HomeMy WebLinkAboutBuilding Permit #80-11 - 21 JOHNSON CIRCLE 7/15/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
�j APPLICATION FOR PLAN EXAMINATION
Permit NO: O " / Date Received
Date Issued:
�to
IMPORTANT: Applicant must complete all items on this pal
LOCATION 01
Print C %
PROPERTY OWNER
Print
MAP 210 PARCEL ZONING DISTRICT. Historic District
Machine Shop'
yes
vow i9'-:-'
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Type or Print Clearly)
OWNER: Name:
Address:
CONTRACTOR Name: Phone: 1
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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: $ $()c 00, FEE: $
Check No.: Receipt No.: 0�3
NOTE: Persons cont cti with unregistered contractors do not have access to a guaranty fund
Sgnatureaof Agent/Owne Signature of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEW 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 DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENT'S
1.
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
DPW Town Engineer: Signature:
uocateo W4 Us ood btreet
FIRE DEPARTMENT - Temp Dumpster on site yes no -
Located at 124 Dain Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
g
Total land area, sq. ft.: c
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NU 1 E5 and UA I A — ( For de
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
ent use
M
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: Building Permit Revised 2008
Location C::2 `V\S or-,. ►��
No. , Date V
,%ORT" TOWN OF NORTH ANDOVER
� t
A X
Certificate of Occupancy $ j
��b'•"°''t�' $ �
Building/Frame /Frame Permit Fee::!!j. 9 ti's
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # ;w
2311
Building Inspector
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of
µORTH TOWN OF NORTH ANDOVER
OFFICE OF
OL
BUILDING DEPARTMENT
e�
_ .1600 Osgood Street Building 20, Suite 2-36
n°q,nD 'paw
North Andover, Massachusetts 01845
Gera]d A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION: �DI�n sow Ct liC 1_ -2
Number Street Address
HOMEOWNER-3APAe S
Name
C"fo 11 9 7
Home Phone
'171 5L7 7 �-
PRESENT MAILING ADDRESS �-10 Sox 0 Y j
M6
City Town
17 �3
Map/Lot
Work Phone
019LO
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE v ('
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
VYf L+Vt AVIV V •'tJ V, VVV�.!l�r �
DATE(MWDD,NYYY)
' CERTIFICATE OF LIABILITY INSURANCE 4/6/2010
THIS CI:RMFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP014 THE CERTIFICATE HOLDER_ THIS
MTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELY 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 PRODLICER, AND THE CERTIFICATE HOLDER.
IMPORTANT_ If the mrdficats etalder IS an ADDITIONAL INSURED, the poky+ies) must be endorsed. ff SUBROGATION IS WAIVED; auk to
the terrlta and eondHlaw of ft polky, ceKain policies may inquire an e++dersemenl. A statement on this certificate does not Willer fighta to the
GertIfiCate holder in lieu of auch enduesemertga
PRODUCER
M P ROBERTS IRS AGCY INC PHONE
1060 Osgood Street (AfC.No.E,a%& (978) 653-8073 AJC x;(978) X83-3 .4 7
AIL
AmRus:sandi@mprobert$insurance.com
North Andovrarr, MA, 01845 PKEA1UGkK
�..r..
INSURED NORTE" AMCV'ER READ CORP.
459 EAST BROADWAY
HAVERHILL, MA 01830
978-556-9834
E:
INSMIEF(s, AFFDFMMG COVERACE NAM.a
ACE PROPERTY & CASUALTY
THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE[
INDICATED. NOTWITHSTANDINt ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOI
CERTIFICATE MAY HE IS$URD OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN WAY HAVE BEEN REDUCED BY PAID CLAIMS.
p TYPE flF INSURANCE INE POLICY NUMBER MMIDDIYYYY MWD
GENERAL LIABILITY I
MERCIAL GENERAL LIABILTrY
OIAnNs-MADE F� OCCUR
GEN1 AGC-REGATE I.IMrr APPLIES PER,
PQLlcyPIAO- !OC
AUTOMOBILE LIABILrh
ANYAUTO
ALL OWNED AU; -OS
SCHEDULED AUTOS
HIRED AUTOS
NON-QWNED AUTOS
UMBRELLA LIAR OCCUR
EXCESS LIAR
DEDUCTIBLE
AND EMPLOYERS` LIABILITY
A ANY PRD-FTp�PWnv'ERJF7q;V0W YIN C4b898155 03/13/10 03/13/11
BFFICEWTdE11015-: EXCLIMM7 WA
rFYap, dewrbe urdcr
OF OPERATIONS t LOCATIONS I VEHICLES (ANNA ACORD 101, Aduktowl Ramarke sdwhkaa, it mom epeta is 11 requfre3)
TOWN OF ANDOVER
F,AX: 978-556-9835
REVISION NUMBER -
NAMED ABOVE FOR THE POLICY PERIOD
;UMENT WITH RESPECT TO
WHICH THIS
HEREIN IS SUBJECT TO ALL THE TERMS,
LIMITS
EACH OCCURRENCE
$
U
PREMISES Ea 22MErenee
MED EXP (Arpy oris pamm)
a
PERSONAL& ADV INJURY
9
GENERAL AGGREGATE
S
PRODUCTS - COMPIOP AG(3
S
S
COM®INED SN. GL€ LIMIT
$
(Ea accident)
8OUILY INJURY (Per pgrBw)
S
BODILY INJURY (Per eocident) S
PROPERTY DAMAGE
$
(Per aeddant4
S
9
EACH OCCURRENCE
$
AGGREGATE
$
s
WG A - OT4I-
T R (e;fTS
E,L. EACHACCrDEN7
$ 500, 0
E, I., DISEASE - EA EMPLO
$ 500,000
E,L. DISEASE - POLICY LUT 1 s 56-0,000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED IN
ACCORDANCE VJTIH THE POLICY PROVISIONS.
AUTHORIZED
CIS 1988.200,q ZORD CORPORATIOR All rights n29@rved.
ACORD25(2009/09) Tha ACORD name and 1090 are registerad marks Df ACORD
The Co"monwealth of Massachusetts
Department o f Itadustrial Accidents
Office offizVeszie ations
600 Washington Street
d Bostori, M4 02111
asp°ov/din
Workers' Compensation Insurance A�
ffda
32Iicant Information � Builders/ Contractors/Electricians/Plumbers
j ( PIF
Name (Business/Organizatiolvl dividual): ,� `J4fvw CC(.(�f Q l I
Address: - C) t�* d4 q
City/State/Zip:f 17
Phone #: LOT—
Are
T—
Are you an employer? Check the appropriate box:
I . ❑ I am a employer with 4. ❑ I am a general contractor and I
2. ❑employees (full and/orpart-time).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the attached sheet I
ship and have no employees These suT}
contractors have
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
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 ins
Type of project (required):
6- ❑ Nev,, construction
7• emodeling
8. ❑ Demolition
I. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
17•0 Roof repairs
urance required.j 13 ❑Other
`= Ticthy* h boy mit also
Sat o :IIe ae':.CQ Cmov' 9:RQY,^^` ::,
I�oIIEOWIIefS WIIQ Sl10ID]T lila affidavit IhdlCatlno il} -y am do' '- --•`M Q�CZ''.L�S' CQ2L`^�^,...:�'*+t ^n r..:.•�� . LL
+ c 41 'wore th- hue O r
COntiaC[ot? thatch W;; �: h..y, m•;oM ., "`€ anti uuidE tom,
-acts .�.W u� -
nom; aui aadinonai sheet showiw the submit a new amda-t indicating such.
r_
came of the sub conuacton; and their
` —4 9"t UMPWycr that is•Providing workers' com errsadon insurance or m e —r• e --.y =,,,�QII.
informafiom P f y employees. Below is the ofi
P c7 and job sire
Insurance Company Name:_ AC e— Tri. r1-0 - a�,
Policy # or Self -ins. Lic. #..
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation oil declaration City/State/Zip.
policy lion pave (showing the policy number .and expiration date).
Failure to secure coverage as required under Section 25A of MG
fine up to $1,500.00 and/or one-year imprisonment, well
lc' 152 can lead to the imposition of criminal penalties of a
Of up to $250.00 a day against the violator. Be advised that a co Panalt'es m the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification Py of this statement may be forwarded to the Office of
I do
_Jy "I"ar nc, Pains and penalties of per.InrY ¢i the in or
® f matron provided
Official use only. Do not write in this area, to be completed by cit), or town offtciaL
City or Town:
Issuirt, Authority (circle one):
P ermit/License #
Fs true and correct
I. Board of Health 2. Buiiainb Department 3. City/To"
6. Other Clerk -4. Electrical Inspector 5. Plumbinb Inspector
Contact Persorr:
Phone'"-.
Information am d Instructions
Massachusetts General Laws chapter 152 requires all employs 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 joint enterprise; and including tie legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees. However the
owner of a dwelling house having not more than three aparm>L entx and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mainte3amce, 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 c-- onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of carimpliance 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 ua-til acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please H out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and if
necessary, supply sub-contractor(s) 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' comp ensation 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 for confirmation of insurance coverage. .Also be store to sign and date the affidavit. The affidavit should
be returned to the city or town that the applic6uon lot the Do license : 1�e
dit or fi isbeing requested, not the.D--partWent. of
Industrial Accidents. Should you have any questions regardiz<g the lav; al if you are :..�irired to gain a workers'
compensation policy, please call the Dep artment 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 p=niVhc=se 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 P=xnits or licenses. A new affidavit must be filled out each
year. Where a home owner or citiz„-.n is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog Iicrose or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office ofInvestigations would bice to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Departitrent's address, telephone .and_fax..number. .
The CommonwealthL Gf Massachusetts
DTartm=t Oflndustri.al Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-S —/7-MASSAFE
Rmnsed 5-26-05
Fu. # 617-727-7749
vrw? R'.mass.. pv/dla.
H3MLS - Assessment and Sales Report Page 1 of 2
Assessment and Sales Report
Recent Mortgage *1
http://h3 c.mispin.com/tools/publicrecord/view. asp?uid=92373797&id=2070088&State_Code=... 5/17/2010
Address:
21 Johnson Or, North Andover,
MA 01845-4624
Map Ref.:
M:00097 8:00063 L:00000
Zoning:
R3
Owner 1:
Terry Lieberman
Owner 2:
Bethany Lieberman
Owner Address:
21 Johnson Cir,North Andover, MA 01845-4624
I,;Z�mt•17-w- �m
Use:
1 -Family Residence
Style:
Ranch
Levels:
1
Lot Size:
0.58 Acres (25265 sgft.)
Year Built:
1975
Total Area:
0 sgft.
Total Rooms:
8
Living Area:
2312 sgft.
Bedrooms:
4
First Floor Area:
1552 sgft.
Full Baths:
2
Addl Floor Area:
0 sgft.
Half Baths:
2
Attic Area:
0 sgfL
Roof Type:
Gable
Finished Basement:
0 sgft.
Heat Type:
Forced Hot Water
Basement:
0 sgft.
Fuel Type:
Natural Gas
Basement Type:
Exterior:
Wood Side/Shingles
Attached Garage:
0
Foundation:
Other Garage:
0
Air Conditioned:
Yes
Fireplaces:
1
Condition:
Average
Ilr•.c.3 r�y i . " t
Last Sale Date:
6/15/2007
Last Sale Price:
$424,000
Last Sale Book:
10795
Last Sale Page:
32
Map Ref.:
M:00097 6:00063 L:00000
Tax Rate (Res):
12.74
Land Value:
$219,200
Tax Rate (Comm):
17.69
Building Value:
$276,400
Tax Rate (Ind):
17.69
Misc Improvements:
$0
Fiscal Year:
2010
Total Value:
$495,600
Estimated Tax:
$6,313.94
t1— 3
Recent Sale #1
Sale Price:
$424,000
Sale Date.,
6/15/2007
Buyer Name:
Tent' R Lieberman
Seller Name:
John D Vanofferen
Lender Name:
Wells Fargo Bank
Mortgage Amount:
$402,800
Sale Book:
10795
Sale Page:
32
Recent Sale #2
Sale Price.
$219,000
Sale Date:
12/15/1995
Buyer Name:
John D Vanofferen..
Seller Name:.::::.:
Matthew D Gold
Lender Name:
Olde Towne M Co Inc
tg.$197,100
Mortgage Amount•
Sale Book:
4402 ...
Sale Page:
124
Recent Mortgage *1
http://h3 c.mispin.com/tools/publicrecord/view. asp?uid=92373797&id=2070088&State_Code=... 5/17/2010
The Commonwealth of Massachusetts
FOR
Board of Building Regulations and Standards
MUNICIPALITY
Massachusetts State Building 780 CMR, Code 7a' edition
USE
Building Permit Application
Revised
,January 1, 2008
This Section For Official Use Only
Building Permit Number:
Date Applied:
Signature:
Building Inspector Date
SECTION 1: SITE INFORMATION
Residential ❑ Commercial ❑ Other Description:
1. Properd-dress:
1.2 Assessor Map & Parcel Number
L la Is this an accepted street? yes no
Map Number Parcel Number
1.3 i nformation:
1.4 ProPropert Dimensions:
Zonin District Proposed Use
P
Lot Area Frontage ft
(q ) g ( )
1.5 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1 30
d 3
30
p
1.6 ater SjU pply: (M.G.L c. 40, §54)
Public Private ❑
1.7 Flood Zone Information:
1.8 Sewage Disposal System:
Sewage
Zone: Outside Flood ne?
Municipal site disposal system ❑
Commercial- Service Size
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record: ' P
rint) Address for Service:
f7e Dg a��
re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WOR K2 (check all that apply)
New Construction ❑
Existing Building ❑
Owner -Occupied ❑
Repairs(s) ❑
1 Alteration(s) ❑
Addition ❑
Demolition ❑
Accessory Bldg. ❑
Number of Units
Other ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use Only
(Labor and Materials
1. Building
$
1. Building Permit Fee: $
2. Indicate how fee is determined:
2. Electrical
$
❑ Standard City/Town Application Fee
3. Plumbing
$
❑ Total Project Costa (Item 6) x multiplier x
3. Other Fees: $
4. Mechanical (HVAC)
$
List:
5. Mechanical
ire Suppression)$
Total All Fees: $
6. Total Project Cost:
$
Check No. Check Amount: Cash Amount:
O
O
LL
LL
L
0
_0
LL
0
U
N
U)
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
License Number Expiration Date
List CSL Type (see below)
Name of CSL- Holder
Address
Type Description
U Unrestricted (up to 35,000 Cu. Ft.
Signature
R Restricted 1&2 Family Dwelling
M Maso Only
RC Residential Roofing Covering
Telephone
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
Registration Number
HIC Company Name or HIC Registrant Name
Address
Expiration Date
Signature Telephone
S E C T 10 N 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25 C (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 .......... O No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare that
the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
1. 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 nothave 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 110.86 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basementlattics, 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