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HomeMy WebLinkAboutBuilding Permit #770-2011 - 9 ANDREW CIRCLE 5/13/2011BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 7 / Date Received Date Issued: IMPORTANT: Amlicant must complete all items on this page X/*'blk 4 UP '7- - -r -1, ! Qp 9P. ' III/ LL TYPE OF IMPROVEMENT --PROPOSED U Residential Non- Residential New Building One family Addition Two or more family industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other WH M . . . . . . . . . . . . . . . ......r, i ivim ur vvvmm I U t= VKhl-UKM ED: 7S 12 j,:s 0 j'v�Z. L 1-4-y .n iv 6-7,-4-2,& <4,7 46 v4 /r f. 5F - 6r /--/s ;7 1/ V7- S - Identification Please Type or Print Clearly) OWNER: Name. 6L.-" /Vdv�&-s c),t6 6,,c Phone: ARCHITECT/ENGINEER 0( /0( Phone: IV 'K ?-' Address: Reg, No. FEE SCHEDULE: BULDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost.- FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to thegu aranz)?fund Signature 6 w n , Or ignature- of contractor Location 041 q rhtu /& /,✓ el(,geZe, '770 ' j /! Date hlty TOWN OF NORTH ANDOVER Certificate of Occupancy $ BuHding/Frame Permit Fee $ Me Foundation Permit Fee $ �`�uv� Other Permit Fee $ TOTAL $ Check # �3-3 2`F i J� Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Piot 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 ❑ ❑ COMMENT ` CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on _ Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: Comments Conservation Decision: Comm Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street yes no Pians Submitted Plans Waived Certified Plot Plan Stamped Plans TN'PE OF SEWERAGE DIS POSAI. Public Sewer Tanning/Massage/Body Art Swimming Pools Well i Tobacco Sales Food Packaging/Sales Private (septic tank, etc. I Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Sian Reviewed on ature Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connectionisianature & Date Driveway Permit 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.$10041000 fine Doc.Building Permit Revised 2010 J ej,�, 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 Doc:.Building Permit Revised 2008mi L -- r 4 - - 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 Pian 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) a Mass check E-nergy 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 o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract o Mass check Energy Compliance Report o 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: Building Permit Revised 2008 '467Q 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) o 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 o 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 .Permii 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: Doc.Building Permit Revised 2008mi NEW ENGLAND CUSTOM DESIGN, INC. 226 LOWELL STREET WILMINGTON, MA 01887 #978-658-0881 Home Improvement Contract Registration No. 102467 ROOFING AND SIDING AGREEMENT This is a legally binding contract. Make sure you read this Agreement and understand it before signing it. Do not sign this contract if there are any blank spaces. NOTICE: All home improvement contractors and subcontractors, unless specifically exempted by Massachusetts law, must be registered with the Commonwealth of Massachusetts. All inquiries about registration should be directed to: DIRECTOR - HOME IMPROVEMENT CONTRACTOR REGISTRATION One Ashburton Place, Room 1301 Boston, Massachusetts 02108 Telephone: #617 727-8598 ds Agreement is made on `y✓�U - 20//, by and between New England Custom Design, Inc. (hereinafter, "Contractor") downer M.,u.vllocPf—&m-e) L/ /Jnt�j�Gl C'dx%l�r,�D r� /1SS. T.t-c_ (hereinafter, "Owner"), of ry / Town 4/4Z)o /-e?C— State ln6L__ Zip (H) Phone Address ("The Premises") (),fr 4 A4 hone ii dJ 5F-5-- 02517 Roofing will beappliedonly on slope roof surfaces below, over present roofing shingles unless specified _under REMARKS. a z MATERIAL Zl 0 3L A/L Color -to de --W, 8 Main Roof '&dr Sr -On G>7 (/ Bay Windows Extensions a, Porches: Front �Side Rear Other Roofs NOTE: Roof board replacement cost c3,S2] per foot OR 4!J . aUper 4' x 8' sheet of r inch CDX plywood. E.MARKS /EXTRAS: Missing or defective lumber is not included in any category of work unless specified here. �e Mn i r rrV O r T(T,/ v cL, i ne Lontractoragrm to perform in a good and workmanlike mannerall work detailed above. f- (.0 r l ( be CASH PRICE $ 'Z 1/". d o 10,IMo,,4- DOWN PAYMENT$ do - Me;AllRoofingCusfoinehs Z e4e%Mtwe /0 e PAYABLE ON START OF WORK $ %,y Op New England Custom Design Inc wili notbe PAYABLE$ held responsible for dust and debns falGtlg In J of Nla' `7 e� attic areas doting roofing installation Please PAYABLE ON CO PLETION $ �j—�y �. '/f/%�LMt 1� remove or cover valuables.` DATE: �20 RIGHT TO CANCEL font e Owner may cancel this agreement if it has been signed by the Owner at a place other than the address of the Contractor, which maybe his main office or branch thereof, provided that the Owner ifies the Contractor in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this Agree- nt. See attached Notice of Cancellation. A cancellation fee representing 30% of the contract price will be in effect if cancellation is requested after the legally allotted time has elapsed. Owner hereby certifies that he has read this Agreement, that the terms and conditions and the meaning thereof have been explained to him, and that he fully understands them and that there is no lerstanding between the patties, verbal or otherwise, than that which is contained in this Agreement, and agrees that onta is not responsible nor bound by any represematiom not con- e,ied in this Agreement, made by any of irs agents, unless the same be reduced to writing and signby the Con or. ON HO DO NOT SIGN Tn3o CT IF THERE ARE ANY B SP 114 ✓. mJ's Mnature - - D to E and Custom Design, Inc. Date mer's Signature Date Uri/28/2011 10:51 9785319442 ��'�� CERTIFICATE CIF LIABILITY INSURANC°584 P.001/o01 OP DATE (MMIOO/YYYY) PROpuCFR ID KC N1L�N-1 O3 28 ll THIS GER I IFICATE IS ISSUED AS A MATTER Kilgore Insurance Agency OF INFORMATION ONLY AND CONFERS O R�F'A GHTS UPON THE CERTIFICATE 5 Centennial Drive HOLDER, THIS CERTDOES NOT AMEND, EXTEND OR Peabody 01960 ALTER THE COVERAORDED BY THEPOLICIES BELOW. Phone:978-531-6550 Fax:976-531-9442 INSURERS AFFORDING COVERAGE -. NAIL # INSURER A: WbtCaPp Wb_Yld Snruranw Cowan New England Custom Design Ron Weinber INSURER B: Safer Indemnity Zns Co 2,96 Dowell trAQt / Unit }34-A Wilmington MA INSURER C: ------.._._..._._.. _...._.-... TravoXore P INSURER 01887 D: COVERAGES I INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT MAY PERTAIN, TO WHICH THIS CERTIFICATE MAY BE ISSUED OR THE INSURANCE AFFORDED BY THE POLICIES DF,SCRIRRI3 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES• AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED INSR 'PD' �"'-"---- BY PAID CLAIMS, LTR NSR TYPE OF INSU NCE POLICY NUMBER _ p ITICY EFFEC YE pOLICY'EXPIRATIBN __.... GENERAL LIABILITY DATE MMlD LIMITS A i X OOMMERCIALOENERALLIABILITY NPP1265260 CLAIMS MADE 03/14/11 EACH OCCURRENCE $ 1000000,-i 03/14/1,2 PREMISES E�aoccuro�nco — $ SOQOO _ x oc_UR f MED EXP (Any ene paemm $ 2500 -' --- _-- i PERSONAL AADV INJURY _1$1000000 GEN'LAGGRErG-A-TTELIMITAPPLIES PER: OEN8RALAG'GREGATE 1$2000000 POLICY I "0-JECT LOC PRODUCTS, $ 1000000 AUTOMOBILE LIABILITY I F3 ANY AUTO 5054921 04/05/11 COMBINED SINGLE LIMIT $ 04/05/12 (Ea accident) ALL OWNED AUTOS X SCHEDULED AUTOS _ BOD14Y INJURY - (Per porsor,} $ 250000 HIRED AUTOS : _ ___•_ ; NON -OWNED AUTOS -- I ; BODILY INJURY j$500000 (Potaecigarel) -- ' �. GARAGELIABILITY - _ I - PROPERTY DAMAGE _ (Poeoftdent) $ 100000 ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ EXCESSIUMBRFLLA LIABILITY I AUTO ONLY: AGO g OCCUR II CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERSCOMPEN$ATIONAND I $ EMPLOYERS' LIABILITY i X,• TORY LIA ITS M-_-_.— ER ANY PROPRtETOR/PARTNERIEXECUTIVE 7PJL1H-0239N23�2 -11 OFFIPRXIM<3FR EXCLUDED? 03/14/11 03/14/12 E.L. EACHACCIOENT $ 100000 Ues, geetribe ur+der SI�ECIAL PROVISIONS holow PLO E.L DISEASE • EA EMPLOYEE $ 100000 - - . _ _ OYnela E,L,DISEASE-POLICYLIMtT $ 500000 ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 25 (2001108) - rr..e� ,vi• 1.3.11111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLFD BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR CORPORATION 1988 The Commonwealth 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 LeLribly Name (Business/Organization/Individual): �� , e (J wry 7v1 IQ /� �'%�, Z�" C Address: 6 L4 wif, u S' 1 City/State/Zip:�/l/l/, L MA d) 8$-Z- Phone #: �J � � - 65-9- Ogg / Are you an employer? Check the appropriate box: 1. L �1 1 am a employer with 4 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. E]We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t 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. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs .or additions 12.❑ Roof repairs 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 affi&4 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: 1 1G44UE L Policy # or Self -ins. tic, #: p r &-- o a. & a�--� f� Expiration Date: ? - I LI - 12_ Job Site Address: - City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to securedile 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/o`f\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 ofperjury that the information provided above is true`and correct. Signature: a Date: Phone M 17 g n , `t - © -00! e- 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_Dep.artment 3..City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions a . 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: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 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 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 d" mplete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill. i t in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill ii the per &license number which will be used as a reference number. In addition, an applicant that must submi ' multiple jpermitllicense app5cationsin any given year, need only submit one affidavit indicating current policy information (if nLessary) 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 owrie�' or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 f number: The Commonwealth of Massachusetts Departmenfof Industrial Accidents Office of `Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia ffie '&wwwnawalM a�✓Cia�raac�ivaelz2 �Lk Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration:, : 102467 Type: — Expir9tIbn:..`712720.12 Private Corporatioi NEW ENGLAND CUSTO DESIGN; INC. * Val Lanza 226 LOWELL ST. ._ WILMINGTON, MA 01887-, Undersecretary :Nlassjichusetts - Department of Public gofer: Board of Building Regulations and Standards Construction Supervisor License License: CS 8828 Restricted to: 00 VAL J LANZA 34 BIXBY ST REVERE, MA 02151 Expiration: 4/20/2012 Tr#: 20843 License or registration valid for individul use only bef6re the expiration date. If found return to: Office of Consumer Affairs and Business Regulation . �..,: 1_Q:.Eark.Plaza-.- Suite 5.1.70-,... . . Boston, MA 02116 Not valid withou nature u: Restricted to: 00 00 - Unrestricted IG -1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS