HomeMy WebLinkAboutBuilding Permit #716 - 24 COBBLESTONE CIRCLE 6/4/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: l.( Date Received (011-13-66
Date Issued:
IMPORTANT: Applicant must complete all items on this Daize
LOCATION
PROPERTY OWNER �tx.4 a.
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Print
MAP NO: PARCEL: ZONING DISTRICT: =Historic District yes no
Machine Shop Village yes no
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:
J n/.4f7 jux- "ri" z11.1AJj1'!J"0-qs SiZC--
'4 Al berms s' &4k'5;D
Identification Alease Type or Print Clearly)
OWNER: Name:
Address:
Phone:
CONTRACTOR Name: �40�1114" Phone: - 3
Address:a 9ZkS,x)V,o' Ao,4p 2 9;; 21) 414 af G -a
Supervisor's Construction License: (:::?J 6'Fe67 Exp. Date:FlaJ2417)
Home Improvement License: l/ 2y,2 Exp. Date: 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: $ FEE: $ 3�
Check No.:Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guoanty fund
Sgnature�of conte
Location
No. Date • d lJ
NORTq
TOWN OF NORTH ANDOVER
�
O
A
Certificate of Occupancy
$
s�CMUstt�'
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$ y
TOTAL
$
Check #`'���
2 2 0
6
Building
Inspector
Plans Submitted Plans Waived Certified Plot Plan
Stamped Plans
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
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
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:_
Conservation Decision:
Comments
Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 3134 USgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
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
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 2008
No
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
/POKRAKA REMODELING
MA REG #119687 MA LIC #059067 PROPOSAL
29 Nashua Road
PEPPERELL, MA 01463 .
Page No. of Pages
ply'
...................
�r�'c'� o�
.rebv to furnish material and labor -
'.............._s1/L......_>. /..._ .................. _..........................................................................
......
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Mete in accordance with these specifi ions, for ta sum of
_ k&lb4' 15)LtiTy dollars tS
Payable"as follows:
o le)ot
All material is guaranteed to be as specified. All work to be completed in a workm ke manner Authorized 0
according to standard practices. Any alteration or deviation from above specifications involving
extra costs will be executed only upon written orders, and will become an extra charge over Signature
and above the estimate. All agreements contingent upon strikes, accidents or delays beyond
our control. Owner to carry fire, tornado, and other necessary insurance. Our workers are fully NOTE: This p may be withdrawn
covered by Workmen's Compensation Insurance. by us if not accepted within days.
ACCEPTANCE OF PROPOSAL — The prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do
the work as specified. Payment will be made as outlined above.
VSignature Date 4141
Date
$o�rd of d[j g R�egatat[u3iS ��itt f � .
Construction Supervisor License s
x-
Lid Ve: CS 69067
4 Frul 0 -331/2010 Tr# 17817
OLO�.
KARLb. PU[CRA1
29 NASHUA RD `_ �✓.. - ri+
PEPPERELL, MA Commissioner
_�_-- .f�ze �omr�maauaP.c�� rr�✓L�.czasaciueae(,t
_ Board of Building Regulations and Standards "
HOME IMPROVEMENT CONTRACTOR
Registration: 119587
Eg}�rot m 811412009 Trot 132884
-Type: t
POKRAKA REMOQELING. & DESI,GN
KARL POKRAKA
29 NASHUA RD -4.
PEPPERELL, N[A 01453 Administrator
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The Commonwealth of Massachusetts
Department of Industrial Accidents
UVI
Office of Investigations
,lilt_ ;
600 Washington Street
Boston, MA 02111
s�� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:pZ>�� �Qv
City/State/Zip:
k
-7 Phone #:
Are you -an employer? Check the appropriate box:
Elr
1. am a employer with _ 4. ❑ 1 am a general contractor and I
employees (full, and/or part-time).* have hired the sub -contractors
2. ❑ l 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.
[No workers' comp. insurance 5. [1 We are a corporation and its
required.] officers have exercised their
3. ❑ 1 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. ❑construction
7. Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 l.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box # I 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.
lContractors 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:
Policy # or Self -ins. Lic. #: —,F027 a2'g — / Expiration Date: Z7
Job Site Address:,3,T.6�ESTMIC � 212G City/State/Zip:X • x.r%Lr r_e
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 theAns and penalties of perjury that the information provided above is true and correct.
Phone #: 16171' - 513.3 C r95;�
Oficial 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. # 617-7274900 ext. 406 or 1-877-MASSAFE.
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY
COMPANYGRANITE STATE INSURANCE
1
KARL POKRAKA
29 NASHUA RD
PEPPERELL, MA 01463-0000
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D#_ _ MA ui#-
AGENT.NUMBER POLICY NUMBERS
i 1111 i
013-66-0408-00
01MMember Companies of
American International Croup
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK, N.Y. 10270
WORKERS COMPENSATION AND EMPLOYERS
L F ROBBINS INSURANCE AGENCY
PO BOX 1428
LIABILITY POLICY INFORMATION PAGE
PEPPERELL, MA 01463-3428
INSURED IS '
INDIVIDUAL
PREVIOUS POLICY NUMBER
RENEWAL 002359862
OTHER WORKPLACES NOT SHOWN ABOVE: SEE NAME AND ADDRESS SCHEDULE - WC 0610
ITEM 2
POLICY PERIOD 12:01 A.M. standard time at the Insureds
..[ling address FROM 04/27/08 TO 04/27/09
ITEM 3
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability insurance: Part Two of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are:
Bodily Injury by Accident $ 100.000
each accident
Bodily Injury by Disease $ ;go. 000
policy limits
Bodily Injury by Disease $ 100,000
each employee'
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT - WC200306A
ITEM 4
The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans,
All information required below is subject to verification and change by audit.
Classifications
Code Number
Estimated Total
Remuneration
X Annual ❑ 3 Year
Rate Per
$100 OF Re-
muneration
Estimated
Premium
Annual [1 3 Year
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES
$93
EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $318 MA
,7 g V V PEA TOTAL ESTIMATED PREMIUM $2,008
It indicated below, interim adjustments of premium'shall be made:
Semi -Annually Quarterly 11 Monthly DEPOSIT PREMIUM
ENDORSEMENTS (FORM NUMBER)i SEE ATTACHED FORM SCHEDULE - WC990612
04/11/08 ASSIGNED RISK 66
Issue Date n#si.e