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HomeMy WebLinkAboutBuilding Permit #166 - 46 BEECHWOOD DRIVE 8/28/2012 NORTH �TLao BUILDING PERMIT OFe,9'�'p TOWN OF NORTH ANDOVER F - f APPLICATION FOR PLAN EXAMINATION Permit NO• Date Received ��ssgc►+uS. Date Issued: IMPORTANT Applicant must complete all items on this page b,.;?arc ;�. ,{\f� Jina#,p $.`.r�,� �r u? _ �w�ri\`IVJC.L N!dnw- < � •[`F" i LOCAT#IONIC fizz a �a ��_ ci Tre— ,� x �nnt PROPEzx 'Et s., a ��g�? r RTYi WNER i - 1 w L �� .v f ��� �� ZONING DISTRICT,.�,..-� '�HistonctDistnct v yes. ��noj� ., E �MAP�NO�a��_ E�aPARGEL�3 -�<R -� �,�-,-�n .M„�� � ,.�, 1� •� � ��: �"K x � ���r��� �' �� r� a ra �.�. p Machine<Shop.Village��yes�; �no: TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Two or more family Industrial Addition y Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other n:> �,� # ` "�F o d -lain <�Watershed District. . , es p � < _j,,g '. r' (mss R 13.,;�,.Ya ,.» ...,., i.�'a}'�-...,+��k'.�r � :k:�, ,:�''4'�:�,.w: ✓�,..5.#7;.�r� ! :L� v..�...�i:.n,:4'S.� +r ""a' t' DESCRIPTION OF WORK TO BE PREFORMED: Id ntification Please Type or,Print Clearly) OWNER: Name: Ui fz:. Phone: � Address: .N„ ' C`®}NTRACsT!®R }Names 62wr' �c�.�Phone'�ZC ;# "? rr.. ,stn.^.n'�E r�^rW` ', ,..'4.,e. -s... +- v r3 a z`• a �s uN� y�� 'i, _,A-_ ess d Supervisor'sConstructionLicense - fry P q.�,j a yid ,` PAF g�{ n;`l �� t , /Mt q,{- y •Y�. L4"Y`T. �i'�rs"+.lt +y" �� �,h151'� ,�te r� Home�ImprovementLicense ' Ezp Date ?- S: r 4. i ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$92.00 PER$90000.00 OF THE TOTAL ESTIMATED COST BASED ON$ 5.00 PER S.F. 10 Total Project Cost: $ _ -' FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner "Signature;of contractor. Location No. Date — e TOWN OF NORTH ANDOVER a ' Certificate of Occupancy $ � Building/Frame Permit Fee $TW Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# / 25659Building Inspector , Plans Submitted Plans Waived Certified Plot Plan Stamped Plans f 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 i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM I 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: Comments ' Conservation Decision: Comments r Water& Sewer Connection/Signature&Date Driveway Permit DPW'Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = TemDum P stet on site yes no. .p .L-ocated at 124",.-MF a i n,Street Fire Del partrrentzignature/date 4 COMMENTS '. � I Dimension I Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop requires approval of 1 Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine 4 NOTES and DATA— (For department use) h 4 y i i ® Notified for pickup - Date Doc.Building Permit Revised 2008 i 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 i ❑ 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 g ng Afrldavirs for Engineered products DOTE: 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 OTE: 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 J15 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation Home Improvement Contractor Registration Program 10 Park Plaza—Suite 5170 Boston,MA. 02116lug 4 Deval Patrick Govemor Massac e' istration Card U �use1111tis _ Timothy Murray Board Of BUIld1 DePartrpent.of Lieutenant Govemor Co ng Reg l�tio Public Salet n.Str " Y uction SuPer-A isorns and Stand License: CS-084,554 $ arcs -0 E check or moneyorder for Please,complete_.(pruit) this f EDw 84554 � _ ARD J �.° ;. $25, payable to: "Commonwe 178]►q�N S MCQhEENEY WES MA 01985 r REGISTRATION NUMBER � M C o rte ^� nl+ssron REGISTRATION(COMPANY)NAi.,«.. er 0710'ration — 8/20.,1 Q; BUSINESS ADDRESS: / ✓��4i v,) c� MAILING ADDRESS(if different): INDNIDUAL RESPONSIBLtFOR HOME IMPROVEMENT CONTRACTS �i A.A.L �tyu `/ SIGANTURE OF-RESPONSIBLE PERSON REQUIRED IN ORDER TO PROCESS SIGNATURE: TELEPHONE NUMBER: LOST CARD WAS: ONLY CARD ISSUED SUPPLEMENTARY CARD IF SUPPLEMENTARY CARD: NAME OF PERSON ISSUED CARD: __SLGNATUREOF'IG'ARDHOLDER FOR OFFICIAL USE ONLY REGISTRATION NUMBER: CEIVDUPLICATE ISSUED BY: AUG 3 DATE: 2012 OFFIC 0 CONSUMER AF-PAIRS Antique Restoration and Remolding Inc. AGREEMENT FOR SERVICES This CONTRACT satisfies all basic requirements of the States Home Improvement Contractor Law(M.G.L.c. 142A),but does not preclude parties from adding language to protect their specific interests. Seek legal advice if necessary.Before agreeing to any home improvement work on your residence you should obtain a free copy of "Consumer Guide to Home Improvement Contractor Lain"by calling the Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787. You may cancel this Agreement if it has been signed by a party thereto at a place other than an address of Antique Restoration&Remolding Inc.,which may be its main office or branch thereof,provided you notify Antique Restoration&Remolding Inc.,in writing at its main office or branch by ordinary mail posted,by Telegram sent or by delivery,not later than midnight of the third business day following the signing of the Agreement. See Attached Notice Of Cancellation For An Explanation Of This Right. Homeowner Information Contractor Information Tria N Sykes, D.C. Edward Mcqueeney 162 Sutton ST 933 great pond road North Andover ma North Andover Ma Phone: 978-771-3553 Business Phone: . Contractor Registration//: 156423 Exp. Date:_7/3/2414_ MA Sup.License: CS084554 Salesperson(s): Edward McQueeney,President i WORK TO BE PERFORMED Supply Permits .Supply Dunapster Install 2x4 studs for new,wall Install 2 electric outlets and stt,itch in same wall I Install _+sheet rock ck Mud and tape some wall Electr•ican will move ceiling lights Install lead sheet rock on walls per print Mud and tape Install lead in ceiling per print Install glass window,from other'store Install wood door in same area with door nob Clean work area Not Inchrded: painting I I The following schedule will be adhered to unless circumstances beyond the contractor's control arise.- Work Scheduled To Begin:08/22/2012 Expected Date of Completion: 09/04/2012 (Date Contractor chill begin contracted work) (Bate when contracted work-will be substantially completed) TOTAL.CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to perform the work, furnish the material and labor specified above for the SUNI OF$5,000*include all finance charges in this amount) Pavments Nvill be made to the following SCHEDULE: S3.500.00 doevn upon signing contract(`Not to exceed 13 of the total contractprice OR the cost of special order iterrrs whichever is greater*) I Payments of S2,000.00 Final Pttt'tnent of$500.00 due upon final walk thru and completion In order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins(Lax,requires that any deposit or down payment required by the contractor before work begins maj,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 mater al which must be special ordered in advance to meet the completion schedule )No final payment shall be demanded until the contract is completed to the satisfaction of the parties thereto. Total payments to crtnotatt to:Fine thousand dollars OTHER IMPORTANT PROVISIONS You are dealing with a Registered Home Improvement Contractor and are entitled to certain rights under the provisions of 780 0MR R6 and M.G.L.c. 142A. Payments: If payment is not received as per the Contract,then the Owner shall be responsible for all attorneys' fees, court costs,and other costs incurred by the Contractor and enforcing Contractor's rights hereunder. Pets: Homeowner agrees to keep all pets out of the work area and take whatever steps are necessary to safeguard them from any harm that may come to them as a result of the work being performed under this Contract,including but not limited to injury on or outside the Premises or ingestion or inhalation of,or contact with, hazardous substances. Company assumes no responsibility for any harm to the pets as a result of the work performed under this Contract. Further,Homeowner shall take all steps necessary to protect Contractor,its agents,servants,contractors and employees,from any harm as a result of contact with said pets. Characteristics of wood: Wood is a hygroscopic material. Wood swells and/or shrinks in relation to the humidity,temperature and environmental conditions of its surrounding. Generally,wood flooring is expected to shrink in any conditions and expand when exposed to moist conditions. Natural wood also contains variations of graining,texture,hardness and/or knots,depending on the wood chosen. Contractor cannot be responsible for the natural features of the wood chosen. Contractor is not responsible for shrinkage,checking,swelling,or Other conditions which are the normal condition of wood or the result of household or environmental humidity,heat,cold,or other conditions. Colors: You may choose colors and finishes for the parts being used in your remodeling project. It is important to remember that a color or finish you see at the store or in a showroom may not look the same in your home,especially after all of the different colors and finishes are brought together upon the completion of a project. In addition,one manufacturer's named color is not the same as another manufacturer's named color? Unless specified otherwise,Contractor will use brand and brand stain. The Contractor cannot be responsible for the appearance or lack of coverage from Homeowner/chosen paints and/or stains and finishes. Building Officials: Any additional costs incurred by Contractor as a result of decisions made by Building Officials will be the responsibility of the Homeowner. The costs of additional work will be calculated as follows: cost of materials plus an hourly rate of$60.00 per man hour. t Liens: In the event of non justifiable non-payment,Homeowner's residence or property may be subject to a.Mechanic's Lien as a consequence of signing this Contract. Utilities: The Contractor will use reasonable efforts to notify the Homeowner in advance of any interruption of utility services. However,there may be instances where the Contractor must shut down these services without advanced notice. Homeowner must arrange for emergency backup service for any utility critical equipment such as medical devices and computers. The Homeowner must also notify the Contractor at the start of the work day if you will be engaged in any utility critical activities in that the Contractor makes a notification in writing in the daily log book or otherwise. Additional work: Any additional work requested by the Homeowner which is beyond the scope of the work to be performed as set forth in this Agreement.. shall be the subject of a separate agreement,and/or if not,subject to the same terms and conditions as set forth in this agreement and billed on a time plus cost of materials basis at Contractor's normal hourly rate. Contractor's normal hourly rate per man hour is $60.00. In the event that additional work is to be perforrned on an hourly plus cost of materials basis,the Homeowner shall be required to exectite a Change Carder which shall include Contractor's best estimate as to the time required.together.-eith the cost of labor as;well as the type and cost of materials necessary. Delays: Contractor is not responsible for delays attributable to Homeowner initiated modifications or additions, or for delays incurred due to the actions or inactions of cin. town officials, strikes. acts of God, unfulfilled customer obligations.vendor delays,interference by other tradespersons,customer supplied items or other delays beyond Contractor's reasonable control. Contractor«•ill use reasonable efforts to stay on each job until substantial completion by allotting specific time periods to each Hwneox ner to complete each job in as timely a manner as possible. In the event that Homeowner dues not allow Contractor and/or his employees or sub-contractors access to the residence or property so as to allots Contractor to perform his obligations and/or to complete the scope of work in as timely a manner as possible,other than for reasons of safety or other reasons mutually agreed to between Homeowner and Contractor. then the Homeowner shall be responsible to pay Contractor the sum of$500.00 per day, on a pro rata basis,to cover the costs of delay. Contractor reserves the right to suspend work and/or delivery of materials in the event of unjustified non-payment. In such event,the Contractor shall have no liability to the Homeowner for alleged delays or damages due to said suspension. Punch-list Items: The Homeowner agrees that routine"punch-list"or repair items after substantial completion are outside the agreed scope of services,and covered by Contractor's warranty obligation and will be completed as soon as practicable and according to Contractor's and Homeowner's mutual availability. Homeowner agrees that it shall use his/her best efforts to make himself/herself available to observe and/or sign off on the completion of any such punch-list Items, and that the approval of one Homeowner regarding the completion of any such punch-list items,as well as change orders shall be binding upon all Homeowners. Unforeseen Conditions/Circumstances: Contractor shall not be responsible for any changes at the request of the Building Inspector. Contractor shall also not be responsible for any unforeseen bedrock/ ledge or latent defects such as structural and/or dry rot or insect damage to the existing structure,or for preexisting faulty or inadequate wiring or plumbing. Contractor shall also not be responsible for any pre- existing code violations or responsible for correcting contiguous work completed by others not under the Contractor's authority. Insurance: Homeowner agrees to carry fire,theft,vandalism,liability and all other necessary insurances to protect their personal property while construction is in progress. Contractor will carryall required and necessary insurances including worker's compensation insurance. Contractor will ensure that all personnel including sub-contractors will be covered by all required and necessary insurance including worker's compensation insurance. Homeowner's Cancellation Rights: In addition to the rights the Homeowner has,as set forth in the attached Notice of Cancellation,the Homeowner may have rights under other Massachusetts Statutes, including M.G.L.c. 93 §48,M.G.L. c. 140D, § 10 and M.G.L. c. 255D § 14. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies of the contract should go to the homeowner and the contractor. Homeowner's Signature Contractor's Signature Date Date You may cancel this agreement if it has been signed by a pare-thereto at a place other than an address of the seller,which may be his main office or branch thereof. provided you notify the seller in writing at his main office or branch by ordinary°mail pested.by teiegrani sent or by delivery,not later than midnight of the third business day following the siunilg of the aueeir,ent. See attached notice of cancellation for an explanation of this right. NO WORK WILL BEGIN 'UNTIL BOTH PARTIES SIGN THE CONTRACT AND THE OWNER RECEIVES A COPY REQUIRED PER1,141TS The following building permits are required. It is the obliUation of the contractor to secure such as the homeowners agent. list ani'and all nece.ssai*v cvnstructioti-related permits. DOTE: Owners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of-1GL c. 142A. EXPRESS WARRANTY All workmanship and materials to be free of material defect for a period of one(1)year. During the Warrantyperiod,the Company may,at its option, either repair or replace products or workmanship which.proves to be defective. This Warranty shall not apply to defects or damage arising from improper or inadequate maintenance by the customer, customer's applied products,unauthorized modification or misuse,damage incurred as a. result of acts of God or civil strife,or normal characteristics of the materials such as wood shrinking,expanding and otherwise reacting to moisture or environmental conditions. The Company's liability is limited.to the repair or replacement, at its option, set forth herein and Company shall not be liable for any consequential,sequential, incidental or other damages not set forth herein. The Warranty set forth herein is exclusive and no other Warranty, whether written or oral;is expressed or implied. Company specifically disclaims the implied Warranties of Merchantability and Fitness for a.Particular Purpose. NOTE: All home improvement contractors and subcontractors shall be registered and any inquires about a contractor subcontractor relating to a registration should he directed to: Director,Home Improvement Contractor Registration One Ashburton Place,Room 1301 Boston,MA 02108 617-727-8598 Unless otherwise noted within this document. the contract shall not imply That any lien or other security interest has been placed on the residence. ARBITRATION The contractor and the homeowner hereby mutually agree in advance that in the even the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration sen-ice which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall he required to submit to such arbitration as provided in\-i.G.L_c. 142A. Contractor: Homeowner Date: Date: NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETFLEMENT INITIATED BY THE CONTRACTOR, THE OVINER MAY INITIATE.ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES_ ACCELERATION OF PAYMENT Homeowner's Financial Insecurity-A Contractor may.not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hint/herself to be financially insecure. Contractor's Financial Insecurity-In instances where a contractor deems himself/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal from said account would require the signatures of both parties. Homeowner agrees to allow reasonable access to allow Contractor to reasonably attempt to remedy any outstanding uncompleted,disputed or non-satisfactory item. If you have general questions or need additional information about The Home Improvement Contractor Law,contact: Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulation 10 Park PlaTa.Room 5170 ' n 1 Boston,MA 02116 617-973-8787 If you have questions about.Contractor Registration,contact: Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One Ashburton Place,Room 1301 Boston,MA 02108 617-727-3700,x25205 NOTICE OF CANCELLATION YOU MAY CANCEL.THIS TRANSACTION.WITHOUT PENALTY OR OBLIGATION,WITHIN THREE(3)BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE. AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN(1 G)BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL.YOU MUST-MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE.IN SUBSTANTIALLY AS GOOD CONDITION AS "t HEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY,IF YOU WISH,COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY(20)DAB'S OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT.ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION.NfAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE_OR SEND A TELEGRAM TO Name of Seller: At: NOT LATER THAN MIDNIGHT OF (DATE)- I HEREBY CANCEL THIS TRANSACTION. Date: __� Buyer's Signature: r "i r NORTH - w . . i. .c ve: No. * , . - h ver, Mass, . COCNIC Nl WICN �d A0RATEO S V BOARD OF HEALTH Food/Kitchen PERMI D Septic System THIS CERTIFIES THAT ........ . .` . BUILDING INSPECTOR . Foundation has permission to erect .......................... buildings on ......` . ....d.�.!�.�..�,. .Q.Q.. d,...a...., .. Rough to be occupied as .............. Chimney ......x... .a. ..... . . . ...................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN NTH ELECTRICAL INSPECTOR UNLESS CONSTRUC 1 ST Rough Service ............. ................................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Stree'c No. Smoke Det. SEE REVERSE SIDE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /•1 (� 1 j� (�rG Rlq�ska—,4;ooa Address: S�— City/State/Zip: L �- Ailicd6urij Mei Phone#: /?4 ) ??3 Are You an employer?Check the appropriate box: Type of project(required): 1.VI am a employer with 1 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # ? Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 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. $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: 6<Gy AC1 -L N S 0CANCF, Co 1M,PAo4 Policy#or Self-ins.Lic.#: AA) uo L `7 14 ri &6s- Expiration Date: 13 ��f 113 Job Site Address: �-� )6Y W V d-:� ZV' City/State/Zip: W rA� A ti�cA4 f'L, 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 fore 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: rUr L(J Date: Phone#: 979- 5— i L 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 Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia x I cn O U O a °O ot� O g � b EXISTING WALL # PARTITION TYPE 3E 1-1 c >00NEW WALL bo t- w �w 36°X6'8" SOLID CORE ODARK ROOM DOOR W/ R� ROOM NAME t NUMBER NA.DOOR SWITCH W w c e CONTROL TO O OPERATOR CONSOLE ENTRY ^' w O° 1X4 2TU5E FLUORESCENT H LEAD VISION PANEL CELING MOUNTED LIGHT YT ON CONCRETE FLOOR WINDOWS 12"X12" FIXTURE N�QJs EXISTINS TENANT YVAITINS AREA A- 220AC, 100 AMP SINGLE BREAKER OR DISCONNECT. $J 3 CONDUCTOR% AUG U a 0 B- OPERATOR CONSOLE t o cm EXISTNG o a C- TRANSFORMER uLL E w D- TUBESTAND = - 0 i/ X O o E- BUCKY �Q �9 GUARD 2 xj OGO -� RAIL F- &" LEAD SHEET M CEILING. `V D 0 RERI=D /-HANDRAIL V1 REQUIRED CENTERLINE FOR BUCKY(E) IS 30"1 - lr= \\�� B It I X-RAY ` 4 REFER TO EQUIPMENT SPECIFICATIONS FOR ELECTRIC 4 FIXTURE MOUNTING ' n ROOM REQUIREMENTS OI _ ��� �\ i MIN 3'0" 1.FLOORING IS V.T.OVER EXISTING CONCRETE SLAB 5U=11461EQUIRED I _-__ �, �� __� CLEAR �� � (TYPICAL FOR ALL ROOMS) EXTERIOR -- - W 2.EXISTING CEILING IS A.T.SUSPENDED.REQUIRED ADDITION TO CEILING WILL BE TO FLOORVT ON CONCRETE 8lS O PLACE&" LEAD SHEETS THROUGHOUT XRAY ROOM I (8'X10')CEILINGS.OVERLAP ALL O O EDGES OF SHEET 2",AND ADD CEILING TIES TO STRUCTURE THROUGH LEAD SHEETS e 4'-0" ON CENTER IF PLACED ON CEILING TILE AND NOT FASTENED DIRECTLY t0 WOOD 0 STRUCTURE ABOVE AT CEILING IS 18 - `\ 3.PROPOSED X-RAY ROOM IS NOT ADA ACCESSIBLE r \l/ LL Z �0 / >, 4.PROPOSED X-RAY ROOM IS NOT AN ENCLOSED ROOM WITH DOOR FOR PRIVACY. DARK ROOM STORAGE OWNER/TENANT MAY REQUIRE DOOR Q ^ O CLOSET w Li vT ON CONCRETE FLOOR o, q cc w Q v Nc.4153 ANDOVER, [ate: 2 3 AUG 2012 z�l�v f MP�P�JS ie: AS NOTED O ob PROJECT INFORMATION: PARTIAL L FLOOR PLAN OF X-RAY ROOMeet I 2362 SUTTON SQUARE CHIROPRACTIC SCALE:1/4"-1'-0" A1D 46 BEECHWOOD DRIVE NORTH ANDOVER MA A� l OWNED BY DR TRIA SYKES Ne.4153 .. '��W000STRIJCTUI_ 44 STRUCTURE 21 _ _ J i • SEE NOTE 2 � ! \ i7i` SEE N• f ••� GYPSUM i •- GYPSUM DRYWALL A50VE CEILING \—EXISTIWu A.T. CEILING TIES A5ovf-: CEILING CEILING EXISTING A.TCEILING Lu/ 1EXISTING A.T. CEILING • s . •EW . � ! AD INED GYPSUM s LINEDGYPSUM .• . ;;• GLUED TOeoARD GLUED TO EXISTING GYPSUM • • N GYPSUMEXISTING DRYWALL ONxISTING VISIoN LUINDOW EACH SIDE NOTE: PARTITION CENTERED OVER ALL ELECTRIC 5E IN Casto WAITLt,�QMM 44 •ND SURFACE 2X4 WOOD STUD imouNTEo ` I&II • ••D STUD AGYPSUM • s DRYWALL • E • 3 • FLOORING DRYWALL ON X-RAY TU5E SIDE RYWALL EXISTING • ° // GYPSUM / - . -• g � / CONCRETESLA5 VINYL TILEVINYL TILEi 0 FOUNDATION CONCRETE s / sINYL TILE Ta CONCRETE --- 11 `�—F-XISTING SLA5 AS NOTED �/ • - CONCRETE2362 © ii 8CALE:3/4n110 1 110 5CALE:3/4"04" A20e