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HomeMy WebLinkAboutBuilding Permit #74 - 56 MEADOW LANE 7/30/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: Date Received /�10RTp\ v tL.� �6• ryO o s - DESCRIPTION OF WORK TO BE PREFORMED' R(MdV.e ei / 11e,Y 38I, )e -5c." k,/ Al, %�iil�(n+.i I!Ly�)` 4-1A, ale/ Ohm N4kiPt </i/Qq,!4q If IV lr,,,4 n Identification Please Type or Print Clearly) OWNER: Name: d- f, goy _/%v44g," Phone: 0178 Ggro-gy)j ARCHITECT/ENGINEER Phone: A11,,¢ Address: iV%4 Reg. No. Allll FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $43-0 Check No.: Receipt No.: 0 NOTE: Persons coAtrcti g with unregistered ontractors do not have access to the guarantyfund y Signature of ge nature of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimmirg Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer Connectio Located at 384 Osgood Street Comments Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.s1oo-s1000 fine 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 o 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 1% Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 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 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 DEPARTMENTMIZORM07 Revised 2.2007 Location No. Date v NORTq TOWN OF NORTH ANDOVER 3�0: i.o ,•,BOOL F 9 Certificate of Occupancy $ �'�S'••°''c�' Building/Frame (Frame Permit Fee $ 9 —� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 20L�L;5 Building Inspector ala Board of Building Regulationsf.-/ Standards Construction Supervisor License License: CS 96927 Birthdate: 7/21/1968 Ex¢iratiow. 7/21/2010 Tr# 96927 Re6biddon- 00 GEORGE SHEPHERD 3 POLLARD AVENUE LOWELL, MA 01850 Commissioner Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR F¢, Registration: 143727 -e Expiration: 7/23/2008 Type: T.Z M. HUME MA11dTA:NCE GEROGE SHEPHERD 14 SHAMROCK RD. i BILLERICA, MA 01821 k f Administrator ;,;;ISSUED BY THE STOCK -INSURANCE COMPANY HEREIN CALLED THE COMPANY GRANITE STATE INSURANCE COMPANY 13102 PENNSYLVANIA K MAINTENANCE INC 908 SALEM ST GROVELAND, MA 01834-0000 SEE NAME AND ADDRESS SCHEDULE - WC990610 - 78347-0000 WC 439-75-56 013-66-o806-oo dMMember Companies of American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.V. 10270 FABRI & ROURKE INSURANCE AGENCY INC WORKERS COMPENSATION AND EMPLOYERS 65 CENTRAL ST LIABILITY POLICY INFORMATION PAGE ISTE 2 I UtUKUt I UWN PIA V 1015-441 1 INSURED ISPREVIOUS POLICY NUMBER CORPORATION sNEW -.-..-----_----- ---- ---- -..-._._. ._...... .err u.�.r• nun Annn[cc crurnm r - wroonAin I W Inca tlYUri nr•f.Ma.ca rw, onaJrr,. n .� �n1, - - -- - - - ITEM 2 1 POLICY PERIOD 12:01 A.M. standard time at the insured's mailing address 08/28/06 TO 08/28/07 FROM ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA 6. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $ 100, 000 each accident Bodily injury by Disease $ 500.000 policy limit Bodily injury by Disease $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Number Estimated Total Remuneration ❑ Rate Per Slog OF Re- muneratton Estimated Premium a []-3„Year ❑X Annual 3 Year Annual SEE EXTENSION OF INFORMATION PAGE - WC7754 dd F TAXES/ASSESSMENTS/SURCHARGES A:� $363 �G % � 10 EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $ 284 MA ro .,oc MINIMUM PREMIUM 5500 MA If indicated below, interim adjustments of premium shall be made: 11 Semi -Annually 1:1 Quarterly Monthly DEPOSIT PREMIUM ENDORSEMENTS (FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 09/28/06 ASSIGNED RISK 66 ` ? ZZ Issue Date Issuing Office Authorized Representative We 00 00 01 39967 NThe Commonwealth of Massachusetts' Department of Industrial Accidents ��'% i 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):—/M ci,44e/t y,<10 /t-1 ",dc Address: go 8 City/State/Zip: Grovc�a /IIA 0100 Phone #: q79 Are you an employer? Check the appropriate box: 1. © I am a employer with a 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. F_1 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions ILEI Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -Any appncant tnat cnecKs box tt l must also till 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 thepolicy and job site information. Insurance Company Name: Cjra.'„.Ir 34cilr ��,5,t,,aP� Policy # or Self -ins. Lic. #: Expiration Date:arl —3sho 7 Job Site Address:/"e,d,, ,, ,.; per/ City/State/Zip: /144- �,ra(or,t,, /'vl C ` S Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ^ Date: 0-713010-7 q7,l 373 - 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. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia ME P�lwaal set., I fftcl-&-r 0 LIA Proposed Work 1. Remove old existing bath window size is 34 3/8 x 391/4 2. Remove house siding 3. Make opening for new window, new window size is 4. Frame opening for new window, see attached drawing 5. Install new casement size 38 inches by 56 inches. New window is a double crank out window, one pane opening to the left and one to the right 6. Flash and water seal new window. 7. Trim interior and exterior of window. 8. Reinstall siding. A EYAMaintenance E�7AMacle Simple, Servking your entire home. Client Name: Leigh Higginbottom Estimate Date: 7/30/2007 Project Address: 56 Meadow Rd MMS SR #: City, State, Zip: N Andover Ma, 01845 Estimate valid Thru: 8/29/2007 Telephone (H): 978-686-4433 Telephone (C): Estimator: George Shepherd Telephone (W): Contractor: maintenance maae Simple 908 Salem Street Total Materials: $1,000.00 Groveland, MA 01834 Total Labor: $1,215.00 Ph: 978-373-7227 Fax: 978-373-7299 Total Estimate: $2,215.00 Page: 7 1 Carpentry Remove bathroom window, Install larger one $985.00 $1,080.00 2 Permit Permit paper work,drawing and fees $15.00 $135.00 Prices can change up to 15% due to material costs changing Estimated Sub -Total Material: Estimated totals: $1,000.00 $1,000.00 $1,215.00 maintenance maae Simple 908 Salem Street Total Materials: $1,000.00 Groveland, MA 01834 Total Labor: $1,215.00 Ph: 978-373-7227 Fax: 978-373-7299 Total Estimate: $2,215.00 Page: 7 GAMaintenance kOAMade Simple, Servicinq your entre home. Teens 8 Conditions: 1.) Materials purchased for the job will be charged in addition to the labor costs. These materials are guaranteed to be as specified. All materials carry a warranty as specified by the manufacturer. A nominal mark up might apply to certain jobs as a warranty cost In addition, some jobs may also incur rental charges for specialty equipment. 2.) All payment required upon completion of job. Large projects may require a scheduled payment plan with payments required upon completion of each project phase. Acceptable forms of payment include: major credit cards, checks and cash. If payment is not received at completion of job, the credit card on file will be used to pay balance owed. 3.) All work to be completed in a workmanlike manner according to standard practices. Maintenance Made Simple carries a limited one-year warranty on all work performed. Some exceptions may apply. Any alteration or deviation from standard practices as directed by client will void all work warranties. 4.) Owner or customer to carry usual premises insurance. 5.) Maintenance Made Simple carries full General Liability Insurance. 6.) It is further agreed that in the event payment is not made as agreed above, interest on all unpaid balances shall accrue at the rate of 1 Y2% per month from the date work was completed. Additionally, if legal action is take to collect unpaid funds, the client agrees to pay all costs and expenses of collection, including reasonable attorney's fees. 7.) The client agrees to pay $25.00 for any returned check for insufficient funds or stop payment. 8.) The prices, specifications and conditions on this document are satisfactory and are hereby accepted. Maintenance Made Simple is authorized to do the work specified. 9.) While Maintenance Made Simple will make every effort to complete projects within agreed timeframe some factors may extend the project timeline. Acts of God, weather, special orders, material shortage, crew shortage, project changes and adjustments. Customer agrees to accept these delays due to these and other circumstances. 10.) 1 represent that if I am not the property owner, that I am authorized by the property owner to enter into this agreement 11.) A facsimile signature is as valid as an original for the purposes of this agreement. 12.) Each Maintenance Made Simple franchise is independently owned, operated, and insured. This contract is with the local Maintenance Made Simple Franchise. The Franchisor, Maintenance Made Simple LLC, is indemnified and harmless. 13) Each Maintenance Made Simple franchise is independently owned, operated, and insured. This contract is between the Client and the local Maintenance Made Simple Franchise. Signature accepts client agreement as listed, and authorizes Maintenance Made Simple to begin work. o r Entire Home & ust€t�ssLLl, MMaintenance Md simple. " I hereby acknowledge the satisfactory Payment Schedule: Total Payment: $ $2,215.00 Large Project Installments: # Payment 1: To be paid when the following work is completed: To be Daid when contract is signed. Customer is entitled to a full refund if contract is cancled in writing with in 72 hrs. Payment 2: To be paid when the following work is completed: After first week of work Payment 3: $2,215.00 To be paid when all work is complete and satisfactory Payment Method: Check Cash Credit Card type: MasterCard VISA American Express Discover Credit Card # CID# Exp: Checks payable to: Maintenance Made Simple :: THANK YOU FOR YOUR BUSINESS ::: ® ®® Maintenance Made Simple - Servicing your entire home. Terms & Conditions: 1.) Materials purchased for the job will be charged in addition to the labor costs. These materials are guaranteed to be as specified. All materials carry a warranty as specified by the manufacturer. A nominal mark up might apply to certain jobs as a warranty cost. In addition, some jobs may also incur rental charges for specialty equipment 2.) All payment required upon completion of job. Large projects may require a scheduled payment plan with payments required upon completion of each project phase. Acceptable fors of payment include: major credit cards, checks and cash. If payment is not received at completion of job, the credit card on file will be used to pay balance owed. 3.) All work to be completed in a workmanlike manner according to standard practices. Maintenance Made Simple carries a limited one-year warranty on all work performed. Some exceptions may apply. Any alteration or deviation from standard practices as directed by client will void all work warranties. 4.) Owner or customer to carry usual premises insurance. 5.) Maintenance Made Simple carries full General Liability Insurance. 6.) It is further agreed that in the event payment is not made as agreed above, interest on all unpaid balances shall accrue at the rate of 1 '/:% per month from the date work was completed. Additionally, if legal action is take to collect unpaid funds, the client agrees to pay all costs and expenses of collection, including reasonable attorneys fees. 7.) The client agrees to pay $25.00 for any returned check for insufficient funds or stop payment. 8.) The prices, specifications and conditions on this document are satisfactory and are hereby accepted. Maintenance Made Simple is authorized to do the work specified. 9.) While Maintenance Made Simple will make every effort to complete projects within agreed timeframe some factors may extend the project timeline. Acts of God, weather, special orders, material shortage, crew shortage, project changes and adjustments. Customer agrees to accept these delays due to these and other circumstances. 10.) 1 represent that if I am not the property owner, that 1 am authorized by the property owner to enter into this agreement. 11.) A facsimile signature is as valid as an original for the purposes of this agreement. 12.) Each Maintenance Made Simple franchise is independently owned, operated, and insured. This contract is with the local Maintenance Made Simple Franchise. The Franchisor, Maintenance Made Simple LLC, is indemnified and harmless. 13) Each Maintenance Made Simple franchise is independently owned, operated, and insured. This contract is between the Client and the local Maintenance Made Simple Franchise. Signature accepts client agreement as listed, and authorizes Maintenance Made Simple to begin work. Date " 1 hereby acknowledge the satisfactory completion of all services rendered:" Client Date Contractor Date Payment Schedule: Total Payment: $ $2,215.00 Large Project Installments: # 1 Payment 1: To be paid when the following work is completed: To be paid when contract is signed. Customer is entitled to a full refund if contract is cancled in writing with in 72 hrs. Payment 2: To be paid when the following work is completed: After first week of work Payment 3: $2,215.00 To be paid when all work is complete and satisfactory Payment Method: Check Cash Credit Card type: MasterCard VISA American Express Discover Credit Card # CID# Exp: / Checks payable to: Maintenance Made Simple WJS Copy - please bring back to office when signed Page: 10 m m m 4 m y EP _v, y CD d C � G � H � n Z y CL M. CD CL = CO) nCO -fl '.� CD o p CD o cr "Cl CD Er CD O CD C CCD y. 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