HomeMy WebLinkAboutBuilding Permit #832-16 - 198 MASSACHUSETTS AVENUE 1/22/20161
4o� ly
Permit No#: ?-3.�? -,
Date Issued: /"/),9
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
K/"'
A-6:
F I IMPORTANT: Applicant must complete all items on this page I
LOCATION leg mos�echu.�(/dl,5. Wo K&�� A,,-, A o si e i
Pnnt L�.c
PROPERTY OWNER 5 re
yes no
P1 t
, MAO- --PARC-a: ZONINdtISTR16T: H i sfo-t I b, D I S tr' I b't 'y"�p s no
Machine Shop Village yes n o
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
El One family
El Addition
El Two or more family
El Industrial
�(Alteration
No. of units:
El Commercial
�(Repair, replacement
El Assessory Bldg
0 Others:
0 Demolition
El Other
XV
'S I-
Map -A
ANtd' NOT 7
e - Ir
M &e_We
A '�' Cat7e, rJR
DESCRIPTION OF WORK TO BE PERFORMED:
00 9f-,Z,5,5u--f-Q V�-��ZA QJ00A )CC�*NN,
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Address:
C'bhtrbctbr Name: ?a -y) Tabd\f -e5 Phone: 07- ce
oan 'Ve Li2bn�- (InhQ
�4 Ab*4�4�7�a mi4.
Supervi "Cb'h"tr' ibh� Li6orise"' Ex'p,�%-'Datel-.:
so 40
Home Imprcivement License: 16 E31 63 Pxp. Date: I/ az
-J]
ARCH ITECT/ENG I NEE
Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT: $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ E3 s-oo.00 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered c a �
0�tractoq do not access to the guarantyfund
A 1.,17^ - - tp -
. Plans Submitted F1 Plans Waived Ell Certified Plot Plan Stamped Plans F1
TYPE OF SEWERAGE DIS�-OSAL
Public Sewer El
Taming/Massage/Body Art E]
Swimming Pools
won El
Tobacco Sales El
Food Packaging/Sales [I
Private (septic tank etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature'.
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection Driveway Per mit
DPW Town Engineer: Signature:
Dimens I ion
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 rnin.$100-$1 000 fine
NOTES and IUA FA — (t -or clepartment use
El Notified for pickup Call Emai
Date —Time- Contact Name
Doc.Building Permit Revised 2014
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
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4, 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/Cross Section/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 .
TE: 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
2012 IECC Energy code
4� Engineering Affidavits for Engineered products
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
Doe: Building Permit Revised 2014
Location Z 2
No.
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$/0
Foundation Permit Fee
$
Other Permit Fee
TOTAL
$
Check #
9.9
Building Inspector
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PROPOSAL
4 GREENBRIAR DR. UNIT 207
NORTH READING, MA 01864
GC LIC # 102965, HIC LIC # 1681.63
JEANTABARESOHOTMAIL.COM
,*3 GOA WK -14"
Customer Name: 198 MassAve Realty, LLC
Address: 198 Massachusetts Avenue
il fu
!)b
0
)-;ow
200 -
Date: 1 / 18 / 2016
Item
�D( tipti6n
)scr
Ouantity
Unit Price
cost
80.0ofs
ag'45
-
rarnp.
(w.
n , 1) jIni
Or
LABOR
lngfalUtiorYof a,handicao handrail fin--the1roht ofthe
')dl 'A'-dtif to�.,
�buildln-q-f I ff I 0"it " is ( f I I
-1�1' k)
r f
SHALL MEET.ALL ADA &MABUILDING.1i
CODES.
*ASPHALT PAVEMENT WILL NOT BE CUT TO
LABOR
INSTALL RAMP.
DESCRIPTION
*OTHERS RESPONSIBLE FOR PARKING AND
TRAFFIC ALTERATIONS OR CHANGES.
*RAILS SHALL BE METAL ADA & VINIL OUTER
RAIL
MATERIALS
BY CONTRACTOR.
1
$ 0.00
ALLOWANCE
"TABARES CONSTRUCTION".
GARBAGE
REMOVAL OF ALL DEBRIS.
$ 0.00
DISPOSAL
Subtotal
$8,460.00
Contractors Fee 10.00%
jWAIVED
Total
$8,450.00
�pqIntra.p.torSig:
Customer.Siga
6 U t-,(
W810 AMI 0,141GA29, HTPOO
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TERMS AND CON
"YJ 1
1)Scope of work: Contractor agrees to furnish all laboy;�spryjqe§,j.n
,Xt9j.jqI§.Jp§tallation,-s ies,
__ p
pp
,,, 1
insurance, equipment, tools and other facilities required for proInp pnd, efficient execution. of the work
described here in a professional and workmanlike manner.
2)Quote Amount: Owner agrees to pay contractor for the strict--.perf6rm- aiR:e;of-,Wo&Ifthe,,suM,as may be
subsequently agreed upon. i). I Q� \ 8 r ,, t :at fi ")
3)Payment schedule: Owner agrees to pay contractor in progress payment as follows:
ayment #10000.00 upon the sipging of the estimate.
05
! ",�
P4MUM #14-;
t6
Firtat
�,p pe0$ 4,QQO 00 upon 100% comp pjAT ok the s6fiiFfh-ag iWH6d
�koon
agreed alon the progres's of the project, "extras".
4)Work scheduley contrac. tor shall c(�mplete the work, as.required, by agreementwtthx�e, home owner,
contractor is! agreed to talke no longei then 3 Days from the starting date (0 1-22-2016) to; complete the
wbr'k. Ihe 04ties hereto �have executed tldg�'A7086'm6htlfoi'.diems6lids,�'theit,"hei�,,-dxdciitbrs, successors,
administrato'rs, and assignees on the day and year written below.
A' 4,
11 All
J jr
Customer Sig: Contractor Sig:
IA' 4
0 AM, , rMIQA214 1-174NOAf
t'�-tW "I, jIJ '301 '�NNINW �Xi'
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TERMS AND
I)Scope of work: Contractor agrees to furnish all labo
,r-;�qe �p
ies,
insurance, equipment, tools and other facilities required for prompj land efficient exec ti ii,qfthework
described here in a professional and workmanlike manner.
2)Quote Amount: Owner agrees to pay contractor for the strictperfbrmance-lofVorki� the,su,mes may be
subsequently agreed upon.
3)Payment schedule: Owner agrees to pay contractor in progress payment as follows:
Pavment #10000.00 u -non the sin2inLy of the estimate.
.- . I
agreed along the
. 1 �'
4)Wor-k seheduley eontra4
I
��gr
contractor isl to tal
wbik.1he'Pintes hereto'
adminis ators , and assig
I
upon 1UY-/0 con�pippqq
I
or me Proiect, "extras".
r,shall c�mpletettiev.orkasxequired byjagreementwith the,home owner,
!19 longei then 3 Days from the, starting date (0 1-22-2016) to, complete the
, f -- - ---
ve executed successors,
-s on thelday and year written below.
V",
�A,
Custom'er Sig':.� . . , . , , " � � � I'-, i;' % , 'I
�Ponlractor Sjq:--. . I . . L..:-
The Commonwealth of Massay.chuselts
Department ofindustrialAceldents
I Congress Street, Suite 100
Boston, MA 02114-2017
Www.mass.govIdia clansfRiumbers.
Compensation Insurance Affidavit: BadersfContractors/E*41
TO BE FILEID WITH TRF, PERMTT'NG AUTHO'UTY'
Name (B,..wiuessiorganizaiionftdividlal)*--j—(A���(��'
Address:
AA Phone
City/State/Zip_
Are you an employer? Check the aPpiopriate box'.
I.V41 am a employer with—, (�_.).rnployecs (full and/or part-tirne).*
Wo king for me in
,2. 1 am a sole proprietor or partnership and have no employees r
any capacity. [No workers' comp. insurance required.]
I am a homeowner doing all work myself [NO workers ' �3orap. insurance required.] t
4Q I am a homeowner and will be hiring contractors to conduct all work on my propertY. I will
ensure that all. contractors either have workers' compensation insurance or are sole
5.FJ I am a gpneral contractor and I have hired the sub-cofitracto�s listed on the attached sheet.
_fbese Ub_c,,tractojs &V� ej�ploye�s and have w�rkers' con�p. insurance.:
6.n We are a corporat�on and i Is gffiqqrs have exercised their right oflexemptionporMM 0.
152� § 1 (4), an� We have [No workers' comp. insurance required.]
.t:, . . . I I
-�b 7 9L3 oz oG
' i
Type of project (Tqquired):
7. El Now construction
S. tgRemodelffig
9. Q Demolition
10 El Buil(�ng addition
11. Electrical repairs or additions
13. F! Roof repairs
14. E] Othbr_
*Any applicant that checks b6x#1 must also fill Out the section below showing their workers' compensation policy inform ' ation.
t Homeowners who stbr�if Us affidavit indicating they are doing all work and then hire outsido-contractois must s4bmit anew affidavit indicating such.
n have
tContrai,tors that check this box ir�ust-attached an additional sheet showing thp name of the sub -contractors and state.whother or jiott�oso G fifies
employees. If the sub-c6ii6c6s fia�� employ-eeg, &� n�uit Pro.vide their workers' comp. policy number.
I am an eftiployer th at is pidvidfilg -w ork�rs' COMP ensaflon insuran cefor MY empl6yees.' Below is th e p o ficy an djob site
information.
Insurance Company
Policy 0- or Self -ins, Lio.
Expiration Date:
fob Site Address: City/State/Zip: ir ti n date).
Attach a copy of the workers, compepsation policy declaration page (showing the policy number and exp a o
Fail -are to secure coverage as required under MOL o. 152, §25A is a criminal violation punishable by a fine up to $1,500-00
and/or one-year imprisonment, as well as civil penalties inthe form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be, forwarded to the oiffice of Investigations ofthe DIA for insurance
coverage verification. formationprovided above is true and correct.
�do hi�?rehy ce�rti
.fy under thepains andpenalfles ofpeijury that the in
0-1-4-1— 4/,ftA 1akW)P)-- Date:
Phone #:
Offleial use only. Do not -write in this area, to be eompleted by city ar town official
City or Town:
peymit/License #.
Issuing Authority (circle one):
1. Board of Ifealth 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Persom Phone
MM
The Commonwealth of Massay.chuselts
Department ofindustrialAceldents
I Congress Street, Suite 100
Boston, MA 02114-2017
Www.mass.govIdia clansfRiumbers.
Compensation Insurance Affidavit: BadersfContractors/E*41
TO BE FILEID WITH TRF, PERMTT'NG AUTHO'UTY'
Name (B,..wiuessiorganizaiionftdividlal)*--j—(A���(��'
Address:
AA Phone
City/State/Zip_
Are you an employer? Check the aPpiopriate box'.
I.V41 am a employer with—, (�_.).rnployecs (full and/or part-tirne).*
Wo king for me in
,2. 1 am a sole proprietor or partnership and have no employees r
any capacity. [No workers' comp. insurance required.]
I am a homeowner doing all work myself [NO workers ' �3orap. insurance required.] t
4Q I am a homeowner and will be hiring contractors to conduct all work on my propertY. I will
ensure that all. contractors either have workers' compensation insurance or are sole
5.FJ I am a gpneral contractor and I have hired the sub-cofitracto�s listed on the attached sheet.
_fbese Ub_c,,tractojs &V� ej�ploye�s and have w�rkers' con�p. insurance.:
6.n We are a corporat�on and i Is gffiqqrs have exercised their right oflexemptionporMM 0.
152� § 1 (4), an� We have [No workers' comp. insurance required.]
.t:, . . . I I
-�b 7 9L3 oz oG
' i
Type of project (Tqquired):
7. El Now construction
S. tgRemodelffig
9. Q Demolition
10 El Buil(�ng addition
11. Electrical repairs or additions
13. F! Roof repairs
14. E] Othbr_
*Any applicant that checks b6x#1 must also fill Out the section below showing their workers' compensation policy inform ' ation.
t Homeowners who stbr�if Us affidavit indicating they are doing all work and then hire outsido-contractois must s4bmit anew affidavit indicating such.
n have
tContrai,tors that check this box ir�ust-attached an additional sheet showing thp name of the sub -contractors and state.whother or jiott�oso G fifies
employees. If the sub-c6ii6c6s fia�� employ-eeg, &� n�uit Pro.vide their workers' comp. policy number.
I am an eftiployer th at is pidvidfilg -w ork�rs' COMP ensaflon insuran cefor MY empl6yees.' Below is th e p o ficy an djob site
information.
Insurance Company
Policy 0- or Self -ins, Lio.
Expiration Date:
fob Site Address: City/State/Zip: ir ti n date).
Attach a copy of the workers, compepsation policy declaration page (showing the policy number and exp a o
Fail -are to secure coverage as required under MOL o. 152, §25A is a criminal violation punishable by a fine up to $1,500-00
and/or one-year imprisonment, as well as civil penalties inthe form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be, forwarded to the oiffice of Investigations ofthe DIA for insurance
coverage verification. formationprovided above is true and correct.
�do hi�?rehy ce�rti
.fy under thepains andpenalfles ofpeijury that the in
0-1-4-1— 4/,ftA 1akW)P)-- Date:
Phone #:
Offleial use only. Do not -write in this area, to be eompleted by city ar town official
City or Town:
peymit/License #.
Issuing Authority (circle one):
1. Board of Ifealth 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Persom Phone
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 litre,
express or implied, oral or written." r
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, partuership, 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 anotherwho 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 ba 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."
Applicaants
Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub=contractox(s) name(s), addresses) and -phone number(s) along with their certificate(s) of
- insurance.—Limited-Diability-Companies-(L-L-Croxi,imited L-rabgity-Pa -tnn rslu-py(LLP) withno employees o er�an 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 may be submitted to the Department of Industrial
Accidents foi- confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The'a£6idavit should
be returned to the city or town that the application for the permit or license is being requested, mot 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-iheir •
self imsuranice 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 burp. leaves etc) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 eat. 7406 or 1-877-MASSAFE
Fax ## 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Office of Consumer Affairs & Bdsiness Regulation ,
HOME IMPROVEMENT CONTRACTOR,
Registration: 168163 Type:
€A �vt
Expiration: ' 4:43f20,17 DBA
TAS RES CONSTIRUG.ION
JEAN TABARES ' w%
4`GREENBRIAR D, RTV207
NORTH READING, Mft O_$ 4,`t Undersecretary
Massachusetts Department of Public.Safet.y
Board of Building'Regulations and 5t"t arils
Construction Su.pemisor
License: CS 102965
JEAN P TABARE�
35 VIII AGE G'tEENllR /f
North Andover N1FAA ;04 a
k, ,w
,Expiration
Commissioner ;08/23/2016