HomeMy WebLinkAboutMiscellaneous - 33 FRENCH FARM ROAD 4/30/2018 (2)O 0
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} BUILDING PERMIT `� o`tt,Eo
TOWN OF NORTH ANDOVER 0�t�,'' o;
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
ACHU`����y
Date Issued: '
IMPORTANT: Applicant must complete all items on this page
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MAP NO: PARCEL: ZONING DISTRICT: HISTORIC DISTRICT Yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
2bne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
0 Septic ❑ Well
11 Floodplain E Wetlands
II' Watershed District
Wates'/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
/�t 47a4/ 3(/ S
Identification Please Type or Print Clearly)
OWNER: Name: �'-' A rpt / 7 S Phone:
Address:
CONTRACTOR Name ot^ JA c -f Phone: '71,r ids' -,7s".1%
Address
Supervisor's Cons#ruction License 91Z Exp,, Date: a
Home Improvement License - Exp. Date: a f
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ cl - 9'P ° FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered tractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
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
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
a Copy of Contract
o 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
a Building Permit Application
o Certified Surveyed Plot Plan
Li 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)
o Mass check Energy Compliance Report (If Applicable)
Li 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)
o Building Permit Application
Li Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o 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 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 2.2007
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
HEALTH
COMMENTS
a
DATE REJECTED
DATE APPROVED
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
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
Located at 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
............................................................................ ........................ _............ .................................................. ................... ........................................ ............ ...... ... ....................... ........... ................................................ .................................................................... ..............................
......__.........
Doc.Building Permit Revised 2007
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Location" yz —,"it'�.�
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ p
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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Fr to : PERRY INSURANCE AGENCY 9786870149 REPR93ENT #252 P.002/002
AUTl OMM ROW43MATM _ 1A
ACORD 2^1 t C ACORD CORPORATION
ACORO. CERTIFICATE OF LIABILITY IM�w� SU NCG F DATE ld Moly
a8M 5/20(
PrODUICEN TMS CERTIFICATE 18 ISSUED AS A MATTER OF INFORIAATION
Internet insurance Agency ONLY AND CONFERS No RfGHTS UPON T14E CERTIFICATE
FtOLOM TMS CERTIFICATE DOES IdDT AMEIIO, EXTEND OR
522 Chickering Road ALTER -pM COVERAGE AFFORDIM BY THE POLICIES BELOW.
North Andover, MA 01845
WtatERS AFFORDING COVERAGE MAIC a
MGM* �„ NORFOLK a DEDHAM INSURANCE COMPANY
JOHN tANZAFAME VASURER B: AIM
DBA ALL UNDER ONE ROOF VOKIRER C:
30 TEMPLE DR RIsuRER D:
L. METHUEN, MA 01844 WARM E:
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THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITMSTANDIN(
ANY REOUBtEI/EIIT. TERM OR CONDITION OF ANY CONTRACT OR oTwR DOCumff MN RESPECT TO WHICH THIS CERTIFICATE WAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEMI IS SUBJECT TO ALL THE: TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
MI "F a A^f-o=m&vr a MRIYQ amnu ! mAv mmm RFFM RPOW-ED 0Y PAID MABAS.
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PERSONAL a ADV INJURY S +.000.00000
GENERAL AGGREGATE S 2.00Q 0D0 00
PRODUCTS • COMP10P AGO S 2.000.000 00
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DATE TH2RM : THE MUM WGURN VML ENBEAVOR TO aeuL 30 DAYS wmr
HOME TD THE CERTIFICATE HOLDER UAIRED TO TIB: LEFT, BUT FAN.URB To 0o 30 sN,
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' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 6Vaslrington Street
Boston, .MA 02111
wrvw.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ACLyi �?L-n 01 c"
Address: I. � � OCC 1,2A
City/State/Zip: /-t �4 d L"v`i ""
Are you an employer? Check the appropriate box:
1.01 am demployer with 1 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ 1 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' comp.
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.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.[�!f_Roof repairs
13.❑ Other
'Any applicant that checks box HI must also fill out the see[iun below showing their workers' compensation policy info Mialion:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck
tContractots that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy air d job site
information.
Insurance Company Name:
Policy # or Self -his. Lie. #: `l 6o P Y` Expiration Date: // /9/° y
Job Site Address: 13 3 t -l-. ��- w^ AQ City/State/Zip
^49
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 forni of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ceiyify under-
lie
�pail's
/a�nd penalties of perjutry that the information provided above is true and correct.
Cion�h�rr• Ai� /���^'� V M✓ rl,�lP• �//�/u
Phone #: 9 '1 Y - ? 7 1— - -7 S-1
Oficial use only. Do riot write in this area, to be completed by city or town official.
City or Town: Perinit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone M.
V (_-Y�t3a( ciS- S�u��
Chimneys Residential & Commercial Roofing All Types Of
Siding CHIMNEYS POINTED -REBUILT -CAPPED Expert Masonry Work
Mass Toll Free Roof Leaks Experts Licensed & Insured
Locally Owned & Operated Since J 976 " "-'�
1 -800 -WAIT -4 -US m s � i License #034200
(924-8487) IKO Calf Vzoem VC Mahn f i We Work Year Round
Proposal Submitted To Phone _ Date .
Street
Job Name
City, State & Zip Code
Job Location
Job Phone
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of:
2 t q -f<'� a Dollars ($ 7
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from specifications be- signature: o M►
low involving extra costs will be executed only upon written orders, and will become an
extra charge over and above the estimate. All agreements contingent upon strikes, accidents NOTE: This proposal may be
or delays beyond our control, Owner to carry fire, tornado and other necessary insurance.
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days.
V `)0,f 12 � v ' j
We hereby submit specifications and estimates for: r
Ur nstall6feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley. 4 roof is stripped, we will apply conventional ice and water shield
( ) ft. high in the same locations previously described and tar paper will cover the
remaining bare wood. Any rotted or damaged boards will be replaced at ( .-- ) per linear ft.
or per sheet of plywood.
Ul'Install heavy gauge aluminum drip edges along every edge surface of each roofline.t.,k;; r.=
Ad Cover entire roof (s) with IKO a fiberglass, premium grade shingles
(Color of choice).Pq z(c
R Replace all pipe boots where possible.
6/ Seal all flashings with clear Geo -Cel sealant. No black tar unless previously applied.
Remove all work-related debris.
Wtontractor warrants roof against all leaks due to defects in his workmanship for 12 years under
normal circumstances.
eLocal current references and proof of workman's compensation insurance gladly given.
6(Remarks: CID J-;" sfy3lt GT 4cfa'Yi4
On ? `� C(' -'t' jz(:--f-
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Acceptance of Proposal - The above prices, specifications
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment Signature: c�11
will be made as outlined above.
Date of Acceptance: I;(/. Signature: ®—v