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HomeMy WebLinkAboutMiscellaneous - 865 GREAT POND ROAD 4/30/2018I N o � W � m m Qo v j o o o 0 N°RTM TOWN OF NORTH ANDOVER FZMsilift; Certificate of Occupancy $ *Building/Frame Permit Fee /Z) dU 'SsAcMusEt Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL �7Building Inspector ! 15.0 PAID 7485 t pyx'" Div. Public Works W a � <I a Y 0 0 m O c N IL X N O W us > z p 0 z Z a o i Q 0 J J a j in W = a' m W K H O O 0 0Z Z m' 4 W I d 0 w a .O < ILUm 0 d 0 0 a Z V H 1 0 � L Q z o 0 l' ^_ "l N `! 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O 3 �ORTM TOWN OF NORTH ANDOVER 40 • Certificate of Occupancy $ �.�s'•^°' E<� sgCMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ :Check # 16517 Building Inspector 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel umber 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I 2.1 Owner of Record �&Iq -,7e7 O Name (Print) Signature 2.2 Owner of Record: Telephone Address for Service Name Print Address for Service: S SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ U- (%t0GK CJ 17 X 0 ::,/` Licensed Construction Supervisor: Address 1 W,4�-W� S1"" Telephone 3.2 Registered Home Improvement Contractor �LL 0,1 D 4-,�z &I (-f ��-r 3 n O/� ol� **IfyJ ��y - 2S 3l K-,NcR �2© License Number �S Expiration Date Not Applicable ❑ IS? 6),5- 1 Registration N tuber l� z 0 Expiration Date 9 -Ij O z M 90 O '17 ic M r Z YI SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check allapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be.OFFICIAL"'USEONLY' Completed by permit applicant . ,..: 1. Building ?Plb �� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) g ��- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. i Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 1 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH ANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1 APPLICANT INFORMATION ege C=nanweaitfi ofMassachusetts (.Depamunt of Imfustriairfira=ts Office of Investigations 600 Was&ington ,,Street Boston, 9" 02111 Workers' Compensation Insurance Affidavit Please PRINT Legibly Location: , )S (9- Cily. / y i�� I Qy L Y ` 0MAS-5 __Telephone, ❑ I am a homeowner performing all work myself ❑ I am sole proprietor and have no one working in I am an employer providing workers' compensation for my employees working on this job �LL ll/1���� 011?L5 d Company Name: � Address: City: �� ^1/1-9.5 Telephone# Insurance Company -Policy - ❑ I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following -,porkers' compensation policies: Company Name: Address City: Telephone #: Insurance Company: Policy # Company Name: Address: City: Insurance Company Telephone #: Policy TM: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that .a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby c&rrift unde the pai s and penalties of perjury that the information above is true and correct Signature: Grt� Datc: Print Name: d1\� ����i�/n [� Phone # Official Use ONLY Do not write in this area City or Town: Permit/License M 0 Check if Immediate response is required o Building Department ❑ Licensing Board o Selectmen's Office o Health Department n Other E\TFORIffiAnQN Il>TSTmucnONS Massachusetts General Laws chapter 152 section 25 regmres all employers to provide workers' compensation for. their employees. As quoted from the "law". 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 section 25.41so-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, 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation. and supplying company names, address and phone numbers as all affidavits 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. city or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements, have been made. 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 Fax # (617) 727-7749 Telephone # (617) 7274900 ext. 406, 409, or 375 ` North Andover Building Department Tel: 978-688_9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40'S 54, a condition of Building Permit Number is -that -the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A.. The debris will be disposed of in: 1 '11 C— . I --E—m (Location of C) Date Applicant NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector I rA W Cl - O o O w v v cn v co O w w U X. x o W to —co x a w U 0 w' '2 v V) iy C w a p 0 C2 C2 C w z q w oCf) cn p x cn UJ z f c y y CL. CD C 0 CD C.i CL CO) Q V o. CO) C O V m L 0 s C. 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C#2 C C C y f Chimneys Siding Mass Toll Free 1-800-WAIT74-US (,924=8487) Residential & Commercial Roofing CHIMNEYS POINTED -REBUILT -CAPPED vks Experts Locally Owned & Operated Since .1976 IKO® wee ?toxin or 9ohv 2 All Types Of Expert Masonry Work Licensed & Insured License #034200 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: 00(s ✓1 Qc1� _C__ �'a o Dollars ($ I �bc'� Q� _71�1 �. 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: 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 pro al may be or delays beyond our control, Owner to carry fire, tornado and other necessary insurance. qc� Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within/0 days. We hereby submit specifications and estimates for: J•c� qp �'tdG>72'/G'7 r dd Install 3 feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof and top to bottom in each valley. If roof is stripped, we will apply conventional ice and water shield ( tl ) 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 ( C- o D ) per sheet of plywood. Install heavy gauge aluminum drip edges along every edge surface of each roofline8l' UrCover entire roof (s) with IKO 25 year all asphalt, non -fiberglass, premium grade shingles (Color of choice). aReplace all pipe boots where possible. EdSeal all flashings with clear Geo -Cel sealant. No black tar unless previously applied. Remove all work-related debris. Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. Local current references and proof of workman's compensation insurance gladly given. URemarklr�i��' �f' i7� t( �'s�2 /�► '` S" G41)0 41 - Ass (41 61604 C" 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: will be made as outlined above. F Date of Acceptance 3 2i "' Signature: v UU