HomeMy WebLinkAboutBuilding Permit #767-73 - 36-38 Johnson Street 5/15/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: 1 Date Received
Date Issued: 5' K
I IMPORTANT: Applicant must complete all items on this bane I
LOCATION - SG%{�ysr:� . _ s 7, --
Print _ •_ - _ _
PROPERTY OWNER/{rte/.
1 -*1 Print 100 Year Old Structure yesno
MAP NO: (� PARCEL: ZONING DISTRICT: Historic District yes no
t Machine Shop Village yes no
.TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
0 One family
❑ Addition
Iwo or more family
0 Industrial
❑ Alteration
No. of units: -
❑ Commercial
"epair, replacement
0 Assessory Bldg
0 Others:
❑ Demolition
❑ Other
El Septic ❑ Well
❑ Floodplain ❑ Wetlands
0 Watershed District,
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
OWNER: Name:
Address: -:� A�-C—
Please Type or Print Clearly)
/17`
CONTRACTOR Namel�'1%/�{iTG,l CSG'jc/I, Phone:l—
Address:
996�-
Supervisor's Construction Licenser' S :67A,27 / Exp. Date:
Home Improvement License: 227a7-1- Exp. Date: �--
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $- cr FEE: $
Check No.: �� -- Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
;Signaturerof Agent/Owner
Plans Submitted ❑ Plans Waived ❑
Signature of contractor
Certified Plot Plan ❑ Stamped Plans
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
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COWENTS
DATE APPROVED
M
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow ! Engineer: Signature:
FIRE DEPARTMF_�7N7T - Temp Dumpster on site yes,
Located at 124 Main Street
Fire Departmerit-signature/date
COMMENTS
Located 384 Osgood Street
no
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 — (For department use
® Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The fohoowing is a list of the required forms to be filled out for the appropriate. permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o Floor Plan Or Proposed Interior Work
o 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
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
o 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
o 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 appaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must bp submitted with the building application
Doc: Doc.Bui?ding Permit Revised 2012
Location
S�
No. - Date ` r
Check #�L
26397
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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O COWNWIFLILTUIrlow
R00FXWQ COMPAILWY
Haverhill, MA / Plaistow, NH ['Residential
.C�1ChIt4Ce�, %Kd�O�Il,�, SSG 1`Gtatt� ❑ Commercial
Date: Estimate For: AR+JAVP,
Telephone
Address:
Telephone 2:
City/Town: State:_ IV
Job Location: ICity/Town: State:
Quotati /Proposal t furnish and install the following:
@Approximate roof area: i.
1p -New Roof ❑ Re -roof ❑ Gutter ❑ Repair ❑ Ventilation
❑ Re -sheathing of roof deck using
plywood
Prepare for re -roofing by ensuring all safety measures are taken in accordance to OSHA standard regulation.
D/Remove existing layers of roof materials down to the roof deck and inspect wood. IF upon inspection we discover any rotted
wood, replacement will be performed at $ per square foot. If wood is sound we will re -nail any loose wood to the
rafters, sweep deck, and prepare for installation.
L 'Knstall 8" drip edge ❑ Install 5" drip edge ❑ Install hug edge ( re -roofs only) 916-lor
VApply ice and water (underlayment) per manufacturers specifications and or
8/Apply felt paper (underlayment) to the balance of the exposed wood deck.
VRe-flash all stack pipes, tie-ins; chimneys and/or roof penetrations as required to ensure water tightness.
❑ Re -seat chimney base using cement and fabric P e -lead and point chimney ❑ Re -build chimney $_
LP,I[nstall new , 3L yr ❑ traditional U46chitectural style shingle roof system
L2color �c e%A Manufacturer _ LZ& <J?4
Vurnish and install a new shingle over ridge style vent system ❑ Solfit vent system $
gill debris generated by MWG Construction will be cleaned and disposed of from the job site in a legal manner. In no
circumstance will the water tight integrity of the building be compromised.
Special Notes-:
ON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A
PERIOD OF TEN YEARS HONORED AND ISSUED BY MWG CONSTRUCTION AND 3a YEARS HONORED
AND ISSUED BY THE SHINGLE MANUFACTURER.
a
Total Estimated Price: $ Date of Acceptance:
Payments to be made as followed: 4-50– � (Home/Business Owner): a,-
/ i ature)
ignature)
Business # 603-382-5929 Fax # 603-382-7955 Cell # 508-783-0511
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North Andover Board of Assessors Public Access
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Summary
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Page 1 of 1
roperty Record Card
Pnrral TPI •)IWAGA n_MdC_nMn n 117v•9n1 2 ( ,w rv,,n;4 .. IV--iu A -A-..,...
xation: 36- 38 JOHNSON STREET
wner Name: CHASE, ARTHUR, R.
CHASE, THERESA, A.
wrier Address: 36-38 SALEM STREET
City: NORTH ANDOVER State: MA Zip: 01.845
eighborhood: 7 - 7 Land Area: 0.12 acres
se Code: 104 -TWO -FAM -RES Total Finished Area: 1961 sqft
ASSESSMENTS
al Value:
ilding Value:
id Value:
rket Land Value:
apter Land Value:
CURRENT YEAR
282,100
106,400
175,700
175,700
PREVIOUS YEAR
307,500
138,300
169.200
http://csc-ma.us/PROPAPP/display.do?linkld=2256028&town=NandoverPubAcc 5/15/2013
The Commonwealth of Massachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 0 ni ECA-/tcL r7c6-r-se�i�
Address:_?9_
City/State/Zip:�il/�tS��t/ XIItil- Phone #: N5_09 -722-05-1Z
Are you an employer? Check the appropriate box:
1. VI am a employer with _-2, 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2111 am a sole proprietor or partner- listed on the attached sheet. I
ship and'have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3111 am a homeowner .doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
5. ❑ 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. F1 Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.VRoofrepairs
13.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they tie 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:. I° ut yAl—
Policy # or Self -ins. Lie. #: %G? i ��� (K�� Expiration Date: A) 3G —/3
Job Site Address: �� �� �%� City/State/Zip: ko AA t�rk� C
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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.
X do hereby certto under the pains and penalties ofperjury that the information provided above is true and correct.
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 #:
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 or other legal entity, or any two or more
Of the foregoing engaged in a j oint 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 ofpublic 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 to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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 (ifnecessary) 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. Anew 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 orpermit to bum leaves etc.) said person is NOTrequired 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 Goxuwnwealth ofMossad-I sets
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tei, # 617-7274900 ext 406 or. 1-g7MAM SS.A,FB
Revised 5-26-05 Faze # 617-727;7749
�vt�ur_mace o-nirfrlia
J
MWO CONNTRVCTION
ROOFIWQ COMPAWY
Haverhill, MA / Plaistow, NH ['Residential
.C&wacd. #7440 cd, State 7dtd ❑ Commercial
Date: --5--110-12 Estimate For : 14 R+24L., , C,,6�2,fa-
Telephone 1:- 3�.— G / Telephone 2:
Address: �� - �� `moo /{,� J 57- City/Town:1,1b A&j8o ,� State: oVli55
Job Location: City/Town: State:
Quotati /�Opos�t(
furnish and install the following:
a
WApproxunate roof area:
f l�New Roof ❑ Re -roof ❑ Gutter ❑ Repair ❑ Ventilation
❑ Re -sheathing of roof deck using plywood
VPrepare for re -roofing by ensuring all safety measures are taken in accordance to OSHA standard regulation.
VRemove existing layers of roof materials down to the roof deck and inspect wood. IF upon inspection we discover any rotted
wood, replacement will be performed at $ per square foot. If wood is sound we will re -nail any loose wood to the
rafters, sweep deck, and prepare for installation.
"stall 8" drip edge ❑ Install 5" drip edge ❑ Install hug edge ( re -roofs only) (dolor 4i,, / /
VApply ice and water (underlayment) per manufacturers specifications and or — �-
VApply felt paper (underlayment) to the balance of the exposed wood deck.
(/Re -flash all stack pipes, tie-ins, chimneys and/or roof penetrations as required to ensure water tightness.
❑ Re -seat chimney base using cement and fabric P e -lead and point chimney ❑ Re -build chimney $
Llnstall new -_ L yr ❑ traditional t- 11(rchitectural style shingle roof system .,
U/color �(6(,yCpCK U4-Aanufacturer
Furnish and install a new shingle over ridge style vent system ❑ Solfit vent system $
&-jgdh debris generated by MWG Construction will be cleaned and disposed of from the job site in a legal manner. In no
circumstance will the water tight integrity of the building be compromised.
Special Notes:
ON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A
PERIOD OF TEN YEARS HONORED AND ISSUED BY MWG CONSTRUCTION AND 30 YEARS HONORED
AND ISSUED BY THE SHINGLE MANUFACTURER.
(�7��n CG
Total Estimated Price: $_ L/ TW • L Date of Acceptance: �` Q
Payments to be made as followed: � j T7 �.
,%%Y / /S (Home/Business Owner):
133)_ (//��i�l/ C!//7� 1;`_ �i ature)
��C (MWG): _
ignature)
Business # 603-382-5929 Fax # 603-382-7955 Cell # 508-783-0511