HomeMy WebLinkAboutBuilding Permit #70 - 217 BRENTWOOD CIRCLE 7/27/2007X
Permit NO:70__
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
tZOne family
❑ Addition
❑ Two or more family
0 Industrial
❑ Alteration
No. of units:
❑ Commercial
W Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
OF WORK TO BE PREFORMED:
c�Y/tSr L�_�,iJG/s, �s �rf,,-:'vG•tJ i�lSv v��h
Identification Please Type or Print Clearly)
OWNER: Name: C-;),-2Z4-Q, M.y !*iA- 14-vV Phone: q'7wl
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULD/NG PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $% Oo.- oa FEE: $
Check No.: Q KS- Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/owner--fl—Signature of contractor
Location d n
No. 70
Date
NORrti TOWN OF NORTH ANDOVER
A
Certificate of Occupancy
Building/Frame Permit Fee $
SLAC MUSE
Foundation Permit Fee $ —
Other Permit Fee $
TOTAL $
Check #
204!
v Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT. ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
01
ED
DATE REJECTED
DATE APPROVED
DATE APPROVED
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 ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _
Planning Board Decision: Comments
Conservation Decision: Comments
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
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
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Camp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o 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/
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan
And Hydraulic Calculations (If Applicable)
❑ Copy of Contract
a Mass check Energy Compliance Report _
❑ Engineering Affidavits for Engineered products
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
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-• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): /�/.G�j��� ��✓..d//J
Address: ,Z//// /Q),
City/State/Zip: �o�aixr /f/,1,� �3v Phone #:
Are you an employer? Check the appropriate box:
1.9 I am a employer with / 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. I
These sub -contractors have
workers' comp. insurance.
❑ 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. insurance required.]
Type of project (required):
6. ❑ New construction
7. P, Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I l .❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks boz # 1 must also fil I 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 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 Name: c-,",
Policy # or Self -ins. Lic. #:_01S 3 Qcp;?- ?IS 06' Expiration Date:
� /D'/9 O y%
Job Site Address: ��ta��u e 0 Cly/rte City/State/Zip: /y� Ww ol,' R." O
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 and penalties of perjury that the information provided above is true and correct.
Signature:. Date:J �� !� %
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 #:
The Commonwealth of Massachusetts
1 I
Department of Industrial Accidents
Office of Investigations
i;t•':' ;`
600 Washington Street
N21 e ° s
Boston, MA 02111
-• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): /�/.G�j��� ��✓..d//J
Address: ,Z//// /Q),
City/State/Zip: �o�aixr /f/,1,� �3v Phone #:
Are you an employer? Check the appropriate box:
1.9 I am a employer with / 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. I
These sub -contractors have
workers' comp. insurance.
❑ 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. insurance required.]
Type of project (required):
6. ❑ New construction
7. P, Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I l .❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks boz # 1 must also fil I 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 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 Name: c-,",
Policy # or Self -ins. Lic. #:_01S 3 Qcp;?- ?IS 06' Expiration Date:
� /D'/9 O y%
Job Site Address: ��ta��u e 0 Cly/rte City/State/Zip: /y� Ww ol,' R." O
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 and penalties of perjury that the information provided above is true and correct.
Signature:. Date:J �� !� %
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."
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-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' 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 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.govJdia
1 J`L6 L6i727720'I7-UJPAZGtlt- P�✓('CCLS::C[Gt2llbE�b ::
-\ Board or Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 105029
Expiration: 7/16/2008 Tr# 124616
Type: Individual
MICHAEL F. GOODWIN JR.
Michael Goodwin Jr.
7 HOLT RDS Cam
EPPING, NH 03042 Administrator
�'�>le lro-mm2oruc�cc�lf �� , %��oitsac>t
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 081670
Birthdate: 08108/1965
v -- - Expires: 08108/2d07 Tr. no: 1.0
Restricted: 00
MICHAEL F GOODWIN
7 HOLT RD
EPPING, NH 03042 C /�
CoinmlSSiloner
il
978-423-8463
Nick Modigliani
217 Brentwood Circle
N. Andover, Ma.
0 Estimate
V,04 45'l
Description
Project 42, Master bedroom bathroom,
Disconnect fixtures.
Gut the bathroom down to the stud and subfloor including outside of the
bathroom and taking out the closet to enlarge the bathroom.
Rerough the plumbing for the new vanity and shower locations.
Rerough the electrical, taking out the strip heat.
Install a new fan/light/ heat unit in the ceiling.
Install new insulation on the exterior walls.
Blueboard and veneer plaster the walls and ceiling.
Install wonderboard on the floor, install tiles and grout.
Install new pine baseboard and window casings.
Install the vanity, cabinets, shower unit, toilet, medicine cabinets and fixtures.
Prime and paint the bathroom.
Total estimate for MB bath: $ 18,200.00
Payment Terms;
A deposit of $ 6000.00 upon starting
A payment of $ 6200.00 upon starting of sheetrocking.
Balance of $6000.00 upon completion
This estimate is good for 30 days.
All rubbish will be removed from premises.
Total
Signature
4/19/2007
Total
CSL #081670 130 Centre St., Suite 45, Danvers, Ma. 01923 HIC 4105029
Page 3
978-423-8463
Nick Modigliani
217 Brentwood Circle
N. Andover, Ma.
Estimate
ON2.-;': O ® Mo
—lr
Description
4/19/2007
Total
Reference are proudly given upon request.
Each bathroom will take approx 3 weeks to complete.
Any tile work is based upon a single style and color for each bathroom floor.
Homeowners to provide all cabinetry, plumbing and lighting fixtures, tile, grout,
bath accessories.
The final price may vary according to type and design layout of the tiles.
Total
Signature
CSL #081670 130 Centre St., Suite 45, Danvers, Ma. 01923 HIC #105029
Page 4
978-423-8463
Nick Modigliani
217 Brentwood Circle
N. Andover, Ma.
Description
Total
Signature
CSL #081670 130 Centre St., Suite #5, Danvers, Ma. 01923
Page 5
Estimate
4/19/2007
Total
$33,900.00
HIC 4105029