HomeMy WebLinkAboutBuilding Permit #807 - 83 QUAIL RUN LANE 6/7/2007Permit NO: ELi
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received. 4"11-
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"11 -
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r IMPORTANT: Applicant must complete all items on this page I
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LOCATION L Q 0 66 ( Ry n
Pri t
PROPERTY OWNER .JC�V (� 1
Print
MAP NO.: PARCEL:
TVPF. ANP ITCF. nF RITII,DING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
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Phone: (o
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
)a One family
❑ Two or more family
No. of units:
❑ Industrial
XRepair, replacement
❑ Demolition
❑ Assessory Bldg
❑Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
M
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Please Type or Print Clearly)
OWNER: Name:
Dcky iy l l
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Phone: (o
Address: ?,3
u&t f?un
A aAouc,
N d (�
CONTRACTOR Name:
e En G k;YILC,
M
Address: Z o S-6 �+rtop—A Su A, 2,2L, NO. Nc) () ve,- H6 6 / 1 YJ
Supervisor's Construction License: Exp. Date:
Home Improvement License: 0 (E �,(o 9 Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSS ASED ON $125.00 PER S.F.
Total Project Cost S 3 (� d • 00 FEE:$ 460
Check No.: 1171d"" �'✓ -"7, Receipt No.: ,
Page 1 of 4
TYPE OF SEWERAGE DISPOSAL
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Public Sewer ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
❑
Permanent Dumpster on Site ❑
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractop `
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ �l G` b�
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED
DATE REJECTED
11
IN
DATE APPROVED
DATE APPROVED
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
FIRE DEPARTMENT - Temp Dumpster on site yes no
Fire Department signature/date
X163UluJ: I a M
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required
Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
NOTES and DATA — For department use)
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
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
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Page 4 of 4
Location �,_`
No. R(? r Date 4-6, e6,
TOWN OF NORTH ANDOVER
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Town of North Andover a� OORTH
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Building Department O;
27 Charles Street
North Andover, Massachusetts 01845 ry V
(978)688-9545 Fax(978)688-9542
CO[MICKI WK M
�A p�fiq TED ►'P�`y Ry
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s15Oa.
The debris will be disposed of in /at:
� Z,
Facility location t
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
i -//?A)7
DAVID CASTRICONE
CASTRICONE ROOFING & SIDING INC.
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 978-374-731!
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below7DJ.'rk
bed: ?
Owner's Name .....VA., I'o..�.(.:........................................I..... Tel hone #.......%A.
C72
Job Address ....... ZI..,J...... �lA.c�./../....... /...1.(d.'1.. ........................ city....l.Y•A.�..�n .a.��/'................ State.... %........
Specifications:
..........................................................................................................................
........................................... .
'/Strip existing shingles() ✓Apply new drip edge to all edges. Q JI/.t� `6
......................................................................................................................................................................................................................
*/Apply _feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane
in valleys and bottom edges of any unheated areas of house.
....................a.............................................................................................;.................-------........------------------- -
1 tett r u erla went. '+'install ridge vent to S - % c
✓APP � I�Pe Y g ��Cec...�s1• s�� ti,
...... S ......................... ......................................................................................
eroof using shingles with a year warranty.
�ounterflash chimney. t pipe, flashing. ")Vega) disposal of all debris......•.••..................•........•..,.•,........•••...........•.,.••,..,
.....................................................3............................
Area(s) to be worked on:11
...........................................�J•.�... 11-.4.er..t•1 .......01...... .................................................................
......... .............................................................................................................................................................................. I..............................
......................................................................................................................................................................................................................
............................................................... ..-Z ... .... ........... ........................... .... ........
.....................................................................................
Roof board replacement if necessary @ /.49 /sheet or V-1- /foot.
.................................................................................................,...............................................................................
Two Year Workmanship Warranty (Not Transferable) N)anufacturer's Warranty as specifi mina ac m,
The c for agrees to perform the workV AIV ish the materials specified above for the S of 5....,. G,?...... �.....
11 / ayable ....U.b'.G........... on ...5A .............
e .......... ..`—
................. on......................... (z
.➢rhBalance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or
conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living
spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon
completion of above work, all undersigned agree to execute and deliver to contactor, their joint note in accordance with his (their) above obligation as requested by
contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is
agreed that, if permitted by law, contractor shall be paid by the owners) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by
contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are)
the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). 7Trere are no representations, guaranties or
wan -antics, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not
herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration
should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108
Tel: 617-727-8598
Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -
related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A.
Approximate starting date of work ................................................ Completion date .........................................................
Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation).
IN WITNESS WHEREOF, the parties have hereunto signed their names this .t,.31 S ... day of.. .�^ ......, 20..41.1...
Accepted:
Signed ...... .fG7.GY...:!t4...... ................... _... ....».. Owner
�v.:r.,t�.. ... ...� .. Signed............................................................................ Owner
David Castricone, President /
1 ne Lommonwealth 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): _0CQ / (,phi �pQ nG
Address: W0
&7k r\ S+rec_+
Std ZZ(p
City/State/Zip: N p.
AMOVU MA
Mg S
- Phone #: 9-7� 6 FS 3 3 Yz o
Are you an employer? Check the appropriate box:
1.P I am a employer with % 4. ❑ I am a general contractor and I
employee's (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t
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' camp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
❑ 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. El Electrical repairs or additions
11. E:1 Plumbing repairs or additions
12. loof irs
13. ETO er
*any apprtcant rnat cnecxs box #I must also till 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 their workers' comp, policy infOTMation.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ' -1- _►
Policy # or Self -ins. Lie. #:11 V V V L 666 54 4 V Q /0(-U � `f Expiration Date:
Job Site Address:__ ` 06- r l n City/State/Zip: NOr`L Wux/ N4 d
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 certify under the pains and penalties of perjury that the information provided above is true and correct
Phone #: 5 % r 6 6 5,3
Oficial 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 #•