HomeMy WebLinkAboutBuilding Permit #461 - 418 MASSACHUSETTS AVENUE 1/16/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: +
Date Issued:_
IMPORTANT: Appli
LOCATION 71U !!A
PROPERTY OWNER
MAP NO: PARCEL
Date Received
must complete all items on this pag
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Print
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 Bid g
Others:
Demolition
Other
Septic Well
Floodplain _ Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
U v3 C�U). l( Alec q
Type or Print Clearly)
OWNER: Name:
Address:
Phone:
6 1-,-7 W/ 77GG ce)
CONTRACTOR Name; �` -lam' c�1141 .Phone:
Address: 20,
Supervisor's Construction :License: Exp. Date
Home Improvement °License Exp. Date
ARCHITECT/ENGINEER
Phone:
Address: tV/ Reg. No.
FEE SCHEDULE. BULDING PERMIT 1.2.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ `al r 7(y) 1 a) FEE: $ (� �
Check No.: *LD10?, Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the-.-uaraft,-tV-fWtd
of Agent/Ownerjr-,J,; A.Ha4Biqhature
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 Departmentprior to issuance of Bldg Permit
96?E6 x.290
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan T.
❑ 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 musf 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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Location��
No. Date
MO^TM TOWN OF NORTH ANDOVER
f �h
o Certificate of Occupancy $
Building/Frame Permit Fee $ f�—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check
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Birthdate -:12/18/1965
Expiration 12/18/2008 Tr# 7189
RestFictton 0dt``
JAMES C PICA
24 MEADOW RD
BEVERLY, MA 01915 J Commissioner.
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The Common wealth of Afanachuseiv
Department of Industrial Accidents
Office of Investigations .
600 Washington Street
Boston, MA 02111
r Z www.m=s gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
Nance (Business/Orgwization/[ndividual):
Address: (, 0
City/state/Zip: 5bl do- 04/5 Phone #:
Are you an employer? Check the appropriate box:
1. ❑ [-am-employer with
4. ❑ 1 am a general contractor and I
ed1hployees (full and/or part-time).*
have hired the sub -contractors
2. 1. am-a.sole proprietor or partner,
listed on the attached sheet t
ship and have no employees
These sW. -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
right of exemption per MOL
myself. [No -workers' comp.
c, 152, § 1(4),'and we have no
insurance required.])
employees. [No workers'
comp. insurance required..]
*Any applicant that checks boil to I must also fill out the section below showin
Type of project (required):
6• ❑ construction
7. jRemodeling
8. 0 Demolition
9. ❑ Building addition
10. ❑ .Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.F Roof repairs
I3:❑ Other
g tr wo compensation ponoy mtonnaion.
Homeowners who submit this affidavit indicating they are doing 1,11 work and than hire outsida contractors must submit a new affidavit indicating such.
4C -tractors that check this.box mustattsched an additional sheet showing the name 6f the subrcortpactors and their workers' comp. policy information
I am an eMloyer that is-Provuting:workers' compensation assurance for my enrpinyees Below is the o
information. / p firy "djob site
Insurance Company
Policy # or Self ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach it 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 and a pahuandp–
that the information provided
ti
Offxhduseanly. Do not write in this area, to be completed by city or townoffi—
and coned
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 lnapecior
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 enWlayer 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 apartmerrts 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 politicail 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-contractoir(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 mquired.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'
oompensation.policy, please call the Department at the number. listed_ below. Self-insured companies should enter their
self-insurance license number on the appropriate Tina.
City or Town Officials
Please be sure that the affidavit is complete and printed iegibly. 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 appiicarrt.
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/licw= 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 ofthe 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 of permit to bum 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 €12111
Tel. # 617-7274900 ext 406 or 1-977-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Pica General Contracting
PDBox 455
Beverly, MA 01815
1-800-488-7422
!
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mn
Till
October 25, 2007
1 -,Mass Avenue
h Andover, MA 01845
terior stairs/porch renovations as specified below:
interior bathroom and ex
r issues and rebuild as specified be
-ope of Work: Demolition of existing interior and exterio
General contracting to pull all necessary permits and dispose of all debris prope
tform to be demoed and rebuilt to existing size and stairs and
11��Z'- Exterior stairs and pla
F footing to be code required as noted. Frame stair platform in pressure treated lumber.
rs. Install post
throughout. Deck to be 5/4 cedar decking, with finished skirts and rise
ts. Reset access door as
with railing and balusters set and spaced per code requiremen
note any finishing or painting by owner —
d and repair wood storm panel. Please
discusse
not included.
Total Option One $3,850.00
i.
b demolition of existing tub shower walls. Install new shower
Bath remove existing tu
Install new tub prior to new tub replace floor joists and sub floor.
I sub
toilet and sink saving to reinstall. Prep floor and
Demolition of existing floor remove
1 floor'to receive new tile throughout mending at all existing ar
ly and install new fan light ducting
Tile walls with soap dish finished complete. Supp
w flash and reframe and tile surround as discussed.
t Save existing shower windo
terial $12,700.00
Total Bath renovation labor and ma
Alternate of radiant heat floor all $2,500.00
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