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HomeMy WebLinkAboutBuilding Permit #529-14 - 212 BRENTWOOD CIRCLE 1/8/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: L� - l� Date Received Date Issued: t P- IMPORTANT: Applicant must complete all items on this !LOCAT.IQN aPrffi �-7I�J-- ala N d fFROPERTY,(5WNER — t '.MAP NO tPARCEL ZONIN DISTiRIGT _ _ __HistoncDisi TYPE OF IMPROVEMENT PROPOSED USE re®y � yes 4 •ri Non- Residential .yes o; ❑ One family ❑ Two or more family ❑ Industrial TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ One family ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic?Well �: _ ]+ h ipWater/Sewer3 •°Fig ❑ F oodplain ®tWetlards'DWatershedDtr DESCRIPTION OF WORK TO BE PEKFOKMEU: kzu) W i mbnj Identification Please Type or Print Clearly) OWNER: Name: 3()4K-, i^/11 • 7�Q U/_% Phone: 6) 3 3 ARCHITECT/ENGINEER — Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT. $1200 PER $100 .00 OF FF1THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ J � FEE: $ Check No.: Receipt No.: Z� NOTE: Persons c ntracting with u registered contractors do not have access to the guaranty fund Signature of A ent/Owner1 Signature of.contractorV g... Plans Submitted ❑ Plan aived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Locatio,�\--1 No. Date TOWN OF NORTH ANDOVER - t4 - Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ , 1 47TV19) N TOTAL $ Check# Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL uocatea Public Sewer Tanning/MassageBody 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 COMMENTS Reviewed on Signature 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: .FIRE:'DEP.ARTMEh Lodated;at 1241-JM9m St Fire -Department s COMMEENTS e uocatea s64 us ooa -)ireei Temp Dempster on site yes no z -et s 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 Call Email Date Time Contact Name Doc.Building Perinit 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 j Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ 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 Hydraulif Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) 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 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 Dor. 1\SPEC"rloNAL SERVICES DEP, kR'1'AIEN'RBPF0R'v1u5 I'a ;e 4 of -1 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 81000.00 m $ - $ 96.00 Plumbing Fee $ 12.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 12.00 Total fees collected $ 220.00 212 Brentwood Circle 529-14 on 1/8/2014 Bath Remodel P Homeowner Information Contractor Information Name Company Name Street Address (do not use a Post Office Box address) Contractor/ Salesperson/ Owner Name I z tly -lbJ-00n G> RCd-f- T- G€v) l�-j City/Town State Zip Code usiness Address (must include a street address) X). NDtyrrnA ©1 E9S -71- D 45--l- Daytime Phone Evening Phone Cityrrown State Zip Code OfFr 5 Mailing Address (It different from above) Busin e W3.10-7 O-7 Federal Employer ID or S.S. Numb ,:! Law requires that most home Home Improvement Contractor Reg. Number Expiration date improvement contractors have a valid registration number %' AA / The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) if-PAmfi-) .->> 3 t A) -C Nsr I -L V) D -)K WI K�0-0J l��w Sid) ave' Mo -*d b to 1 Ni7mjJ Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of y Date when contractor will begin contracted work. MGL chapter 142A.) i / Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule�'y� OC) The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of: 34 -�� - M Payments will be made according to the following schedule: $,/ 6� tl.- tr not t� otexceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $/ or upon completion of $ by / / or upon completion of $__[ Qom_ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special ordered before the contracted work begins in order to meet the completion schedule.(**) $ t or o e paidfor _ NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. Home/owne s ignature Date 14c 171 of_- 8LX Office of Consumer Affairs& Business Regulation 1 ME IMPROVEMENT CONTRACTOR egistration: 1j,1990 Type: xpiration: -2/1 1-26115 LLC ,E ' ` ' ROBERT i + 7— - . � _--`. L.~_.,~ � 79wDALE S7 ! NANDOVER, MAO1845 Undersecretary I Massachusetts - Department Of Public Safety. _Board -. Building Regulations and Standards Construction SuPen-isor —�- License: ROBERT-_ ' 795 DALE ' . N ANDOVOMAP1018415. | ' --~_. � ^om"ismo»er. Expiration 3 0 H • Iel J 6u.. LL 0 m N N Y LL v ? VI .Q V) O U a Z Z m C t6 3 LL t O T N C t U LL 6u d ? Z cc G d t O W jp C 4- X W Z V W W ..O O cr u .L N N N c LL O V' d Z V) (D t j O d' 7m C LL Z WWC G Q YJ c LLJ cc LL N � m Z y G1 � .. V1 + N � Y O V) rmk7 p 0 ca C U. . W `• •QL :a •�::cn CL :Ll • z Q °) Q C7 :z o N4 CL as �, o to � o � o`� Z~ d 1�3 .: lu Q.C co_J L O Cl) ai L rn W 'yea xZ ` 0 0 F - ca o c CO W W J 0-Z CL CD m V �•C L cc 0 .y O OY r+ C •a C C V C •O i— OU) V m O W r-�o —oi5 O O " •y 3+=+yt.+ Z W E c • U 4)0 -0 Q N w a) > _ y mO 0O F— 0 Q O V 0 z O E i O 0 Z C D C a N 0-- 0 G .E m m a0� d — A O �+ v � O m O O' � Q OM _ V J .CL O .4+ C Z V CLN •C N 0 0 U) N W W C9 W N The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.rnassgovtdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegibIy Name (Business/Organization/Individual): &0 1—L C Address: City/State/Zip: td�)- A -PO oVa_P, Oji Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with d• El am a general contractor and I 6. El Now construction employees (full and/or part-time).* have hired the sub -contractors 7. ` J4R ����`fi g 2. 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. workers' comp. insurance. g_ ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL ILEI Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.0 Roofrepairs insurance required.] employees. [No workers' 13.❑ Other comp. insurance required.] !Any applicant that checks box##1 must also fill out the section below showingtheir workers' compensation policy information. "Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N, Policy # or Self -ins. Lic. ExpirationDate: Job Site Address: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 ofup 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. Jr do hereby c9'tV undegjthepains."dpenalties of perjury that the information pro videdabpve 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:' Aa 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 ofa 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 Ideal 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 b eon 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-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, axe 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. A new 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: Tho CQmMolmaid , of Massachusotts Department ofIndustrial &cidonts Office ofInvestigatlons 600 Wasbington Street Boston, MSA. 02111 TQJ. A 617-727-4900 ext 406 or. 1-577- MMS.AJFB Revised 5-26-05 FAY, 0 617-727-7749 _WWW-MAss,govfdia