Loading...
HomeMy WebLinkAboutBuilding Permit #815-2017 - 497 WOOD LANE 3/2/2017w vt' BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: g� s Date Received Date Issued: ANT: Applicant must complete all items on this LOCATION Print PROPERTY OWNER_ Rise Redevelopment, I I C: Print MAP NO: 99 PARCEL: 63 ZONING DISTRICT: Historic District yes Machine S.hon Villaoe ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building N/One family SAddition 0 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 Identification Please Type or Print Clearly) OWNER: Name: Rise Redevelopment, LLC Phone: (617) 9224370 Address- 11 Norton St, Boston. MA 02136-1414 CONTRACTOR Name: Simone Renovation & Design Phone: (978) 652-8210 Address: 19 Harbor Street, Newburyport MA 01950 Supervisor's Construction License: CS -059997 Exp. Date: 8/28/2018 Home improvement License: 180603 Exp• Date: 12/07/2018 ARCHITECT/ENGINEER:T-Design Phone:(617) 797-6637 Address:1248 Randolph Ave, Milton MA 02186 Reg. No.: 45563 FEE SCHEDULE: BOLDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project -Cost: $140,0.0.0.0.0. FEE: .$ 1,68.0..00. Check No.: 1' / �'�`�' Receipt No.: 3/ffly NOTE: Persons contractin with ur gistered contractors do not have. access to th guara fund Signature of Agent/Owner Signature of contractor r d TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page PROP ER�,TtYInw� Pnnti 10Yearj0ld Structure yes] no, 1 "'� 1 - f _ MAP NO xPARGEL=ZONINGDISTRI;CT1Histon®i"stnct� yes4 , 11A...�L...:.■C4,'.. r;.\'Y•Il;�,iioc'. i'rrst TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building [j One family ❑ Addition ❑ Two or more family ❑ Industrial :Alteration No. of units: ❑ Commercial p;Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other `.❑ Septics Well A� = n- SIRd-LO dplain M ®iWetlands3 0� Watershed Distric"t, i� DESCRIPTION OF VVOIKK 1 O tat FLKi-u iq:., Identif• ation Please Type or Print Clearly) OWNER: Name: ��S � F e1 ���w��,,J'r LLL Phone(,_2,9p,70 Address: l �or �� L i GONTRA`CTOR`tName _ -- - - Phone.; _ -.a _ .. _ . _ _ _.� r : S:upervisorrs,C,onst�uction�Lioense �... _. _ y EXpp, Date _ w K- - - - Horne:Improvementcense P, �� 31 ARCHITECT/ENGINEER Ti.��v- IVa.��, -,... Phone: Address ����� '��--��� �� ►-c. V�t,��,�., C�-t 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: $ Iqo FEE: $ t 0 Check No.: Receipt No.: NOTE: Persons contracting it r gistered contractors do not have access to the guaranty fund signature of Agent/Owner Signature of confiractor Plans Submitted Waived ❑ Certified Plot Plan ❑ Stamped Plans •T•- P I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE -OF SEWERAGE DISPOSAL Signature Public Sewer ❑ Tanning/Massage/Body Art ❑ ... Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ Driveway Permit THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENT CONSERVATION Reviewed on Signature COMMENTS HEALTH' Reviewed on—' COMMENTS Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments " Conservation Decision: Comments Water & Sewer Connect! on/Signature Date Driveway Permit 3 DPW Town Engineer: Signature: FIRE ®EPARTMENT - Temp Dumpster on site Located 384 Osgood Street yes Located at -124 Main Street no Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions- Total imensions_ Total land area, sq. ft.: ELECTRICAL: (Movement of Dieter 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 NOTES and DATA — (For department use B Notified for pickup - Date Dor-Building Permit Revised 2010 Building Department Tine foKowing 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 o 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 o Copy Of Contract ❑ Flo or/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 VOTE: 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 -1OTE: 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 app. -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be- subwted with the building application Doc: Doc.Buillding Permit Revised 2012 Location 7197 CU009 L'A.." No.� Date 011e%7 Check # 1,5.S - ,s l 5 3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ GG Building/Frame Permit Fee $' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector a.. . .a. Plans Submitted IV Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans V 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 PLANNING & DEVELOPMENTEl COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments SConservation Decision: Comments ?Water & Sewer Connection/Signature & Date Driveway Permit • Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS no Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 140,000.00 m $ - $ 1,680.00 Plumbing Fee $ 210.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 210.00 Total fees collected $ 2,200.00 497 Wood Lane 815-2017 on 3/2/2017 full renovation and second floor addition 0 e% 00 x J _ LL O O Oui m v Y \ O O LL N v, U Q N Ln p U ai v z z m c O '6 3 O LL L 7 O C' v C s u 5 O LL O W 0 z Z J a t hp O � O LL Q W � z J v V J W L CO p CC u v N C LL O W V1 Z N Q � L 00 p K C LL z W Q W O LL O Oaj m z° N N N o N Y O {n c O O F� C L O W� •CL L �a 0 0 Y N E a, O O h c a 0 o m N . *Ab;o Q cu !: U J ma o -a � Cc L 'o a o N cO C t U E c oZ CL r- 0 T O o 3 �i c c a� a 'S N O m W -0. O O LU LLO N C y CL O N O � :r LU E 0 � a i V Q O O ,, am U) H cu s O C. O U V+ ace 0 Cfl 0 s� V W aZ W O U uj CL Z Z-1 'fin s 't3 141) i w z INDEPENDENT CONTRACTOR AGREEMENT THIS INDEPENDENT CONTRACTOR AGREEMENT (the "Agreement"} dated this 21 st day of February, 2017 BETWEEN: SIMONE RENOVATION AND DESIGN Kevin and Michele Simone 19 Harbor St. Newburyport, Ma. 01950 (978) 652-8210 www.SimoneRenovationAndDesign.com And: Rise Redevelopment, LLC Justin Benster Project Address: 497 Wood Lane North Andover, Ma. 01845 BACKGROUND: . A The Client is of the opinion that the Contractor has the necessary qualifications, experience and abilities to provide services to the Client. . B The Contractor is agreeable to providing such services to the Client on the terms and conditions set out in this Agreement. IN CONSIDERATION OF the matters described above and of the mutual benefits and obligations set forth in this Agreement, the receipt and sufficiency of which consideration is hereby acknowledged, the Client and the Contractor (individually the "Party" and collectively the "Parties" to this Agreement) agree as follows: Phase 1 Of the Protect: Simone Renovation and Design Will Provide the following services for phase 1 of the project: Pull a permit with the Town of North Andover. The permit price is a percentage of the total of the contract. The client is responsible for payment of the permit. SR&D will utilize the dumpster that Rise Redevelopment has on the job site. Lolly columns installed as indicated on blueprints. Headers over windows will be installed according to code. First floor Interior walls framed according to blueprints and code. Triple LVL 12" x 32' will be installed as indicated on blueprints. Second level floor joists 2" x 10", 16" on center will be joist hung off triple LVL, spanning entire front to rear span of structure. Install 3/4" plywood subfloor on first and second level. Second level exterior walls will be 2" x 6" KD Roof rafters will be installed, 2" x 8" per blueprints. Zip system exterior sheathing will be installed on all exterior walls of second level per blueprints. Zip system sheathing will be installed over all roof area per blueprints. All exterior finish i.e.: siding, trim, windows, roofing will be done by Simone Renovation And Design in accordance with the blueprints and state building codes. Install new architectural roofing shingles over new sheathing of addition. Install new vinyl siding over all new and existing building. All trim will be covered with aluminum coil stock. Install new construction windows throughout the house, first and second floor. Replace the bay window on the front of the house with a picture window with two double hung windows at each end. Cathedral the ceiling height in the family room area. Remove the existing flat ceiling joists, expose the existing rafters, sister 2" x 8" rafters to existing 2" x 6" rafters. Install foam attic venting and insulation, drywall to finish. Frame second floor addition according to blueprints provided. All drywall will be hung, and exterior walls will be insulated per code. New exterior walls will be finished to a watertight condition. Total Labor For Phase 1: $38,400 Phase 2 of proiect: Simone Renovation And Design will provide the following services for Phase 2 of the project: Hardwood flooring install in all areas specified by Rise Redevelopment Install baseboard trim Install interior window casing and trim Install interior door casing and trim Hang doors to rooms Hang closet doors Install kitchen cabinetry and cabinetry molding and cabinet hardware Install vanities Hanging wood mantle on fireplace Install and trim out sliding glass door Install front entrance door and trim Install rear entrance door and trim Install handrail for staircase Install treads and risers on staircase Total Labor for phase 2: $24,000 Materials: No materials will be provided by Simone Renovation And Design. All materials will be purchased by Rise Redevelopment. This contract reflects labor only. Term of Agreement: . The term of this Agreement (the "Term") will begin on the date of this Agreement and will remain in full force and effect until the completion of the Services. Performance The Parties agree to do everything necessary to ensure that the terms of this agreement take effect. Currency Except as otherwise provided in this Agreement, all monetary amounts referred to in this Agreement are in USD (US Dollars). Compensation For the services rendered by the Contractor as required by this Agreement, the Client will provide compensation (the "Compensation") to the Contractor as follows: * The client will pay a total of $62,400 of labor for the services to be provided. • Amount due upon signing of contract: $6,000 (received 2/21/17 Ck # 1549) * Amount due March 2, 2017: $14,100 * Amount due upon completion of drywall, roofing, windows and siding (original Phase completion). $14,100 * Amount due upon completion of hardwood flooring install: $14,100 * Amount due on completion of our end of the job: $14,100 Capacityflndependent Contractor in providing the Services under this Agreement it is expressly agreed that the Contractor is acting as an independent contractor and not as an employee. The Contractor and the Client acknowledge that this Agreement does not create a partnership or joint venture between them, and is exclusively a contract for service. Dispute Resolution In the event a dispute arises out of or in 'connection with this Agreement, the 'Parties will attempt to resolve the dispute through friendly consultation. If the dispute is not resolved within a reasonable period then any or all outstanding issues may be submitted to mediation in accordance with any statutory rules of mediation. If mediation is unavailable or is not successful in resolving the entire dispute, any outstanding issues will be submitted to final and binding arbitration in accordance with the laws of the Commonwealth of Massachusetts. The arbitrator's award will be final, and judgment may be entered upon it by any court having jurisdiction within the Commonwealth of Massachusetts. Dispute Resolution In the event a dispute arises out of or in connection with this Agreement, the Parties will attempt to resolve the dispute through friendly consultation. If the dispute is not resolved within a reasonable,period then any or all outstanding issues may be submitted to mediation in accordance with any statutory rules of mediation. If mediation is unavailable or is not successful in resolving the entire dispute, any outstanding issues will be submitted to final and binding arbitration in accordance with the laws of the Commonwealth of Massachusetts. The arbitrator's award will be final, and judgment may be entered upon it by any court having jurisdiction within the Commonwealth of Massachusetts. Modification of Agreement Any amendment or modification of this Agreement or additional obligation assumed by either Party in connection with this Agreement will only be binding if evidenced in writing signed by each Party or an authorized representative of each Party or will be binding as a verbal agreement if both parties agree. IN WITNESS WHEREOF the Parties have duly agreed to this contract with their signatures under hand on.this2l.st day. of. February, 20.1.,7 stin Benster -'i�ede pment Kevin Simohe - Simbne-Renovation And Design r Michele timone - Simone Renovation and Design M. �f I_ j - g a C7i ' fti W T in /.. 0 »�. 1 c c 477 _ r - 7 Lin E S 116 ya �, rn m 0 rJ W drl V �lj �. I� i > i? l -�% f t rn cl 1N 0 ,Jt cy q� rf COO T' w . y Et U :r r,t t- 1 I jt w 6+ 1 Ji t ' �Thp 4 r i— 1CC- lar �'. '� • - ne rr T '7. J: I r r r F.. •C . 1.+' .ny. .tiw ,�W,y, %. {it R�",I/ J� / • r +'fT -T C� g a ��ml. ' fti W T in /.. 0 »�. 1 c c 477 _ r - 7 Lin E S 116 ya �, rn m 0 rJ W drl �lj �. ,�W,y, %. {it 0 a n ' fti W T in /.. 0 »�. 1 c c 477 _ r - 7 Lin E S I ya �, rn m 0 rJ W ,�W,y, %. {it 0 a ' fti W T in /.. 0 »�. 1 c c 477 _ -aC, Lin E S ya �, rn m 0 rJ W drl �lj j� V SZ > i? M J� #2 -�% rn 0 1N 0 ,Jt cy q� rf COO T' w . 9 t� Et U :r t- 6+ r i— 1CC- lar �'. '� • - ne rr T '7. J: F.. •C . 1.+' .ny. .tiw It n .alt { i- �' fii -i t n i T c- f ' ! (3 12 E- -43 � ) i} C3 T1 t;3 r w 1' S91 F /� ,�W,y, %. {it 0 VppJ IV 'C.i W 0d•.��� *=t p« -aC, Lin E S � 0 rJ W drl j� V m > i? ,�W,y, %. {it 0 �•�••f *=t p« -aC, Lin E S � 0 rJ W drl j� V m > i? 0 0 0 Et U lit 6+ n .alt { i- �' fii -i t e ,j r w 1' S91 ` j r� � r kit m ILI ACOR09 INSURANCE BINDER DATE(MWDDIYYYY) `� 11/14/2016 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM. AGENCY COMPANY BINDER # Amity Insurance Agency, Inc. Lloyds of London GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR 7 _ 816111406307 EFFECTIVE DATE TIME EXPIRATION DATE TIME 500 Victor Rd Victory . I$ 50 000 X AM PERSONAL BADV INJURY X 12:01 AM Marina Bay North Quincy MA 02171 11/18/2016 12:01 ' PM 05/18/2017T, 5 18 2017 COMBINED SINGLE LIMIT ON PHONE (A1C, No Ext : _ ( 617) 471-1220 (AIDC No): (617) 479-5147 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY PER EXPIRING POLICY 9: XS276638 CODE: I SUB CODE: CUS OMERID: 00041003 DESCRIPTION OF OPERATIONS I VEHICLES I PROPERTY (including Location) Dwelling located at 497 Wood Lane, North Andover, MA INSURED AND MAKING ADDRESS 'Rise Redevelopment , LLC 01845 11 Norton St. $ Boston I MA 02136 COVERAGES 1 InelTc TYPE OFINSURANCE COVERAGEIFORMS DEDUCTIBLE I COINS% AMOUNT PROPERTY CAUSESOFLOSS BASIC FIBROAD FX]SPEC Builders Risk Completed Value Form Existing Value Completed Value - Full replacement cost $2,500 100 $161,250 $271,250 GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR 7 _ RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE Is 1,000,000 A RENTED PREMISES I$ 50 000 MED EXP (Any one person) s PERSONAL BADV INJURY J$ 1 000,000 $ 2,000,000 GENERAL AGGREGATE PRODUCTS - COMPIOP AGG $ VEHICLE _ LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ S BODILY INJURY Per person BODILY INJURY Per accident) $ PROPERTY DAMAGE $ _ $ MEDICALPAYMENTS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ VEHICLE PHYSICALDAMAGE DEC) COLLISION: OTHER THAN COL: ALL VEHICLES u SCHEDULED VEHICLES ACTUAL CASH VALUE $ STATED AMOUNT GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT S OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE $ AGGREGATE S SELF-INSURED RETENTION $ WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY PER STATUTE E.L. EACH ACCIDENT S E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ SPECIAL Premium has been paid in full. CONDITIONS I OTHER COVERAGES FEES $ 150 TAXES $ 49,9C ESTIMATED TOTAL PREMIUM $ 1.448 .96 MORTGAGEE X ADDITIONAL INSURED Town of North Andover LOSS PAYEE _ 120 Main St LOAN #: North Andover, MA 01845 AUTHORIZED REPRESENT /zo- Page 1 of 2 ©1993-2013 ACORD CORPORATION. All rights reserved. ACORD 75 (2013109) The ACORD name and logo are registered marks of ACORD INS075 (201309) The Commonwealth of Massachusetts Department of IndustrialAccidents X Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE ]PERMITTING AUTHORITY. Anulicaut Information Please Print Legibly Name (Business/Organization/Individual): Simone Renovation & Design Address: 19 Harbor Street City/State/Zip: Newbury, MA C Are you an employer? Check the appropriate box: Phone #: (978) 652-8210 1.❑ I am a employer with employees (fill and/or part-time).* 2.[ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] In I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.0 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.Q 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): 7. ❑ New construction 8. [VRemodeling 9. ❑ Demolition 10 Building addition 11.❑ Electrical repairs or additions 12. Plumbing repairs or additions 13. [Roof repairs 14. ❑ 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. Iain an employer that isproviding workers'compensation insurance for my employees. Below is the pollcy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #; Expiration Date: Job Site Address: 497 Wood Lane City/State/zip:-North Andover MA 01845 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 violatol-,4 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance I do hereby cgt1fyhpVer Yie pains an Xnalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # 1 Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact 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 -contractors) name(s), address(es) and phone number(s) along with their certificates) 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia "r �i CA uj So CAt.1 .t0 Ti Q C E 0 U I! SlmnHO SSV aJAOC y HIO� ��v Ylo���vyroa+aaNvni oono 98LZ0 wl -Nol-1IN AVI QOOA �6C+, 1£99-161-Lt9 3�,y Hd�00Na2i BtrZI U w a»u� m .. o0 _._ c� Pc,�SEiTS z� N IE r r zZQ��'g .� H O Up \ ?��4dVPJD O Z O W Wa z_ O J v ~ :D w W OZ a I -- w Z pr U� w �I to.:z w W o d a LJ Q G o• z U O 0 F-- (n Qz O CIL W 4 Z A U G O w U 2 M—I J m D cn J 0 x Q W O F - L'iZ Z w --j J O U zZ0 }I LLJW Q U � O o O w 0 O OQ = W F (� Q - z Z 2 J W O Wcn O G U cn mO- W U W CD T< Z W a z o cin v m �Z v ww nw� U �, OO 0 LLj Z o� z wTz �=O in D w W Ow U > U o w LjjJ Q Cl)O O o L � W Ch 0 Z Of w o cr Q D_ W O �1 z' w L -J } � Q ® Q z L w 0 (n O O D_ 0 W O LJ ZT W Z �O� L WO a1 O w OD m Z �=> Qm~ z �Qcn cnw�_ 0 `� Lu N r') ;I- L[) co l� 00mNLn IIIIIiIIIIIII Q w m Ch W_ O U JZ Q m- a QQQQQQQQQc mcnocn OU � �L, J O O m O O y u � Q= - Lj O S > >Ww wzw O w-zQ W II U� Z >> G Q 0 d H m S �O 00zZ (n LJUW WIQLf C~.J 1-00 > > W D' I-- [1' W 0_ _ F Z Q Q F- wwW> Cf J z�Qw Q Q�z CnL� J W ZWwww D Od LLJ JO CD J J C/) (n i I- Z D' Lj 0- 2 2 0> zQa�wwz8 z omQu' Zcnn ZQm Za0_mL�G_0 J -j O F- D' JAG_ Jw0 a a W �z z zQJ O -J QD_a_�C) WLi 0 D �Q =F-. OO Of F-- � J =�Jp D O--'nnnin z a < :2 O=—U cnOQ� QOO J��a 0Qz z0�W a C0000 zz z�� `ZOOOO��QQQ (%) z�zz��zzw� ��� nw- wWW,Omm��� D_D_ D aaLl0-1 0 OOQ 00 U�wU �OOQQ2w JEm0� ?U ��CJo �oZ cnQ�_w�000 OZZ� m m n m w JowOLLJ LiZU oZ Z Q z Z Z Z --~ m,2LQC)QQQQOW��w OJ Q = J O= of 1--QUHD D = S D -�Q-iU J O w ww <acn ZNzN�zzzzL w H- 0- 0- F- F- H H H 0W w C 7 .- N M '�t C.O I� oj 01 N O O O U 0 0 xxxL:�D_xxxxLhW OD' X1 WD_ WLLIl- I.LLLILLIIWLiU1<ClhU O Or-Nh?SY .- N LO IL C6 0� .F . QV S11�SIIn�YSSVW ❑�^II}l.�oa Y HAON iw wie a�yOO'�ir�yoa3dNVna OOnO 9B[L0 -VW 'NOl IIW INV] aooM L6b L£99-L6L-L �9 Shy HdIOONy21 BbZI — mmw oii�aa d3 doa a oil no 3� w n - H a J d �.. s w z y ®y r�a6 O II If II II III II I � I I I 1 I 1 +I a II -- :D- - }L - - - --- ii I I f I I ------------------- QII II n 11 I N z ' o W +I u n Q In Z W ^ J u U n II LJ (n X �/ J Q II F- I I.rJ J M Q t�f _J (� Cf) II � II ij \ I I I I ccn X +� w CD wW I + o o < , I I I ---------------- ,o I I I +„t7 -,0Z A .c1 LI _ S113Sf1H�ySSbW d�l\OQ H fIl�OCC '�xv IMOO�IIYM0>3dNvni0OnO 991Z'O "VPN 'Noill4 Yp1 3W QY LUV L£99-L6L-Ll9 3AV Hd"IOONIV6 2i Z1 ' OIlI00d d31N�0a aNV NOIldA0N3H -'" s a ' a�n�Na SETTS V 7 Q. ����QNiN10'J O QQ Z Q p N — 1 z ® ® ® p W N W ^II -iv U� +I _.. < L.Li J Nma (.J W M J t— W O ----------------- a_ O ry 0 ;+ n ---------------- +,2l SlihnHOVSSVW d]AOQNV HIdON wa�a iyoD�itlY1�3aNtlni�ono 99tZ0 'VV4 'N0l-I1m 0 0 Z a 9 �1 INN� QOO� ��t V 'o wva L£99—G6L—Ll9 3hH Hd-I00NVH 94Z1 i mxw o � III I 1 1 Q o llaad Mdoa aNd NolIVA01do w avo.b :Z�> --I --I ` H !E> I s :29 a +,2l 0 0 Z a o � III I 1 1 Q 73' I �.-----' 1 II f it F— I LLJ w IU°. tf� LO I ..Z-16 I T-1 '.r - II O �. O n w 11 ``p IJ II II II II II -----------------------------1-a��yi :Fl \ // I I `Al O 00 II Z II > 11 II J +I 'I O u II I II 0 - 41 J I I m ;; u 11 1 1 � II n 11 SIIISI IHOdSSY d] oQ VF{,il (jo <�ro MoD'I.a 1V�3dNvni sono L £99—L6G —L t9 98120 'V V'i 'NO1lIW 3Ay Hd�00NVii BtrZI 3Nb1 Q0oM L6� ga3nro Noiilaa �3 Boa ONV oil no�i��a N CD � � :ER CD —L G,�SEZTS z� F zz Q� AIN O O Z J W Q W 2 Z I I -1 Q nn 4I CO LO I I I L— 0 I O I I W e z � I__L LL - W � co I � I Q W ox I ASO I cn o M z J u U •. � d� I Q 9 bj W cn �o °+ O C� O O 00 O W ~ J > J d U SllIS�NJYSSY a3 �Q Y NlaO ei/owmmoo•�ivy��aadNvnl oonc 48420 "d {�y 'N011lyi 101 a00L6y, L£99—L6L—Ll9 VHdIOONda BbZI -MHOIS W�now U 3N 011IQOd d3 dOd QNV dll AO 3d PV �» �4 Z Z QW 6 1- 00 J U z Q o 0 o� Li O o m o w m m �I O � o .w U ® N Z II _ O �a LC) m O M U =o w �� O C) r`' o w O/� N O n LO m 0 cV O O r/ m O a_ w m U b�Nsn 32"(052"(H) DH ININDOW U=0.3, DOUBLE PANE EXISTING FRONT ELEVATION ViE SCALE: J"=1' CONTINUOUS RIDGE VEN PROPOSED FRONT ELEVATION VIEW SCALE: { "=1' "" ""- -T- o = � I c_- r--4, L- L- c *"„ RENOVATION AD DORMER ADDII TIO -0 FA 1248 RANDOLPH AVE 517-797-6637 497 �'OOE LAND ui"zaen+ MILTON, MA. 02186 QUOCTUANK001, IL.COI,) y - M NORTH ANDOVER, MASSACHUSETTS JFM MF - - ------------ EXISTING [RIGHT ELEVATION VIE SCALE: 32"(W)x52"(H) DH WINDOIN - U=0.3, DOUBLE PANE j I �q C OFAN PROPOSED R9QHT='ELEVATI0N VIEW m T NGUYEN yp. 45563 9F IS AL A- T Q !S�; i C-- H L L C 11248 RANDOLPH AVE 517-797-5637 MILTON, MA. 02186 OUOCTVANPE®OMAIL.COM �:*� RE OV TIO D DOR ER ADDITION 497 �OOD LANE ORT ANDOVER ASSACHUSETTS �;�; Nrlmyi¢ M - Ell] e I a EXISTING REAR ELEVATION VIEW SCALE: 32"(W)x52"(H) DH WINDOW U=0.3, DOUBLE PANE TEMPERED CLASS- CONTINUOUS LASSCO INUOUS RIDGE VEN I L L I ' JL'_l 1Li)-ll 1J .I 1LI-L1J_LL Il_1W I I_I I_� Lll� _' I' I;I II I I I I I it LLD 1.JL,1_L L L ILiJ LOLL -LTJ -Lu LJLL LL�111 f 'LLL111j LiU LLi ,LL L !' L� I WL 11 11 11 1 I i I I 11 1 L_- -- a i NEW WINDOW SAME SIZE OF EXISTING— OF c v> Tu AN PROPOSED REAR ELEVATION VIEW NGUYEN SCALE: {o"=i' No. 45563 X90 9FGISIEP S AL ry T" D E iE.—::; i G IV , L- L_ c 'MA M RENOVATION D DORMER ADDITION A — 8 1248 RANDOLPM AVE 617-797-6637 497 4�OOD LANE MELTON, MA. 02186 OV OCTWNPEOOMAi�,00�A AwFq(¢ T4 NORTH ANDOVER, MASSACHUSETTS i EXISTING LEFT ELEVATION VIEW SCALE: �8 --- 8r�-, 32"(W)x52"(H) DH WftlDOW 12 12 U=0.3, DOUBLE PANE a ------------ PROPOSED LEFT ELEVATION VIEW SCALE: J"=1' �jHpF TUAN CyG V. N c NGUYEN No. 45563 9FGI �ONAC�G -F CD E S I ER DDITIO RE OVOOD LANE 497 F -124 A 9 124RANDOLPH AVE 6 WILTON, MA, 02186 0 ORTH ACHUSETTSr S11�sIIHOYsSY �1�%��VHAO Wa�a«ar eoim :ura yyoo'iiv Vi063aNVni oono 991Zo 'VPN �NOi"1lyj. Hd�00NVLi 9bZI,�, � 3t dL6b L£99—L6L—Ll9 3AV 011100 �3 X00 0 13� —' cUSETTS p c^ z j r z �--- 03 � I NMoHs sd 0N—1xz �Jllsls O X I I I I I I I I I r- - I I I I I I I I I I I i N Fn x 0-W 11 N O U _ - d wO Z � 0 i i i I Z M U W i i i I i II i i I i i I i I i i I I i i I S I I II I �1O I I I I I I I I I I I W � L _ II� r , f �NN I I I I I I I I I I I I'- ! -,v, J l 1 7 i i i i i i i i i i i i I I I i I II Q i i III C) U i_ l I II i I i i i i i i I I�--r--r---i---r---r--h I i li i i i I i I'I I .i I I i i i i i i i i i i) i i i I i i i I i I i I i I ISI I I I I i i i i i II i I II I i i I i it I i i i I I I i i i i i i III i I I I i I 'I ili i i I I �I i i I i I i i i I II I I I I I I' N� I IIII i I I I I i i i I I i i i I i i i i I i I i i i i i I i i i I i i i i i i i I i i i i I I i ill I I i i i III i I i t I I i I I I i I II i I I I I II i I II i I I I I i i i I I I i I i I I i i i I I I I i i I i i I I I I I I I i i I i I i I i I I I I I I I I I I 4SE7iS \ o ? > j Z v �4 4j z Q Z Q O J Z O V I � d Z O Q i S113S(1HOVSSyW 'd3 AOa �` Hl�IOiNy,, ,"„�°v; "'°'„"'��93d"""•'o"° 9e�zo vw �Nol�wV TV] VO��1 L6V wmau>o L£99–L6L–Ll9 any Hd�OQNya 8bzl r?—� � N011laQd 213WNOa QNV 011 CD CN LLJ CD A O l'- O co O X N W Z 0 3?J 4SE7iS \ o ? > j Z v �4 4j z Q Z Q O J Z O V I � d Z O Q i S113S(1HOVSSyW 'd3 AOa �` Hl�IOiNy,, ,"„�°v; "'°'„"'��93d"""•'o"° 9e�zo vw �Nol�wV TV] VO��1 L6V wmau>o L£99–L6L–Ll9 any Hd�OQNya 8bzl r?—� � N011laQd 213WNOa QNV 011 CD CN LLJ CD A O l'- O co O X N W Z I i I Q I i I � N • x j ^gym O o O N J p "� N I ��. P� J J - J S ^ xl O I � �I (jll X ' N I N SETTS o » a e ����WW09 Quo 0 3-2x10 3-2x10 -- Ll I I --� o O X. N N I M M 7 L � J C� W Z_ d O U Q CD X �I H� O p N M � � w I � cD w -I <�/ m LL D LL L G - 00 00 o X N r , LJ 0 o I— X X Q N N � I I I N I 3-2x10 3-2x10 S11 IJIIH�ySSY a��1OQ y HIO 3Nd1 QOOM L61� INV] NOI100y 43W�00 Ow 011 A0 321 ���3dNvni�ono 98tZ0 V {"i 'NOl"11n -L 6L -L l9 3ny HdIOd NY2! 8421 -1- —S �NO&Md W .—L£99 w ��� �w Q LJ F-- — m LJ Q CDJ n J � O /J U Z - m U `j II C� O p co — > U I 0 x �, N x — x N N N — N i I — it 3W�oa aNv NoilvnoN3� S113SflHJbSSd /1 ��OQ nb HAON 3Nd� QVQ� /Gy, Nolaav d `wry°��iVYY�adNV ni sono 9812 'd i^ 0 l 'NOl IIW 3/�y Hd�00NV2� 8421 �—S NoiSV�aa Z w 3 �G Q � Z Q � � w LL II 1. O O C/')L �w Q LJ F-- — m LJ Q CDJ n J � O /J U Z - m U `j II C� O p co — > U I 0 x �, N x — x N N N — N i I — it 3W�oa aNv NoilvnoN3� �w Q LJ F-- — m LJ Q CDJ n J � O /J U Z - m U `j II C� O p co — > U I 0 x �, N x — x N N N — N i I — it S113Sf1HOdSSy d3 00 H1d0 W �30tle� aveyu MOD idry0a3aNvnySono 99�ZO 'VM 'NOi-10 33AO DOOM L6b L£99-L6L-Ll9 3AV Hd-IOONV2d 9VZl —S Waaw 01100y d3 doa 0 d NolIVA03d ETTS P Z ' z w ``7 O F-- < a Qt ~ Z Zcn wg = L Z ZQ C<�J-Y a w0 mw Qac == � m �KvO � =U[if N w (D J J Q � p I °0 a o Ld m C' m z Ua a 0 O aOf N j, F - m z O N Q vai o Q N J Jg J of °O J X �ij CD ~ p Z U ! Z J ° Q o O vo J J N O� J x x U N Uo �� W Z X X U� Q I-' O I.I.I X m w I I—w0 (� ��.�I Np Z M U7 =Uw = o O J N W a0Of U _ 11J1 U a w Q p i�i li QLLJ = N cn 2 d C) � Q � Z --- >- w �z O H m O ~0 J cn o Q� a I Z � w U) � O li