HomeMy WebLinkAboutMiscellaneous - 45 PINE RIDGE ROAD 4/30/2018 (2) NORTH
own of - Andover
No. d 24
odover, Mass.,
COCNK ME WICK A.
V
ADRA7ED \
�`S E BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT..........�1�m ......��.e...�....... .... ........... ..............................I.................... Foundation
has permission to erect............... ........................ buildi gs on ..... ... ...... ....I�./.1/.�.,�
Rough
� � Chimney
to be occupied as........... .. ..1 .. .�....... ... .�.....,K40.a.���..............................................................
fi errtfit shaiin very respect conform to the terms of thea lication on file in
provided that the person acce t g ry p PP 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
PERMIT EXPIRES IN 6 M014THS Final
UNLESS CONSTRUCTI STARTS ELECTRICAL INSPECTOR
Rough
�.................... Service
BUILDING I1Q51'ECTOR
Final
Occupancy Permit Required to 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.
D
✓/LC ID07�7/IYC9J2lI�C2LG/2 6�✓l/(,CtdJCi.C/2LLd��
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 104569 Board of Building Regulations and Standards w-
Expiration: 7/14/2008 One Ashburton Place Rm 1301
.Type: Private Corporation
Boston,Ma.02108
DAVID CASTRICQNE ROOFING,SIDING&
David Castricone.
200 SUTTON ST SUITE 226 -
NORTH ANDOVER, MA 01845 Deputy Administrator Not valid without signature
> E
The Commonwealth of Massachusetts
Department of Industrial Accidents
w Office of Investigations
600 Washington Street
Boston,MA 02111
wM 5.•`' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumberg`t`
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �,�U �t) yr-iS C'�G C� IJ RV D i l) 6 4- �� f�j 1 G.RC--
Address: b 6 SCibA)
City/State/Zip: o .A TJ D 6 V ii�-K 01 M'Phone #: q-1,811,
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.05 Roof repairs
insurance required.] t employees. [No workers' 13.[:] Other
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 they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractots that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. rn
Insurance Company Name:
Policy#or Self ins. Lic. #: V W 1... 6 OO ! T 0 OO I ALJ D Expiration Date: T'i?3 ` d G
Job Site Address: �S +p�`Q '`t No A -tgn /yL"+ City/State/Zip: 0 o
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'unprisonment, 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:
Signature: �J C � Date
Phone#: -/ / 0 (a 0 e3 T�-
0)71eial 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 of hii%;
express or implied,oral or written."
,a.
An employer is defined as "an individual,partnership, association, corporation or other legal entity,or aay tvyo or.moret`
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 numbers)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 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. A new affidavit must be filled out each
year.Where a home owner 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 fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
Town of North Andover
4S ,E0 t�
Building Department 1
27 Charles Street
North Andover, Massachusetts 01845 oh
(978) 688-9545 Fax(978) 688-9542 p� `°Ar
`�`
���SAcwuS�K��
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 facilityas defined b MGL c 1 1, s15
Oa.
The debris will be disposed of in/at:
Facility location
Signature of Applicant
9ZL01d 6
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
a�
DAVID CASTRICONE
ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS'
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 -
200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845
7 HILLSIDE ROAD,BOXFORD,MA 01921
In North Andover 978-683-3420 In Boxford 978-887-6147
In Haverhill 978-374-7314
I/we 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 below described:
Owner's Name......,1 ►..Y4.yL. ..�...r - .. Tel one#...... . .10..T.a .?...r4 Y.
Job Address........ ... ..t,n..P—e... � ...... ....... r....city.... a,,... ra..{A e�'.........State......IV14.......
Specifications:
....................................................................................................................
Strip existing shingles tkpply new drip edge to all edges. {,tf J"
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.
�......................... ..............................ns.................................................. ..................................
t/Appiy fel��er and r yment. tall ridge vent to : *"A i x,. LI -9/
)e41 ....... ..................... ......................... .......................................I.............................
Pr�i
..Yferoof using Cl //. A„_ shingles with s 3rd year warranty.
n
4 unterfiash chimney. Ww vent pipe flashing. gal disposal of all debris. S
....................................................... ..`.......J................................................................. .............. ...........................................................
Area(s)to be worked on.: n
1......., J�,..�.. .. 5........ ....... .t�.S�.l�.................................
�. ...... ........ ,.;k,. �,........ .L�........ 4.1...................................I.............................
......................................................................................................................................................................................................................
.........................................................................................................................................................................................................I............
......................................................................................................................................................................................................................
One Year Workmanship Warr of Transferable)
Manufacturer's Warran as specified nufacturer
Materials and Labor to cc $... Z)............... Payable'det.�y..jt4..�.......on... t-Y...........
Payable............................. .................................. Balance 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,water stains when roofing shingles have not had adequate time to cure).
Upon completion of above work,all undersigned agree to execute and deliver to contractor,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 owner(s)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 maybe assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates.
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).
There are no representations,guaranties or warranties,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 shall be excluded from access to the Guarantee Fund.
Approximate starting date of work..................................................................... Completion date..............................................................
Receipt of a copy of this contract 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. `
IN WITNESS WHEREOF,the parties have hereunto signed their names this........... ..........day of.. S——\J..................20.0k.a......
Accepted:
Signed...a1^. ..........................Owner
Signed.........................................................................................Owner
Per........................................................................
Representative
Ot,NORT"1ti
° TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
,SS4CN1`�t�
Permit NO: 0 z k Date Received:
Date Issued: d ZC
IMPORTANT: Applicant must complete all items on this page
LOCATION
(� int .
PROPERTY OWNER V1 v1 i► CV,
Print
MAP NO.: 15 PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 0
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
C New Building 4One family
Addition E Two or more family Industrial
Alteration No. of units:
Repair, replacement Assessory Bldg - Commercial
Demolition
C Moving(relocation) Other ❑ Others:
F72 Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Please Type or Print Clearly)
OWNER: Name: AfAVI Ptev'-ke_ Phone: q,7f Le(a a0;� 9
Signature
Address: �� ��
CONTRACTOR Name: JCLU I CY {;t s"�' �`3 , a ,�g l' Sa' "! Phone: q7 e &(F334.110
Address: 1c) b
Supervisor's Construction License: Exp. Date:
Home Improvement License: 10 if 5(P 1 Exp. Date: • / 2�'
\RCHITECT, ENGINEER Name: Phone:
lddress: Reg. No.
FEE SCHEDULE BI LDLVG PERMIT.510.00 PER,51000.00 OF THE TOTAL FSTIMA TED COST B,ISED O N $115.00 PER S.F.
Total Project Cost :$ i 4 LL , xI0.00,4EE:$
O
J
Check No.: _[7.�j Re;ccipt No.: ��<
Of 14ORTH'Iti
p TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
,SSAGHU`���
Permit NO: 4I;2—k Date Received:
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
PROPERTY OWNER VA V\ �t'.t5y1-I`�-�
Print
j MAP NO.: PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT I ES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
C New Building One family
Addition Two or more family Industrial
Alteration No. of units:
?Repair, replacement Assessory Bldg E Commercial
Demolition
1= Moving(relocation) Other ` ❑ Others:
Foundation onlya
DESCRIPTION OF WORK TO BE PREFORMED
2- Q
��c'r
�t 4- f I 0 I7 u.l� S�.,ry,�� �-'f`�- 5 o--1— lL-6 u—p—
Ident1ification Please Type or Print Clearly)
OWNER: Name: Avivi �V�C�� �- Phone: ` `7f (0 a a4
Address: Signature ur� I }t'u,acum., m
CONTRACTOR Name: Jay C f� L-(1 c uwc I 4i's f St k-t JPhone: q?� & Lka'd
Address:-10b �n /ug Jkk L-L� IYL,4
Supervisor's Construction License: Exp. Date:
Home Improvement License: I 0 'L Exp. Date: `� • / 2 610
ARCHITECT ENGINEER Name: Phone:
Address:_ Reg. No.
FEESCHEDULE:BL.LDLVG PERMIT:510.00 PER 51000.00 OF THE TOTAL FSTIMATED COST RASED OJN 5115.00 PFR S.F.
Total Project Cost :$ I� t� , x10.00-TEES �—
Check No.:- 1-7.3 Receipt No.: /f,-�2tl-�- .