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Home My WebLink AboutBuilding Permit #854-13 - 201 CARLTON LANE 6/6/2013 (5)TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: c7) IMPORTANT: Applicant must complete all items on this page LOCATIO.IV' Pr nt PROPERTY OWNER.: o -i- - _ Rnnt Tw Y`r.old Structure_ yes an MAP, NO_nn PARCEL: ZONINGDISTRICT _ _ Historic District yes trDe Machine 8h ill. yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition Two or more family ❑ Industrial I&Aiteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other YjSe tic, Q Well= D516odplain. ❑ Wetlands ❑ Watershed,District a Sewer 1 DESCRIPTION OF WOR 0 BE PERFORN)ED: �� .-o `C��..w.+�._"i� �+4ltN✓> U �� n Lel.. �h. � (��i!_w..o.� `��-�f � p r Identification Please Type or Print Clearly) OWNER: Name: Phone: 68 -1 - b bbd Address: ?-\)k LCQNT+RAC3TOR. Name: "Address: ' Supervisof's Construction Licenser 0531)-q°1 Exp Iinprovement,�L ARCHITECT/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: $ 2� ; OSU FEE: $ 25 3 Check No.:112 �L Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acce s to the guaranty fund Slgnatlire of Agent/Ovuner' ,_ Signature of contractor. � Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans Locatio , (� No. — Date ,A; Check j T�2-7Z' 26492 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ •" TOTAL $ Building Inspector Plans Submitted ❑ Plans Waive Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL 11 , 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature a -COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Towii Engineer: Signature: Located 384 s o Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124.Main-Street... Fire DepartiM66f$ign6tu"re1date COMMENTS • 4 J LLJ = U. C cc O m O uQJ Y -0 O LL N to U +-' O_ N by� N Z Z m O 2 N "a C O LL t O d' T O C E t U ro c LL OO V 0. N Z Z co 2 d t bD O w m C LL L.7 W N Z V cc u W W j O K j N VI is LL �' O W a Z N O bb O Of io C LL H Z W Q W c w 7 CO z N +`� 0 0 N O E V) J 0 LU U) z CD o m 2 � 0 O dg - Cl) U W a Z x O � U W M Z v O z: Iz- `Iv E O Z CL O CM D = ' O .Emm a ~ t O V 0 A� O Q I.a. CL � Q E- 0 'a t t.) -ca J .CL O 4; Z 0 CL 0 t/1 m C. a E- E- O �- c � o •Q. L Q. r �a o o2 N C E a. c � o � �O QQ c1 cL m m c c ��as 0A��00 w — o= N � E .�0 "z O" U. N .o � N O o � Q C d � d � V ++ c c00 .N c -0V �O O c ~ y0+ R d•vm N c "o— O W O ° ti N to N c .= .E v W V Q O 'a m y d '— .Q >04- _ 2 F- m t. o c o . CLOU J 0 LU U) z CD o m 2 � 0 O dg - Cl) U W a Z x O � U W M Z v O z: Iz- `Iv E O Z CL O CM D = ' O .Emm a ~ t O V 0 A� O Q I.a. CL � Q E- 0 'a t t.) -ca J .CL O 4; Z 0 CL 0 t/1 m C. 1(.evin Mip h Building Contractor Proposal To: Rob & Michelle Doherty 201 Carleton Lane North Andover, Ma 01845 From: Kevin Murphy CC: Date: 6/6/2013 Job: Kitchen wall / Front door / Windows Date of plans: None Architect: None Location: Same Section 1- Work Schedule • 98 Forest Street • North Andover, MA 01845 • PH: 978-688-6335 • FAX: 978-688-7207 All Home improvement Contractors and Subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Prmsiau of Chapter 142A of the general laws, must be registered with the Commonweafih of Massachusetts. Inquiries about registration and Status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108.(617)-727 8598 Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in writing contractor will begin work on or about 5/15/13. Barring Delay caused by circumstances beyond Contactors control, the work will be completed by 6/15/13. The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11- Warranty The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair correct replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. Section III — Scope of Work Page 1 of 4 Kevin Murphy Building Contractor 98 Forest Street North Andover, MA 01845 PH: 9788885335 FAX 9788887207 General Page 2 of 4 Proposal is to remove existing petition wall between kitchen and dining room, replace front door unit, and install replacement windows in existing house. Building permit will be provided by contractor. Demolition Exisiting wall between kitchen and dining room, will have upper half removed. Existing countertops will be removed. Building All framing materials required to create half wall will be provided. Existing front door unit will be replaced. An allowance of $1000 has been included for door unit. Twenty four existing windows will be replaced. Harvey, all vinyl replacement windows will be supplied and installed. Windows will have grilles between the glass, and half or full screens. Any rotten trim around window frames, will be replaced. Existing interior trim to remain. Plumbing Plumbing required to disconnect existing sink / faucet, and install new ones, will be provided. New sink / faucet to be provided by owner. Electrical Electrical work required to relocate switches / thermostat / wiires in existing wall, will be provided. Plaster Any plastering / patching required to remove wall, will be provided. Interior Trim/Doors Interior trim will be supplied installed in kitchen / dining area, and around new front door unit. Some of the exisitng upper cabinets in kitchen will be relocated. Other Allowances New hood fan will be supplied by owner, installed by contractor. Waste Removal All demolition / construction debris will be disposed of by contractor. Items Not Included There have been no allowances made for any painting. No allowance has been made to supply or install new countertops. Kevin Murphy Building Contractor 98 Forest Street North Andover, MA 01845 PH: 978688-5335 FAX 978668-7207 Section N - Price Schedule Total Page 4 of 4 We hereby propose to furnish material and labor — complete in Accordance with above specifications for the sum of ..................................... $211050 Payment to be made as follows: Percentage/ltem Description Amount 1 Permit obtained $2000 2 Windows / door installed $12,000 3 Job complete $7050 3 $21,050.00 "Notice: No agreement for Home lmprovenierrt contrad ng work shall require a down payment (advance deposit) of more that one4hird of the total ooritract price of the total amount of all deposits or Payments which the contractor must make, in advance, to order ardor otherwise obtm delivery of spedal order materials and equipment, whicteder is W eater Contractor: Kevin Murphy 98 Forest Street No. Andover, MA 01845 Registration No: 101874 Section V — Acceptance Acceptance of Proposal — I have read this document and accept the prices, specifications, and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signature 2-2-a-�DCLAn=1Date 0511 Signature Date y --..wt' CERTIFICATE OF LIABILITY INSURANCE 12i i 012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON &THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poficy(ies) must be endorsed. R SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endomemend. Astatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER M P ROBERTS INS AGCY INC 1060 Osgood Street North Andover, MA 01845 LXMIAGI NAME PHONE Kc, No 978 683-$073 (Fl. No): (978) 683-3147 AooREs sandi@mprobertsinsurance.com INSURERS) AFFORDING COVERAGE N=0 INSURER A: PROVIDENCE MUTUAL INSURED KEVIN MURPHY BUILDING 6r REMODELING 98 FOREST STREET NORTH ANDOVER, MA 01845 INSURER B: MERCHANTS INSURANCE INSURER c: GUARD INSURANCE INSURER D: INSURER E: INSURER F: %1VvCYN%%.7r- l;tH I IHL;A 1 E NUMBEROMfiernm nn uRmr=D• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LLTTRft TYPE OF INSURANCE NORTH ANDOVER MA 01845 yrwo POLICYNUMBER WMIDDIYYYY) P MIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERGAL GENERAL LIABILITY PREMISEs (Ea oca,rerloe) $ 500,000 CLAMS.MADE i " r OCCUR MED EXP (AnY omPersort) $ 15,000 A BOPI068945 1/22/12 1/22/13 PERSONAL &ADvmArRY $ 1,000,000 GENERAL AGGREGATE s 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPtOP AGG S 2 000, 000 POLICY PRO- jECTLOC AUTOMOBILE LIAMUTY 1,000,000 $ BODILY INJURY (Peer Petsim) $ ANYAUTO aLLOIINED SCHEDULED MCA701360$ 1/23/12 1/23/13 $ AUTOSX AUTOS BONLYINJURY (PWaoddent) E HIRED AUTOS AUTOS PROPERTY $ O er acdderd) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS UaB CLAMISMADE AGGREGATE $ 1,000,000 CUP9145304 1/22/12 1/22/I3 DED RETEnom s $ WORKERS COMPENSATION X AND EMPLOYERS' LIABILITY YIN LIAttITS ER _ EL EACH ACCIDENT S 500,000 C � EXC ❑ NIA (In KEWC317800 7/01/12 7/01/13 ELDISFASE-EAEMPLOYEE s 500,000 ffyes, describe under EL DISEASE- POUCY OMIT IS 500,000_ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS /LOCATIONS IVEHICLES (Atla<hACORD 101.AdIfional RemarksSchadtftff more is rammed) tiCKl frit-AIt HuLutK r`AAt!`CI I ATV16l TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VMLL BE DELIVERED IN NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS_ AUTHORIZED wr (0 1988-2010 ACORD CORPORATION. All rights reserved. ACORD25 (2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kly 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):, �c—C%/ Address: S (6 h r S City/State/Zip: h�v �j.._al.w�/. 1 . UQJ"C5 Phone#: 4n 'S- • 6T W - S33� Are you an employer? Check the appropriate box: 1.6 I am a employer withl 4. ❑ I am a general contractor and I employees (full and/or part-time).* have lured 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. workers' comp. insurance. 5• ❑ We are a corporation and its [No workers' comp. insurance required.] officers have exercised their 3.0 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. 0 New construction 7:-611emodeling 8. 0 Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 LD Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks-boxft 1 must also fill out the section below showing their workers' compensation policy information. I 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. X am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. /, el Insurance Company ILK Policy # or Self -ins. Lic. #: kC—EZ✓C.. 3 h1 9 VQ Expiration Date: "�� 1 \ �� Job Site Address: -2-0 (Z A V- rJ "V -4w City/State/Zip: �,k 4l—�l 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 here cert under the pains and penalties of perjury that the information provided above is trice and correct z Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License V 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 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 Doc.Building Permit Revised 2010 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 L3 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: Doc.Building Permit Revised 2012 The Commonwealth of Massachusetts FOR Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CMR, Vh edition USE Revised Building Permit Application August, 2012 ed This SectionTo Use.Only Building Permit Number Date Applied:` Signature Building Inspector Date SECTION 1. SITE INFORMATION Residential ❑ Commercial ❑ Other Description: 1.1 Proer i Addxe�� `�� 1.2 Assessors Map & Parcel Numbers o (C l .la Is this an accepted street? yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, § 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ❑ Private ❑ Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑ Commercial- Service Size Check if yes❑ %SECjjON 2: PROPERTY OWNERSHIPI 2.1 Ow erg of Reco ods-/fi Nance(Prin Address for Service: _ Si re Telephone E -Mail Address SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply) gew Construction ❑ Existing Building ❑ Owner -Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work: SECTION 4: ESTIMATED. CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ I. Building.Permit Fee: $ 2.. Indicate how fee is determined: ❑ Standard City/Town Application: Fee 2. Electrical $ 3. Plumbing $ ❑ Total Project Cost' (Item 6) x multiplier x 3. Other Fees: 4. Mechanical (HVAC) $ List: S. Mechanical _ (Fire Suppression) $ Total All Fees: $ 6. Total Project Cost: $ o Check No. Check Amount Cash Amount a Z SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) ® 0 ( Z D C (2 24 1 > License Number Expiration liate List CSL Type (see below) V ', Name of CSL- Holder J bk PIZAI*4& Address ��1,yI �� 2'� Tye Description U Unrestricted (up to 35,000 Cu. Ft. Signature R Restricted 1&2 Family Dwelling M Masonry Only RC Residential Roofing Covering `I Telephone l /l J ^ G� /J S s�� / d ! / WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation E-mail Address D Residential Demolition 5.2 Registered homeI provement Contractor (HIC) All 010-e- "2 � t n ��- l 3 i 15, 17 Registration Number C. 2 2 g� xpiration Date HIC Company Name or HIC Registrant N Address f�77' 9�171 y Signature Telephone E-mail Address SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached? Yes .......... H"- No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, LA &1,,2, , as Owner of the subject property hereby authorize z . V-, A a G to act on my behalf, in all matters relative to work authorized by this building permit application. L-2,, A Signature of Owner Date SECTION 77b: OWNER' OR AUTHORIZED AGENT DECLARATION I, t V-1a/qvl ��G� , as Owner or Authorized Agent hereby declare that the statements and informa ' on the foregoing application are true and accurate, to the best of my knowledge and behalf. Signature o er or Autho ' ed Age Date (Signed un er a pains and penalties o e ' ry) NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basem`ent/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half%baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7`h Edition Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two- Family Dwelling SECTION 8: ADDITIONAL APPROVALS 1. Ballardvale Historic District Commission: Date: Comments: Application # (s) 2. Board of Health: Date: Comments: 3. Conservation Commission: Date: Comments: Application # (s) 4. Design Review Board: Date: Comments: Application # (s) 5. Electrical Permit Number: Date: Comments: 6. Fire Prevention: Date: Comments: 7. Planning Board Date: Lot Release: ❑ Yes ❑No Decision 9 (s): 8. Preservation Commission: Date: Comments: Application # (s) 9. Zoning Board of Appeals: Date: Comments: Application # (s) SECTION 9: CHECK -LIST ® Plans Submitted ❑ Yes ❑ No ® Stamped Plans ❑ Yes ❑ No ® Plans Waived ❑ Yes ❑ No ® Certified Plot Plan ❑ Yes ❑ No ® Dumpster Required ❑ Yes ❑ No o Fire Dept. Permit ❑ Yes ❑ No o Health Div. Permit ❑ Yes ❑ No If no, how will debris be disposed of? ® Certificate of Libility Insurance filed with the Town Clerk's Office for a sign projecting over a public right-of-way in the amount of $2,000,000 0 Yes 0 No 6 1 14 The Commonwealth of Massachusetts mar - Department of Industrial Accidents 911 Office of Investigations �} 600 Washington Street Boston, MA 02111 www.nmss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): At U-y10-eA 6 n,z /2 o.s/— Address: City/State/Zip: Phone#: �� `� -71 71 Are you an employer? Check the appropriate box: ]� L ❑ I am a employer with 4. l am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t 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 10. El Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other p *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 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a penalties of perjury that the information provided above is true and correct. Signature: Date: S i t 12;1 l 3 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: �T Phone #: Location6�L 740 Pd - No. W2 --i-3 Date ar 1KCheck # 7 -) TOWN OF NORTH ANDOVER Certificate of Occupancy 41$ Building/Frame Permit Fee $ Foundation Permit Fee $- Other Permit Fee $ TOTAL $ Building Inspector