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HomeMy WebLinkAboutBuilding Permit #803 - 164 Old Town Road 6/6/2007Permit NO: o Date Issued: `0 7. BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 6 �'�'' °•° OL of a 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 DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name:o r -o Phone: 9V Cf 3'K?1 Address: 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: FEE: $ Check No.: Receipt No.: a1 oR ("�'l NOTE: Persons contracting with unregistered contractors do not have access to the„guararyty fund S �rt�tur 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer Connect Located at 384 Osgood Street Comments Comments OMMENTS r 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 Doc.Building Permit Revised 2007 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) ❑ 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 ❑ 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 zThe Commonwealth of Massachusetts fa Department of Industrial Accidents Office of Investigations k1w 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Au— (f/1 e7 L=%/ Address:_ 17 O T&-KOL&I 604 City/State/Zip: t,- eJ "/a Phone #:_9v - Are yob an employer? Check the appropriate box: 1 -2 I am a employer with 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. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t 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 • -•v • ,...••• •••••• ­­­ — — "wat albu nn uur me section oeiow snowing 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 their workers' comp. policy information. 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%7m 1-4 U- J4 Policy # or Self -ins. Lic. #: %}wt:... 7y.y C S ( f' 2 '14 3 Expiration Date: / 9 o 7 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the funs and p nalties of perjury that the information provided above 's true and correct. Si nature: 6 Date: C. i Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: INTERNET INSURANCE Fax:9786870149 Jun A ZUUr I3:Jl Aco - CERTIFICATE OF LIABIUTY INSURANCE r..ww....w ONLY MI Irdernet lnsurence Agency I "CLOW 522 Chickering Road I AI.IWIN North Andover, MA 01845 AFFORDBiG COVERAGE joHN LANZAFAME ORA ALL UNDER ONE ROOF 30 TEMPLE DR METHUEN, MA 01844 r.uI DATE (WnWY! .05/04/2007 OF INFORMATION THE 49IMFIOATE cND% EATEND OR TW FOLKM OF L4MJRA= LRMW BCWWMYf.:✓X WWJLW IV IflGmmwncwmrww-wrwwvug%m 1rmT_W avw r'`ra.ar... I 1.wrn•rn.• ANY IM aU1R Wa. TEAM OR CONDITION OF AMY CONTRACT OR WMER OOCINNT VA M RESPECT TO VMOH THIS CERTIFICATM MAY BB ISSUED OR MAY u.ra•w . ... ww�.wwnwuw ww w.,w',.a PERTAIN POLICIES. THE W5URANC$AFPVRUM NT TnA VUL0612M wc141c.ncu n n`% w vvwcv..v•w ti rr.a .c..m............ w�.w.,..� �............,, .....��.. AGGREGATE LMAITB WOWN MAY HAVE BEEN REDUCED BY FWD CLAVAS. TVPE or s"gh"CE POLICY1441111m smimmm Um" A LIAMT Rl WMMRCIALGEMERLVBILm LAB en AOMGAM LPW APPLIES PENC POLICY f7lpmxv QLOC R0401433A 62007 6/3=8 EACH s 1,co,000.00 s 1,00,000.00 MWfXPIAI!y8MaW) = 6,000o© PEROONAL; Aril @WRY I 1,000.000.00 ciEllenALAOOREQATE f 2•o00.mlo PROOIiM - COWAP AGG S Zoo0,000.00 AUfONOOILEL.IMRRY AWAUTO ALL OWNED AUTOS OCtIFAAA.ED AUTOY MREDA{1T08 NON4YA% D AUTOS L ILLINlLLE LUIT = (ggpgY�Y , gppLL«��y s (I 6,P oAaACE s CARAUWABOdTV AMI AUTO .EA 'AUTQODLY-L:AACCOW s ACC S " '�-fir AGO s g LIABILITY Omm CLABAS MADE DEWLIGME RETENTION s ,T+�+Alm ANY PR AATIIEAfE7IECUTWE Oi6 CLUDED? 1912A . OMS bob* AWC7000464012003 11119ttM i1I6t2007 EACH OCCURRENCE s _ AGGREGATE s s • uIaTa E.L EACH ACCIDENT s 100,000.00 ---- EL 01lbISE•EAF�[4YES s tOD,000.00 E.L. DISEASE • POLICY LIMIT i OTINER . SH(A"AMT OF TRE ANOV6 062CWW POLICIES ITE CAMCELLED BEFORE THE EXPIRATIOI DATE TIfMW. TIN O NI=M W LL MWANOR TO Mft 30 DAYS WRITTT,R NOTICE TO THE CWWAATE VOLOER HAILED TO THE tZFT, WT FAILYRB TO 00 60 $HALL opow NOOBLE9ATI MI OR I mmm OF ANY ANILE INCH THE NIBIIR6R, ITS A08NT6 0R ALTMOBQE i rmw✓ s"nar E, w _ A- La LL CL IMUSED1EM ©MM EpOOC7 Chimne=ys Residential & Commercial Roofing All Types Of SidingCHIMNEYS POINTED-REBUILT-CAPPED Expert Masonry Work Mass Toll Free * Roof Leaks Experts * Licensed & Insured 1-800-WAIT-4-US ® Locally Owned & Operated Since J976 =...... t, License #034200 (9::24-8487) ezee Wazw oz .,�7ohn We Work Year Round :IIKO Proposal Submitted To t lC I 1` W2,0& O Phone G r I'll ?' co vl�__ Date Street Job Name City, State & Zip Code Job Location Job Phone A) 60 &-yz /Mla--ss d046— We Propose hereby to furnish and labor in accordance with specifications below, for the sum of- W4 e-,,,7 2L0,)1j (2 toN Dollars 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 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. We hereby submit specifications and estimates for: S%�2<Y f �� A?a6J_1 /,j 0-F Tit e .L JOG= j2r/Y/! �� 1=f 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. A 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( , - o 3 ) per sheet of plywood. ad Install heavy gauge aluminum drip edges along every edge surface of each roofline.3a2,e Cover entire roof (s) with I , premium grade shingles (Color of choice).P/?•TLC TnCLu0C s 3���1 CAw-4Rs ?CIf7Z ,1*1 r �Sfl�,�,✓ isGC.� Replace all pipe boots where possible. QrSeal all flashings with clear Geo-Cel sealant. No black tar unless previously applied. &Remove all work-related debris. IdContractor 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. ElRemarks: A1CsT f ,In- JI-A-11 &4FC'o42 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 abo e. Date of Acceptance: / �s 7 Signatur E i� � x GO o w° a U) o a w° N rg U Ca w a � �. m w a W W U W W o w chi � w a o U moo o c� — c w z W W v cn ° z cin L o cn O F=4 E L- IE N O N C O a cm m 12 01 C m o cm c_ �C N m 0 Z 0 0 O �o z O U �1 169 v O 4 •r.a I co cm C C 'wCD O ■� Q CO2 CD FE m m L- H �c CL _4-0 CD CD � � L m CL ME rm CO2 C O= *-a C ccc CJ J= C x CD CL V CO) CD C �C C c a H 0 0 LLI A W W W U) cc Em X N rg c4i av E c :.o 0 o 'r 2 �mcnc h A .0- Omo 0 m; C � W m Q y V7� •� Z � m .r :z c CA E L- IE N O N C O a cm m 12 01 C m o cm c_ �C N m 0 Z 0 0 O �o z O U �1 169 v O 4 •r.a I co cm C C 'wCD O ■� Q CO2 CD FE m m L- H �c CL _4-0 CD CD � � L m CL ME rm CO2 C O= *-a C ccc CJ J= C x CD CL V CO) CD C �C C c a H 0 0 LLI A W W W U) cc Em av h O O C Q y O Q y V7� •� Z .r c n o H m y O c = O m r O W C OyZ�L Liu o ca •Va m_..c.. MD O ac .E C 7 +' .y ,o U C.3 mca , V1 O' m .5 O :5 Z W .0 ` y = =CL *-a4m E L- IE N O N C O a cm m 12 01 C m o cm c_ �C N m 0 Z 0 0 O �o z O U �1 169 v O 4 •r.a I co cm C C 'wCD O ■� Q CO2 CD FE m m L- H �c CL _4-0 CD CD � � L m CL ME rm CO2 C O= *-a C ccc CJ J= C x CD CL V CO) CD C �C C c a H 0 0 LLI A W W W U) Location ��� om No. Date k4` d ,401tTIy TOWN OF NORTH ANDOVER 9 i �, ....:.:..: Certificate of Occupancy $ s�cHus Building/Frame Permit Fee $ _.s Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # G r 20 6) Building Inspector