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HomeMy WebLinkAboutBuilding Permit #707 - 188 CHESTNUT STREET 4/5/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION D Permit NO: Date Received Qf t,�LEO 16 �•P O TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family. ❑Industrial No. Q Commercial ❑ Alteration of units: epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic, r �rWelfi,� 4 � ' - � r � # �'Floodplam"�' ¢� V�/e'tlands ` ❑� Watersheds®�s'trlc� �� � ; } � Crater`/Sewers t ' - - urn. UtbUKIY 11UN Ur YYVM- M I V VF- Identification Please Type or Print Clearly) OWNER: Name: �"S N A SSa. r Phone: ��� — `� g S� Address: 1 `% `6�- e -S 'J T Toy- 'CON�TRACTOR� Name' 14, Phone , SYS Address'. r vSup_ r ervisor's�Canstrocti+on License a � r Horne lmprovement�icehse`'.3 z ,.._ - . - ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ (© 663- FEE: $ I Check No.: 2 Receipt No.: I S NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund h Location 1 �S C �!S 6t 0 T No. Date �i� , • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1� l Vl�a 25157 Building Inspector 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 HEALTH ❑ COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED J DATE REJECTED DATE APPROVED 0 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street COMMENTS` b }< v A 4 f r.y a4 v.1 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 • R.; w wPw uw O P, x x Fol O u o O w " a v cn A w a � 0 p w � O w C U ; G w a p rs: G iw w w p w 5 y V) C w t7 0co r�: w w C� E co o z Bi cn Q O cn 5 0 OmC O ` O y C O Q C-3 CL. cc C3 C m C O co co N = :Ea %11F o v . � n • V *00o y .o m s, w 3 co m CA ca C � m J C C � — m O A A 1 h mo aC ` '�'-'my Z 'C O OQ . w y � COL. Ll ,t � Co h z F w: o a m h -m C = m COL p H w H o� W C O5'pt rr N dt O C O � NJ LLJ = .i v v c CO a mL3 CD0zip� O22 CLGo = l0 :..O y .0 E a h h ;a H C cm CD C?, C m 0 cm c �C N CD O Z O cm zip U O O 9 co O E CD • O Z O 0. O y � C O cm i O M E m m CD CL _~ t O � O � ; C O coL � O d c c *-0 c ev cc v'FLCD J .� C CD �..± y O C C cc — h is uj 0 LU W W W W N The Commonwealth of Massachusetts - I D2 Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): r� t° S 4' Ci N�1R_ Address:_ 1A PaN e � S �- City/State/Zip:_ fy _ 4-/4a,C, /A Iq Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. El construction ` __ employees (full and/or part-time). * have hired the sub -contractors �-- ?• emodeling 5�� 2. M am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. F1 Building addition [No workers' comp. required.] officers have exercised their 10. ❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i employees. [No workers' 13.❑Other 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 aie 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 Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 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. I do hereby certiAunder the pains ant alties ofperjury that the information provided above is true and correct. Phone #: i -7,g 6,9 a— '.)-d a 3 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 ofhire,• 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, §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 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 (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. 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 or permit to burn 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 Q£Iuvestigatitons 600 Washington Street Boston, SIA, 021.1 t Tel, # 61.7-727-4900 at 406 or I-877,MASSAk'B Revised 5-26-05 Faze # 617-727-7749 __WWW-mass,gQV1dia Building and Remodeling 5 APPLETi ON STREET NORTH AMDOVER , MA 01845 (978) 682 2023 Proposal Submitted To: H J Nassar 188 Chestnut Street North Andover, MA 01845 HOC Lic. 920296 Expires 99/99/2093 CSL Lic. CS 54718 Expires 6/8/2012 Proposal Job: install new replacement windows April 4, 2012 Home Phone: (978) 258-6995 Obtain building permit Complete removal of all demolition and construction materials generated by Testa Building and Remodeling and its subcontractors. WINDOWS Supply 25 new Harvey windows. Remove sash and sash balances and install in existing frames. DOORS Replace the weather striping on the existing front door. THERE IS NO ALLOWANCE FOR PAINTING OR STAINING INTERIOR OR EXTERIOR Start date 4 / 11/ 12 Ending date 4/18/12 A finance charge of V/2% per month (18% per year) will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection, including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of: $10,663.00 Ten Thousand Six Hundred and Sixty Three Dollars One- third to start, one-third after windows are delivered, one- third upon completion. Authorized signature I reserve the right to cancel this contract if not accepted in_30_ days Signatu Signatu DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES ;9 0 CD A 0 r 0 LO IS '16 0 . 11, 0 .0 Z to D 0 UJ 00 ul 0 CD W uj vu-) uj I 0 CN NI IN (U C zo zo C, jj -�n 0 WF- > o < < <