HomeMy WebLinkAboutBuilding Permit #669 - 24 Pine Ridge Road 5/13/2008Permit NO:
bUILUINU rr-MIVIl I
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
0 Alteration
No. of units:
El Commercial
0 Repair, replacement
❑ Assessory Bldg
❑' Others:
❑ Demolition
H �
b�^.'
cg„ z
❑ Other
wn
Ii1 s �' 4`Y -
Al3A£ �def
`9
un a,_•MR R"�
OWNER: Name:
❑t5GK1t' I IUN Ur YYUMM 1 v DC rr«rvrXwiw.
Identification Please Type or Print Clearly)
Phone:
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: $ Ap, Goof o ® FEE: $ 15-1—
Check
S'rCheck No. id 63 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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)
o 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
DATE REJECTED
DATE APPROVED
El
DATE REJECTED DATE APPROVED
N
DATE REJECTED DATE APPROVED
:HEALTH
.f .
COMMENTS
FER
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision: Comments
Conservation Decision: Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
Located at 384 Osgood Street
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 — (Fnr rJenartn,nr,+ ,.,e1
Doc.Building Permit Revised 2007
❑
Notified for pickup
- Date
Doc.Building Permit Revised 2007
Location
4T
No. Date
&OWTN
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #(JO �3
52
Building Inspector
CA
m
m
m
CO)
m
CA
F)
i
v
C �
� d
O
CD
n Z y
CL n.
C
CZ CO)CO
a�
Co
o p CD
CD
Q
CD
CDo CD
w 0� B
S
=- O y
CD
I
� v
CO)CD
O
� Z
O CD
O
C
CD
dW�
r
z
d
L
z
O
.X
n,�
C-) C.)
co
W .
� O
(n
E3
ro
dp
Cn
.'*i
d
o
�yQQ H
O
E
IF
',i7
O
C”
n
mma�
•jJ
O
o�v
?
��.,
to
d
y
O
.d•� O
„•r d
CD
c
°
n
ro
O
d
O
�O
:
p
O
gymCD -1'
m
m�p
O
O
y
!09
. .� O O
C
� fn
a
m
CL„. �• :
Cl =r
s
O y '
CD
Cid:
am
m
Hd
d
Q
N
C
m
CA
H
m �
O
O O
m:
z
O
.X
n,�
C-) C.)
co
W .
� O
(n
E3
ro
dp
Cn
.'*i
p7
G
►firCD
d
',i7
O
O
Cn
',i7
O
C”
n
',r1
O
•jJ
O
o�v
?
��.,
to
'z7
O
_
(�
`Jd
O
oCa
T
a
w
G7
z
c
°
n
ro
O
a
S
d
yr.,'t �, + t +c,. t i -'+ t •G» + �c� Ii int t � tif: Cilli ��
I Tye Of
Steel Tc-�'.. ., r;� � Masonry Work
NIas= -} F ; Licensed & Insured
800Jnr,69" L, .; - _... 3License #034200
(924-341 _._ __ �� We- Work Year r <mnd
ti"
Proposal Submitted To:
Date:
Dr. Mark & Linda Klein
2/11/2008
Street:
City, State & Zip:
22 Pine Ridge Road
North Andover, MA 01845
978.689.6212
Proposal
1.
Strip all shingles from house.
9. Contractor warrants roof against leaks due to work -
2.
Remove all Hix Vent drip edges.
manship for 10years under normal conditions.
3.
Install all new custom bent aluminum drip edges
with a longer face that will extend closer to the
Shingles are covered by manufacture.
gutter so we don't have to remove the gutter.
4.
Apply 6ft of Ice and Water Barrier on all eaves
10. Remove all work related debris.
and top to bottom in valley's.
11. Includes all building permits.
5.
Above the Ice and Water Install heavy 301b Felt
Underlayment sheet.
6.
Install two power roof vents by GAF. One will be
Total Amount: $12,600.00
a Power Roof Ventilator and the second will be a
Gable Ventilator. Note: Doesn't include any, Elec-
Payment due upon competition
trical work. Note: These vents will take the place
of the ridge vent.
7.
Install 30yr IKO Cambridge architectural shingle
color dual black. Note: Doesn't include the lower
new section of the roof.
8.
Install Button Style vents under sofits where pos-
sible for ventilation.
? iC Sspecificatictis
and cmditions are sailsfacffA4
YOU ai-e lid.. tfioi-1%c l to do ulbliattlr
.7!�li��:ltiE
—,:awy j
Beard of Na"as Recab #iem ead stmadnnh
: 137057
�► 10!1P2008 TID 128146
Type. DBA
*AA. UNDER ONE ROOF
JOHN LAIAZAFAME
IN A MERRIMACK ST
ZMT"EtiN. MA 0184` Adc*cbovbr
lor vsW fw b3dhifal an aafp
befteft ifs. ctrsr s Ix
Baud cc ezoftg ftwobam aa6 Sbudnr&
Oct Aslbafto !'mot Rm 1301
etsftm ilk. calm
JOM W LANZAFAM
30 TERUILE OR
UEilfllW INA 01841
Co.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations .
t d 600 Washington Street
Boston, MA 02111
www.mass:gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legihly
Name (Business/Organization/Individual): �(� J✓1QC?'l CZ�� /��ar' T�1,� 2 -All 7147--7
Address:
%L�� �- ��
(�-(� -�i-(�Z�S I�r,✓IQS�
t�� `�
City/State/Zip:
Phone #:
A�ym
an employer? Check the appropriate box:
1. a employer with 4. E:1I 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
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
lo.[:] Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #E l 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-
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I anz an employer that is providing workers, compensation insurance for my employees. Below is the.policy and job site
information.
Insurance Company Name:
/10 ii/- (
Policy # or Self -ins. Lic. #: A1J C- i o 6 9 k4G u U( ZO ° 1 Expiration Date: 1! 19 1 0
Job Site Address: q p/ �J C — C- s 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 insuxance coverag.q_verification.
I do hereby eezli fy ndehe pair, and pezzalties of pezjury that the information provided aboveistrue and correct
Trate 'S 13/ a y
Phnnn. #- U 9 11)Il - I? 17's-
12 ,SCJ
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Perri t/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 #:
1 �
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 hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation 6r 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, §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 -contractors) name(s), address(es) and phone number(s) 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 tocarryworkers' compensation insurance._ If.an LLC or LLP..does have
employees, a policy is required.. Be advised thatthis 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 pernlit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/liceftse 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 bum 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-N ASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia