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HomeMy WebLinkAboutBuilding Permit #773 - 89 JOHNSON STREET 4/26/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y T 4 � Permit N0: Date Received ��A°RATED gSSacHusE� Date Issued: ORTANT: Applicant must complete all items on this page �:t. .,w. n -..Yr �.r„x.•-< < - s.. ie c' a. j �S./�•% g -tF �� �aL��..rrr�+ �,,��A tc t j , �t�+ - -• •{ - 4` � s� �y+�r. � �� � • *'4t !f� t �.,fY � ai' a `A ay4c�tr{t =Ll®CATION� Cn,rt e� PR©PERTYOWNED MAPtN®=FARGEL®NINGWIDI TRICT'HisforiDistnct. +eyes ?Machrine�Shobi illage?` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building IDdne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial C<epair, replacement / ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other eW I.I' �' `'�« ^� Flood lamb❑ IlVetlands' tr a,=Watershed Districts ��,�x. ; �U u t•`,� #tit 9 {s i. * - ` 1 ` ,it?. µ❑Water/Sewers DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: e Gass Phone: 017? -6?? -,9 A ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDIMG PERMIT: $92.00 PER $9000°00 OF THE TOTAL ESTIMATED C'OS/T BASED ON $125.00 PER S.F. Total Project Cost: $ ` (w FEE: Check No.: �0i Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the' aranty fund Signature}ofAgent/Owner...;i£:,�� ..n..t y.",* Signafirg bf'contraetor. :.� 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS, x Reviewed on Signature Reviewed on Signature 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 DPW Town Engineer: Signature: 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 Ll Notified for pickup - Date Doc.Building Permit Revised 2008 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit P 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 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) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products �14 OTE: 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 2.2008 Location ` r No. Date Check #.- 25236 TOWN OF NORTH ANDOVER Certificate of Occupancy $ / Building/Frame Permit Fee Foundation Permit Fee , Other Permit Fee $ TOTAL $ Building Inspector The Commonwealth of Massachusetts Department of lndustrigl Accidents Office of Investigations qu 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/Individual):_ Address:` City/State/Zip: . Phoe#: % ?1 A 735`y302' r Are you an employer? Check the appropriate box: Type of project (required): 1. Tam a employer with _ 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or -part-time) * 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. x 7. ❑ Remodeling ship and'have no employees These sub -contractors have 8. E] Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance.9, 5. El We are a corporation and its [] 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.❑ Plumbing. repairs or additions [N . lf m seo workers' comp. Y p 0.152, § 1(4), and we have no 12. ❑ Roofrepairs insurance required.] t employees. [No workers' 13.❑Ocher comp. insurance required.] "Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating theyare 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lia #: 4A P 1 U �Y Expiration Date:/ -30//Z. Job Site Address:_ S©VN S i City/State/Zip: �,V do av<r _ Vre • cx Y Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certo under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: Offcciad 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 ofhire,. 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 ofpublic 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), 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 maybe submitted to the Department of Industrial Accidents fox 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. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license orpermit 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 q please do not hesitate to give us a call. .uestions, The Department's address, telephone and fax number: The CommoRwoalth OfM@aSsa.,chv.,sPtts Department offadustral Accidents 4frce OURVestigatirom 600 Washington Street Boston, MA. 021.1.1. Tel, # 617-727,4900 ext 406 or 1-$77,:MA.SSA�� Revised 5-26-05 Fay ,# 617-727-7749 - ' w-mass,gov/dia a j shoMeservices(a,,comcsst.net BBE Name / Address Lane (;ass 90 John%nn Strce, North Ando Ver. MA 01845 /10610%b66 Is�ltlpgarr. u�r'a>aw�INlli� 1565 Lakeview Avc. Suite 204 Dracut, MA 01826 www.aisbouieurvicts.com Office: 978-735-4309 Cell: 978-8074336 Fax: 978-735-4327 REP TELEPHONE Job Site 89 Johnson Street A13 979-697-2232North Andoycr. btkI Item Deatxiption Rotting KJ,'MOVI: AND REPLACE HOUSI•: ROOF Fully Licensed and Insured Insurance certificates presented upon request. ()braining all necessary permits included- RFP ncluded -Sr'r (1P TARPS TO PROTECT SWING AND GROUNDS. -RT;MOV ' ROOFING DOWN TO ROOF BOARDS. PREP ROOF (BANG IN OR PULL OUT ANY PROTRUDING NAILS). APPLY B OF GAF STORM GUARD ICE AND WATER SHIELD ALONG ix)writ LUGrs OF ROOFS) AND IN A .I. VAI .I.I:Y'S AND AT ALL ROOF/WAL.I. (UNCTIONS. -APPLY GRACE TRI FLEX 30 SYNTWI I1C UNDFRI..AYMENT TO REMAI 'DER OF ROOF AREA. -INSTALL 8" (.0241 ALYIMDRIM DRIP EDGE 7'0 At-]. PFRIMETER I;IX;ES OF ROOFS - WHITE. -PLEPLAC11 AL1. APPLICAFILI; PIPE FLANGES. -CUT INTO CHIMNEY AND INSTAI.I, NEW LEAD FLASHING. -APPLY LIFETIME WARRANTY GAF TDABERI.IN1E ARCHI CECIVRAL SHIN(i1.liS 'I'O t2MRE ROOF AREAS. COLOR - CHARCOAL. -CUT ROOF RIDGE OPEN AND INSTALL. COMITMIOUS ROIL RME VENT ACROSS ALL ROOF Pi AKS. _Cl.L•AN 11P AND DISPOSE OF ALI, ROOFING DF-13RIS. -ANY RO'rfED WOOD THAT NEEDS REPLACF.MfNT WILL BE AN ADDITIONAL CHARGE. OPTIUNAI.: GARAGE. REMOVE AND REPLACE FOLLOWING SAME PROCEDURE AS FIOUSE- ADD 54100.00. I)1SC0(IN'f TO GO OVER EXISTING ROOt RA'M-R THAN REMOVAL Ol:1;XIS'rING: RIGHT SIDE ADDMON ROOF <$350.00>. ALI. �.� REMAIN ING ROOFS EXCEPT UPPER SHALLOW PITCHED DOWERS IN REAR <51500.00> Qty I Date I ENlmoto a I Total 3/20/2012 1 239-1656 'recurs A Conditions Aaron Beaudoin CSL Lit #100691 APs Hoax Scrvica. HICR#122560 Cont I Total 12,200.001 12.200.00 $12.200.00 Acccpla 1w ot'prol+o»al: The above price+. sprcifttations and conditions are satrsfeciM and aro hereby aecepte9!enAture You are authoriit:d to do the work as specified. Payments will be made as outlined above. !J TO 39dd 6W9 TZ98T898L6 90:£0 1766T/£Z/50 T 0 J - >K C U N L � VD 1 v N 0 C .= N ZLO CD LU N''I''a`; 1!;IMI`,P`p ,,hr1,•4 t„ •\iy LU N w LU w d a '> CD eV4)0 W N -'..--Q" 00 Lu"" O E O 0 X U W Z) O Sd' W 0 m Y z0� ll�D = Z 1 c uJi �: U o m O L m O L Q Q to 0 T J - Cl) N N 0 C .= N x w d a '> CD eV4)0 Q a o .�� z0� ll�D 1 c uJi �: O M o m O N li m O L o v U _! Q W L« y o Y Z J m :. 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