HomeMy WebLinkAboutBuilding Permit #528-14 - 425 CHESTNUT STREET 1/8/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: //u �I Date Received `
Date Issued: 1
IMPORTANT: Applicant must complete all items on this page
100 Year Old structure yes. no
CT: ,Historic District yes no
Machine Shop Village_ yes no
TYPE OF IMPROVEMENT-
PROPOSED USE
Resid al
Non -Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alt ion
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic []Well
❑ Floodplain El Wetlands.
❑ Watershed District
❑ Water/Sewer
OWNER: Name:
Address:
CONTRACTOR; Name:
Typeo Print Clearly)
r)WJ, -
6
Supervisor's Construction License..,-,, v _ Exp. Date:
Home Improvement License: _.w _ __ _ _. .. 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.
00
Total Project Cost: $ �, �n�It_� FEE: $ 3
Check No.: Receipt No.: 2-] 7Zo
NOTE: Persons contracting with unre istered contractors do not have access o he guar, my fund
_Signature lgnafur--,of contr '
Plans Submitted LJ Plans Waived ❑ Certified Plot Plan 11 S amped Plans El
Loca
c o
No. J"" —� Date
Check # 4721
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ T
V ',
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
.TYPE.OP-SEWERAGEDISP-OSAL '
-
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales E
:•Food Packaging/Sales ❑
Private (septic tank, etc. ❑ _, :.
=Permaneint DOmpster on Site ❑
THE. FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE. REJECTED:
PLANNING & DEVELOPMENT ❑
COMMENTS
DATE_APPROVED
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 ConnectionlSignature & Date Driveway Permit
DPW Ton.! ]Engineer:
Located 364 Usg000 Street
FIRE DEPARTM -Af-Temp Dumps ter onsite yes.. no
Located -at 124tMair,'Str'eet: f :«
Fire 606ftlmdri gnat,. date
COMMENTS . F r
Dimension
Number of Stories
Total square feet of floor area, based on Exterior dimensions._
Totai land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service crop 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
Ll Notified for pickup - Date
Doc.Building Permit Revised 2010
ii Building Department
The fo0,3wing-1s411ist of -the required.forms to beAlled out-Wthe appropriate. permit to.be obtained.
Roofiiag, Siding, Interior Rehabilitation Permits
❑ B..ailding Permit Application
❑ Vkrkers 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
o Workers Comp Affidavit
o 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)
o 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
a 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 casts .if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Building permit Revised 2012
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The Commonwealth of Massachusetts
Department of Industritcl Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
City
Arron employer? Check tUe�.ppt
1.a employer withI` _
employees (fall 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.] i
date box:
4. ❑ I am a general contractor and I
have liired the sub -contractors
listed on the attached sheet.
These sub -contractors have
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. insurance required.]
� ON M-4091�
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 L ❑ Plumbing repairs or additions
12.❑ Ro repairs ,
13: they —
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
tHomeowners who submit this affidavit indicating they o're 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.
X am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. <_ ,
Insurance Company
Policy #,# or Self -ins. Lie. #1:^ �'` ExpirationDate:
Job Site Address: j r:l City/Statelzip: �
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 o. 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 IA- for ins co coverage verification.
X do Izerebce t fy under the s a p �lfi of perjury tliat the information provided above zs d ue and correct.
��
Of 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 orimplied, 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 employes."
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 mumber(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 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 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 Commomealth of Massachusetts s
DePartment ofZudustrialAccidents
Office QUAVestigatiom
640 Wasbiugton Street
Boston, M,A. 02111
Tel, ## 617-7274900 at 406 or 1-877MMASSAJFE
Revised 5-26-05 Fax ## 617-727-7749
www.mass.gov/dia
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7.
Permit Services
WINDOWS CONTRACT
'rlrursday, October 31, 2413
401 246 2868 p.1
This Agreement is entered into on the date shown above an(] is by and between_Robert Leonard _
having a mailing address at X125 Chestnut St., North Andoycr, MA (die -0wi T'') and Next Sta p Living Inc.,
21 Drydock Avenue, Boston, MA 02214 ('`NSI:'). -- ��
NSL Copy
1. THE WORK AND THE MA'rutlALS.
NSL shall perforin all work and supply all materials described on Exhibit A* (*Next Step Living window proposal) atlnclted to
this Agreement and will be responsible for any and all equipment's, supplies and appurtenant items as may be required and
necessary to perform all %York described on Exhibit A and ally perfuratance reasonably inferable from it, itacluding clean-up
assoeiatvd with NSI °s work (the "Wnrk").
2. CHANGES/t'ERFORMANCC• Or THE WORK_
2.1 NSL will not make any changes in the Work other than those dcscnbed or, Ullibit A, unIOSs agreed to in writiog by file
'Owner.
2.2 NSL represents and warrants to the Owner that (a) ncc materials and equipments fumished under this Contract will be of
good quality and new, (b) that the Work will be free from defects, and (c) that the Work wi 11 conform with the dcseription of the
kVork described on Exhibit A.
3. 1 -P -0E FOR PE9P0RN4ANCE.
NSL shall ensure the Work will be done in a timely manner and will ensure that the work is done diligently without delays ur
interruptions until completion. Irthe Work is to bedone in stages, the previous sentence shall apply to each such stage,
4. TERMS OF PAYMENT.
The Owner shall pay NSL the balance: upon the completion ofthe Work described on CAibit A.
S. INSURANCE AND LICENSING.
NSL represents and warrants to the Owner that NSI, is validly licensed and that NSI, has all insurance required by applicable
law and normally maintained by prudent contractors in NSL's field, including, but not limited to, workmen's compensation for
all cnaployLts who will perform the work. .
6. QUALITY OF WORK.
NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will ensure repair and
replacement. at its own expense, and promptly upon Owner's request, any defects in workmanship and materials provided by
NSL or subcontractors of NSI. which appear up to one (1) year atter the date of final payment for the Pro jcct to NSL or within
any lunger period as permitted or required under applicable law.
7. GENERALYROVISIONS.
7.1 Any disputes which may arise between the thinner and NSL shall not impede or interfere with the diligent performance by
NSL of the work.
7.2 This Agreement shall be construed in accordance with the laws of the State of [Massachusetts.
7.3 NS 1, may not assign this Agreement or any of its +fights to payment without [fie Owner's prior written consent.
21 Orydock Ave 2nd Floor, Boston, htA 02210
Phone: 1.865.867-8729
%Yww.NexlStepUvingl nc.com
Permit Services
DL-xt. .ste,.,4 f lit
401 246 2868 p.2
8. fRGGX15T1NG Cq\DITIONS Sc PRO!'ER"1'Y PRUTI:Cf1UN
8.1 N,- 1, shnII not be responsible for any damages as a consequence of the Work performed in the home dtte to pre-c-,istin,
conditions. 'these conditions include but are not limited to cracked or broken drywall, old piped and fittings, rotting wood,
faulty electrical wiring, etc.
9.2 NSL reserves the right not to perform work upon the discovery of asbestos, mold, or any other potential health risk. til this
event, the customer is responsible for removing the hazardous materials and all bills For services shall be paid immediately.
Work cannot resume until remediation is complete.
8-3 NSL will make best efforts io protect any properly of the customer, but it is the custoiner's responsibility to tctaove or
protect, including dust protection, any personal propeny including the hot tic itsc11. NSL will not be responsible for damages to
or losses of the above mentioned property not properly protected prior to the commencement or work.
PAYI EMr
9. t Total estimate amount is $ 118,528.43 . Customer shall pay 113 of estimate amount, or S 6_,176.14 upon acceptance
of this contract and final payment of $ 12_,352.28 will be due upon completion.
9.2 if customer is using financing. Down Payment deposit due at signing. Pending fundingapproval, final payment will bedue
upon completion.
'total cost of project. $18,528.43
Deposit required: __$300.00 _
Balance due upon completion: $18,228.43
lrusing tine Heat Loan for this purchase and installation, this contract is contingent on Ute customers receiving ten- Heat Loan
authori7mlion and approved financing by 1u; customer's lending institution.
This Contract, including the documents incorporated into this Contract, 1011115 the complete integrated agreenne»t between
Contractor and the Owner. The parties represent and warrant Uiai in executing this Contract, they are not relving on
representations other than as expressty contained herein, There are no other terns or conditions that form a binding agn:entcat
between the parties other than this Contract and its incorporated documents. This ContCact supersedes tilt prior agreements
bctwcm the Owner and Contractor and may not be altered absent a subsequent written agreement signed by bout parties.[loth
parties have reviewed this Contract and represent that Urey understand and agree to all terms herein.
We have read this Contract
Rotjeft OI
lit�llre tsrri
Jnc. --
and 4ree to its terms.
71
r./
_
10_/31/2013
Dare:.—._..-�.
_ 10/3112013
.aan
21 Orydock Ave 2nd Floor, Boston. MA 02210
Phone: 1-866.867.8729
VA—. N eAS1e p 1. ivi N l n e. corn
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