HomeMy WebLinkAbout201505131555 BUILDING PERMIT �aoRre�
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TOWN T �� o
APPLICATION FOR PLAN EXAMINATION
Permit NO. Date ReceivedsreDED
CHO
Date Issued: 6
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
,PROPERTY OWNER - i
Print
MAP NOPARCEL: ZONING'DISTRICT: Historic District yesCn
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: J +, 1, Phone
Address:
CONTRACTOR 'Name: ( Phone:
Address:
Supervisor's Construction License: 9 Z Exp. Date:
Home Improvement License: Exp. Date:
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: $ b o , oo FEE: $__ .
Check No.: Receipt No.:
NOTE: .Persons contracting with unregistered contractors do not have access to,4he guaranty fund
Signature of Agent/Owner Signature of contractor
I
Town of 11 T.11.,
ndover
0 0
1i
e ver, Mass,
COCHICHgWICK
04AI-ED J"
L) BOARD OF HEALTH
PER IT L D Septic System
BUILDING INSPECTOR
Foundation
has permission to buildings on
,, •• occupied
Final
provided that the person e rii �&s permit shall in every res t conform to the terms of the application
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the T• of • Andover. i .
VIOLATION of • r or • • Regulations Voids this Permit.
Final
PERMIT EXPIRES IN S ELECTRICAL INSPECTOR
UNLESS ■ TAM r Rough
r
Service
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildin 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 / Approved r Building Inspector.
Street •
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��` � ,�, r air : ,pA c. r-��d�' �'d 4D u.a%"s t�
(924-3487) a ,°a
Proposal TO: Brett Guisinger Date 411%20115
Street- 159 forest St. 978-337-211,35
N. Andover, MA
Roof proposal Brett.gu ��itzger@i�))grriaii.com
IKO Cambridge
I. Extra
caution will be taken to protect building 13. Removal of all work related debris. Planks will be
exterior and landscaping as best as possible. (tarps placed tinder dumpster to prevent any damage to
etc.) Magnets run at final clean up. driveway.
2. Remove all shingles from entire house. 14. Building permit included.
3. Inspect and re-nail any loose or lifted plywood. 15. Contractor workmanship warranty: 10 years
Any compromised plywood will be replaced at an under normal wind and rain conditions.
additional cost of$65.00 per sheet of 1/2"CDD. Total roof cost: 9,000-00
4. Install heavy gauge 8" white aluminum drip edge IKO Shield Fro Plus Extended I�'Li G vmarranry.
to all rakes. Existijjg 11-lieks" vent drip edge will A fell 100% coverage on material, labor and
remain as parto fthe ventilation system. debris removal for as full i.aon faro rated period
5. Install 6' of IKO Arnlourguard ice and water of 20 years. Included to our local referrals and
shield along all eaves and top to bottom in all in this l;a•oposal at no additional cost.
valleys. m Option: Upgrade to WR -;race ice and water
6. Install Rhino synthetic underlaymez-it to rearraining i shield, (hest defense against leaks from ice
sheathing up to ridge. dams) $400.00 additional cost
7. Install all new pipe boats, Option: Install (1)Lonaeaaco HT 2000 theranof
.
8. Install IKO Leading Edge starter shingles to all 1 "lu nidistat controlled po A,er vent.
eaves. $425 additional cost. No electrical included.
9. Install IKO Cambridge Limited Lifetime *Note*: Please be advised if applicable,valuables in
architectural shingles to the entire house. 15 year the attic should be moved or covered due to minor
non pro-rafted warranty by mfg. (See warranty debris,dust and asphalt particles that will accumulate
info) All shingles will be installed and fastened during the stripping process. All Under One hoof not
according to mfg. specs, responsible for any damage or clean up that may
10, Counter-flash chimney lead with ice and water occur in attic.
shield, tie into new shingles and seal with black �
rubberized cement. Balance clue u on comraletic n
11. Install a new GAF Cobra ridge vent capped with
color matched IKO hip and ridge shingles. References avaaiiable no" a-ec�is_est
12. Install (2) new Broan exhaust vents on the roof
line. Attic connection included. Ili i11 a ated meanber of the acs reditecl l3liB and
Angle's List
Thankyou!
A RG l.V//LLLLVLL YVGILLLLL VJ LYl ILJJULLL LLJGLLJ
a� Department of Industrial Accidents
t u Office of Investigations
w
tl 1 Congress Street, Suite 100
e' Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): d
Address:
City/State/Zip: MV4ftone#: �
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp, insurance.$
required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 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.
$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 isproviding workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
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 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 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 un Ili ains and penalties of perjury that the information provided above is true and correct.
Signature: Date: s—/
Phone#: `
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 Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
tilgbtfax UJ--L
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