTOR Final
Occupancy Permit Required t0 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.
The Commonwealth ofMassachusetts
Department of-1ntlustrialAccidents
Office oflnvestigations
600 Washingtpn Street
s�
Boston,MA 02.111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plurabers
Applicant Info>rmaiion
Please Print Le�biy
Name(Business/organization/fndividual): (
CO✓1 WtJ��N u1
Address: 1�
City/State/Zip:_ I C, S'ly, 0010
6Phone -
Are Pu u an employer?Check the appropriate box:
1.[JI am a employer with 4. []I am a Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors
6. E]Now construction
2.❑I am a sole proprietor or partner- listed on the attached shget.t 7• ❑Remodeling
ship and have no employees These sub-contractors have
working for me in any capacity. workers'comp.insurance. 8' ❑Demolition
[No workers'comp.insurance 5. ElWe are a corporation and its 9• ❑Building addition
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑I am a homeowner doing all work right of exemption per MGL 11.❑Plbing repairs or additions
myself.[No workers'comp. c. 152, §1(4),and we have no
insurance requited.] , 32• oofrepairs
9. ] �T employees.[No workers
comp,insurance required.] 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 anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I ain an employer Aat is providing workers'compensation insurance joY
il2forYlZatlon. my employees fle
Below is e policy and job site Insurance Company Name: ATM M U
—W
Policy#or Self-ias.Lie.#:_ WQ ��, �� 1
f 7 � Expiration Date:__
Job Site Address:_ 1 5C4 h Ah
"Var /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.
rdo hereby t under thepains andpenalties ofperjury that the inforalzationpro videdabove is true and correct
ii nature: f
Date: /
'hone
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitUeense#
Issuing Authority(circle one): ,
I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical inspector S.Plumbing 6. Other burg Inspector
Contact Person:
' Phone#:
i
f
JET=;r.Ir.I7L L:YtIN
i 1 -ATE F 1 1 1T Y 1 SU RAN E _sr,r 311 E R,
THI=3 CERTIFICATE IS ISSUM AS AMAT ER INF-7RMA:` !�oPt -;SLY AND _NFERs U;=.?N T!t;= C= TIFICATE E"aLfSER- Ti-€IS
CERTIFICATE DOES Nn. T ArFIRNPIAMVEI'-' O6= NE" :T('i€L_' AMEND, =YTE4
J
Y
1
q at
j
N
- 111
j=
V!i€1 ard 10V _ _a-M , NH 02386-55
-3'60 -93 0 Sm
Date: 9-14- 2 1
Z-treet: _ -iia Lane
iE Novi re f , M1 a 0 84
Phone INIum`bar-
lNe hereby p-o cse to Vmsh materials and labor necessar'=for the comp a-on of.
-Roof shingle rep ace ent on 82 visa Lane . Andover #f �18A� ThiLeif: tnC ue;
1, 'Strip- r reef _n f¢ fr Sq feet in the a€° =n area- Please nate t t sere f
currertf I (one_= layer of shin es on this ser-tion of tie hu=fin .
2. Instal6 8 €r k-vhite a€� -nur�_ ri e p a. al edges.
3. install feeE}{f ice a n a %ma er thief u1nder shingle a_ Cafe quitter eudges. and
`--Meet a:�und al'�-n3 penes ?nd Fyl`g€
. c ►e the ice fie tee ) nstall organic Shir -e IDe_t urder'ay� ert-= ne 1-5.
. Install ne- roof fian es on af£ vent pines.
6. Re _-We aH _ e Witivelrot=e r Of boards- a IR A. 0 per fco4 os 4S5 0 e x _R11
°nch sheet of plywood. (4t�is a fti�nal yea may. if necessan r� �as��
aeon my preflminaia vie �f existing roof,€ do n be_imi-}e tha-phis �H. 1pe a
problem)
7. RR all lo=se,roofb0girds.
–over bpi` n em � �b�Wit i E m a u=ins E�=their r�fecfid r.
. f ri an re;EII�_ea=t e rls iEy fr l fn magnetic cfeanufir rails. Vie will
-eWIM t i si_e for cleani� o aff -e -fair irg deb-is unt_l =tee are satisfied ftf
he n.shernduct.
10. S ecial attention g=ill e f�cu-ed on ensuring first-class flashing on he chimney
area
11 h=in Je qi_;ota is Y-4F EL K Ti_7be-ii_ ei. F� r;-.n �h=rr qle t fco
sumeh Affairs&Susinessliegulatio9
y.
Office of Oop ENT CONTRACTOR
..m HOME IMPROUEM
Registrabat �149657
Tr# 292705
1`12F1`2012
Expiration
i e�l�
TyP
D.
LEE CONSTRUI
1.1WILI ARp WAY = Undersecretary
2
QLgISTOW,
titass.lclltlr;cits- Dep lo-trnent of Pp59'c S-life th
i
Board of Suildiii Re,uiations xnd St;tntllyds
;construction Supervisor License
License: CS 81688
Restricted to: 00
DAVID G-'LEE
112-W ILLARD WAY »;
PLAISTOW, NH 03865
Expirat}nr,: 1.2/15/2011,.
Tr#: '(4126
srqpase hereby to 'Urni'sh material and labor complete in accr -
- _a,rdanc e vv ith above
specitricationsfur the slim of.e'Q.5Des far the roqreplace lent as described a bone in points j-*
1L The initial dePosir ql_-535vO and a sigyned- contract is required to obtain all permits and
inusurance birders n eeded-to perhirmi all-- --t d
art=_as his e
Payment to he rnade as fallow:
Deposit to cover NOW permiffing& mererial's g 3500)
M ofrentain." 9 hala- ce at start ofic-b (W3500)
Rernain; g balanece upon corn plOtion, of-jibb (,_5=3 5 0 q)
Al'! Mate-7rialf is guaranteed to be as specified. All of a to be completed in a
sub stanthalind'orkn7anlike- manner according to specifications submitted per sitandards-
p.racri-cess. AU wtemtioni or d'eviati R from above specification in-fohang extra costs
till be ex=ecuted onlf upon -wri.- n orders and midif becorne an extra c-hialgree over and-
above the esfffina4e.
In the event-material cossts of the contractor Rmnose more then 5%prior to or during
the work petfor-i-ned Py thre contractor under tis agreement , or prior to Wal
payment the customerishali pay thte contr ctor such increased aniount i.rnmedi tell=
u, =on pro nifof-such- fficrease.
M We no losponsMy for dust or c1ehris in your attic- lvvihen jrFastalfing the roof rage
vent. Tease cover or remove ahm'vel abies.
One year labor guaranteSpAhon conimence upon fn payment.
/0-
Authorized Sig -ureas Date
/O-ff
n ani
Acceptan' ce of proposal Signature: 104a, Date:
and are hereby
The above pricet specMcaHons and conditions are sat ?;_4
accepted. You are authorized luz comple=te the work as specified. Payment be
made as outlined above.
Acceptance Date:--