HomeMy WebLinkAboutBuilding Permit #075-2016 - 56 SUGARCANE LANE 7/17/2015 �
BUILDING PERMIT o` NoRTytLEo ,6q4'O
{ I'� TOWN OF NORTH ANDOVER 2
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APPLICATION FOR PLAN EXAMINATION10 '
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21 o K ey
Permit No#: � Date eceived '�tq"°R�reuW�PP'R`y
SSgcHus�
Date Issued:
IMPORTANT:Applicant must complete all*ms ems on this page
LOCATION v \.
Print
PROPERTY OWNER AL
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resid ial Non- Residential
❑ New Building ne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other _
�� ® Septii ❑mW ® Flo®tlpla- LLn�--PDWeands f� OW`atershecl Distinct
r-�" 4' 06 WOOL
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DESCRIPTION /OF WORK TO BE PERFORMED:
�C� f �� � �c � "f8 L,`�/J"+�ci rbbl/!n G(,j �0✓� ,
Identificatio - P ease Type or Print Clearly
OWNER: Name: Gr��s � �- Phone:
Address: J7 G
Contractor Name: /-,o 7c Phone:
Email: o
Address: 9 47 ,q o c�
Supervisor's Construction License: _Exp. Date:
Home Improvement License: 1-5'3 Exp. Date: zz�7/zz
V,
4
ARCHITECT/ENGINEER Phone:
Address: 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: $ AS
_ �Yj C� `� FEE: $ cbc —
%Q-
Check No.: 2ZI?5 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not ave access to the guar my fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swh ming 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
PLANNING DEVELOPMENT Reviewed On Signature_
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
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
'"a..«`+o.-�"....� f,"". .-rT2'1'�^VL t .i'-' 'ri 5 s +t>-... a .iS-�?'rv' h•i+ f3.a 9R'{,w.sr s i', - R�I 1! .y
FIRE DEPARTMENT - Temp 's 1,
� "
4Loeated at 124 Man Street
Fire De arfinent i �Y
gnature/date N
`� .,gig ,�yp �' ` ��° 4 i.+• Y. ;� f- ��� 4 �1 .f 5 a �k moi.;, 4
h:7:,�'*�,e}e,�G r4 •'�U'v^ '" < ,�§�� Y` Y�+-3,�'.�,:� �`�s' ' �.r .- �4��� J r� 1�i�f�'�.� �� �*�`� �r�� �»'
yw`...`ir"1v�3*,�-+ak'S.►��.- �p a4e' ,,.k a; t x #7t 1r'�' �T f`r`t +`.}�-�#'...,�� �,c�.t^,lt,,,t.�'� ' s� e � �.t"4%�`k• t�"�,^�i,P 3s�y:,F '
a.�....'�.r.�...tt.L�ats,a.r�..:a.5..«.,...Ci��—..`.r...:.al3e... .-.,.3. s, '...sL-. .-aw.t.' 'i:r.A'��.:;ta.. w fs`r.Ai�. tit..1..,.aG«t.,s.�`�..�L.L�I:-sY:.���x#r„✓�
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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
i
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)
I
El Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: 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
4� Copy Of Contract
4. Floor/Cross Section/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 .
OTE: 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
2012 IECC Energy code
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
\k
i `
Doc:Building Permit Revised 2014
Locationo
No.' _ Date
. - TOWN OF NORTH ANDOVER
�n=
_ Certificate of Occupancy $_ I �;`
Building/Frame Permit Fee y
I
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 1
I
Check#:
2_ ui ding Inspector
E
NORT#j
owhoff l., Andover
o -
15 -� �
h ver, Mass
COCHICKIWICK
ASR^TED Ap '�5
S tl
BOARD OF HEALTH
PERMI LD Food/Kitchen
Septic System
THIS CERTIFIES THAT (W44W........ BUILDING INSPECTOR
............ ..... . ..:. ..................:............................................
has permission to erect ........... ............. buildings on ...... ..... � Foundation
Rough
to be occupied as ....... .. .. ...........:....... ... .. .... ..... ...�- -s
.............................. Chimney
provided that the person accepting this per it shall in every respect confo 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 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI A S Rough
Service
................. .......................... ......... ............. Final
BUILDING INSP
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
Street No.
Smoke Det.
i
Proposed Kifcien I living roort1 project
Staff fan"
W!S;;Wri3ne.
N.Andover IAA
6102115
1_ The Contractor agrees to provide all tabor and materials required to per kxm
the following work
■ Design kitchen
® Orin permit(fees included)
® Remove and dispose of all Idtc peri cabinets
Remove kitchen appliances and share ahem on the property unto new
appliances arrive
Remove existing flooring in the Icitchen area
• Remove wallboard as needed
■ Install new hardwood flooring to Wtchen and fving. (estimate based
on$91st)
■ New insulation added to walls and ceiling as needed
■ Install new l"blue board and piaster to ceiling(sand } texture)
• Plaster patching as needed to walls(smooth finish.)
■ Install exterior venting for oven
Do to joist placement%exterior venting is not -possible. In
this rase a recirculating feature of the oven vent will 1;1:ed
■ Cabinet installations
® E.shnlated install time for cabinets and trim(4, )
Cabinet palls included
a (cabinet cost$14211.34)
Coordinate granite counter template and installation
• Granite cost not included(estimated at$ IU
® Existing windows to be kept as is
Install new baseboard molding and window dings
Matching ousting douse ming as closely as possible
11Page
4
E Kkic ian to:
• e Install 2 pendent lights
e Reptace 2 recessed cam
e Add 4 recessed cans to the living room area
o Upgrade eleclrical receptacles
o Move for range
o Cap off old vwall oven electrical feed
o New dedicated circuits to all
e Add a receptacle tD kitchen Wand
e Price assumes gas stove not electrical
■ Plumber to:
e Install new or reused sink;faucet dishwasher-garbage disposal
and stove(oemalcer hookup included if al present)
Paint walls
e Prim as needed
e Paint 2 coats white
e Paint all stained trim in the When and living in xxn area white
Total Costs $26. 00
Not included in the above estirrrabe:
Cabinets
Granite
Pendent lights
Repairs needed far unforeseen damage
Unknown work required to meet current code( /plumbirglel al upgrades)
Appliance costs
Strove
Range
Dishvrasher
Rotor
DNposal
Sink
Lighting
Faucet
Etc.
The above is an estimate only and is subject to change based on the customers final choice
of materials and any changes to the work order brought on by requests or the
need to meet current building code.
2 The Owner hereby agrees bo pay the contractor,for the aforesaid materials
and Labor,the sum of$25,300.00. Costs for this pmject are at this time. The
estimated costs are neither a minimum or rna)dnum cost amount
21Pag '.
�J
o Payment schedule not yet determiued pending final agreed estimate with
Owner
Fid fttefiaft approx. $(This amount is subject to change bated n actual choices
of finished materials made by the homeowner)
1006 due at time of order(finished materials vnll be ordered and at various
times during the duration of the job)
Some finished materials may not be able to be returned or cancelled oi ice the order is
placed and some may be subject t D a 20%restaddng fee. Theme cha ges will be the
responsibility of the homeowner if it is the homeowner requests the.exchange or return.
3. This remodel is scheduled to begin(July 2015)
4.The Contractor agrees to provide and pay for all materials,tools and equipment
required for the prosecution and timely completion of the work. Unless Dthetwise
specified
All materials shall be new and of good quality- There is a one year on materials
and craftsmanship,if manufactures s warranty does not apply_
5. in the prosecution of the work,the Contractor shall employ a sufficie number
of workers skilled in their trades to suitably perform the work-
6.
ork6.All changes and deviations in the worts ordered by the Owner sho be presented to
the Contractor, by the homeowner in writing,the contract sure being incased or
decreased accordingly by the Contractor.
r 7.The Owner Owner`s representative and pubes auk shall at al times have
access to the work.
8. Construction and Jobsite Details:
ExmbW lawn&driveway may suffer some damage due mconstruchor -
attempt is made to minimize the damage,however the shk not hold the
yrs liable for the extra cost if damage situations appear.
Any unforeseen discoveries that may affect the construction costs are.hey
responsibilities of the homeowner.For example:asbestos,lead paint, nold. ledge.high
wafer table etc.
9.In the event the Corrtraclor is delayed in the prosecution of the by ads of
God,fire,flood or any other unavoidable casualties;or by labor strkes�late delivery of
materials;or by neglect of the Owner,the time for completion of the v irk shall be
extended
for the same period as the delay occasioned by any of the atrxernentk ined cauls_
10.The Contactor agrees to obtain insurance to protect himself,his Workers and
subaonbac, .against claims for property damage.bodily injury or dearth due to his
perWmancB of this agreement i
11.This agreement shall be intarpretad under laws of the State of Mw§sachusetts.
12.Attorney's fees and court costs shall be paid by the defendant in event that
judgment must be,and is,obtained too enforce this agreement or any mach thereof.
13.certifications
Massachusetts Construction Supervisor Dense#96 462
Massachusetts Home Improvement Contractor Registration 153859
31Page
94_Insurance: tjoNCrty Insurance cerfficate available upon request.
IN WITNESS WHEREOF,the parbes heretD set their hands and sealsthe clay and
year wnden above.
,ct
400
/ s
E n a IC—EgRt SIG TU VD
OWNER'S SIGNATURE
S ADDRESS
�Aaron Scarpello
CONTRACTORS- E CONTRACTORS SIGNATUR� DATE
2 Maqggfig Ave Salem NH 03079
CONTRACTOR'S ADDRESS
4.lPage
144"
41" 83 „ 39," UF3B�
90" 364'' � 424"
• W33i3 X 24 DP i3LIT i
1 DHW24 #S �3-10 1
BtNI3T1t3� s.�.
WIs36SlaTT i
Y' 8'*base filler i 1
tr9atirned to fit .s
Wali cabinats an ' W
i
Bock of Peninsula na
built up off Door i UF3 N CL
Blind cabinet built ,
113 hlgh.3 t)g3d l a.
I Inst flush S'iiicffi
filler installed against �
wall to gives Full Ovaday i InsiaRi 34x3f3 Aaron�carpeUa
doer gwlry` clearance of Dago door ® p .a f3D3>8$$>fi399
COP912aseboard D I on gitt3 3466-810889Molding Install6d / C15ILING 1-18101-IT!96
n TOP CA131NOT ALIGN:90
1 � MANUFAi;rU13SR=Arrotrit;on Wa®dmarl
Dishwasher End Panel C ! DOOR:Sharabrook Pointed
Installed to tt of Fridge � Dt11:I3LAV:Full.
to allow swing clehfanoe � � WOOD:Mede
Fpdif34!skin trimmed Hold y
for gone Corner Cabinet FINISH:Linen
w
ir�eiailod at end of PP4834 "e" Cg)N$TUCgI 1N 4di�f::Standard
peninsula to hide sears -- _ TOP MOLDING:NoneTOP F5539t3$
flush reveal,(2)1WO , . BOTTOM MOLDING;SOMg
Coco dears installed an Dila 's 593E i},. EXPOSED END APIcLiCAYIONf Flush pl
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5901 NCCD30>g •';` axoapt peninsula with fininhod panels.
f3 � . V11'ti(f� .✓ � �r43d sU1`P't
6CP81Used as 8eseboard molding
flushed it)cabinets an Flat
Screen Udall
930 2FWY BUTT
11e"
.a
94 s"
All dimensions si>e de.gignations This is an original design and must I Designed: 9/4
given are sul�jcet to verl tication on a not he released or copied unless ilrinted, 7/4/2
job site and adjumment to rujoh applicable fee has been paid or job
condition,g. dreier placed.
6IS03ct sAli �-Drazwing#; I No
,T�1111.
Gc
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2 3 BSS36L
golf
All dimensions size designations This iR an original design And ni'ugt Designed0/4
given aarc subject to veriPicaation can not be released or copied unless Printed: 7/4/2
job kite and aicuu- nnent to nt,job applicable fee has been paid or job
conditions. order placed,
tSi A sib Front Of Poninkuin DraaIng N. 11 NO
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rr sr
CD 0 Y .3030BUTT W2730 BUT ' 3030 1
BU
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go
All dimensions size designations This is an originni design and.must (Designed: 7/4
giver, are sul1jec:t to verification on not lie released or copied unless Printed: 7/4/Z
lab site and ackluetment to fit jab �` applicable fee has,been paid ar j9b
conditions. ardor placed..
13030b Back€&FPenidsulaDrawing#: 11 No
14411
ti 11 73-2111 -
31
li ti
632 392
G �V tl a7 1 I� L3 4� U F 3, 9,2
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WF-P.2436L 1236L
MKISPACS- W-331-8 X-24-DE!E! MUTT
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p,qq,�� �g �y
IVIVV�1 100 8
2) 6"x42" fillers provide
to greats tali oven
.f I_
cabinetBL845/48R F DISHW24 SB36 BUTT TO 5WBT16-2
W33'12-X_2 DIS RUTT
- Toekick
_ _..243 ..�...�_. ...- fill
-5314" 077811
,
All dlme11910ns sire demignrations f 6iiq is an original design and must f Designed: 7/4
given nre subject to verifica tion on net be released or copied untess l printed: 7/4/x+
Job site find Acliumment to ru.job applicable tee has,been paid or'ob.
Conditiolm order placed.
V
G l 303cfb ,Sink Wallt�r€a�ving N: 1 �No
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441111 ! /
d /
W3315 X 24 OP 1 ILITT
V361 8 X 24 DIP BUTT
1536 WER24361-
- Ui=
•MW.MOOD
RffF.2D CE-1D
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DW-R3(L)
All dimensions s.ib:c designations � 'rh9s is an original design and must Ocaign ds 7/4,
given are sul jcct is verification an I not be released or copied unim Priotedi 7/4/2(
job site and adjustment to rn job d applicable ret; has been paid or,job.
conditions, order placed.
f i 303cft' i F cf igcraataxr Wall rarz�ia�g#: I �Noi.
24' 94/i -- 36'i - _ 24li 8
WOAD 0-1
WEIR24 6 N2436 BENT 1N24313 U
YOY
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P V8836 - �'�VL', 1 toN�aJ� 1 9F7�. B1 8R,
- II
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/ 6tl 511 i -- 3 . 11 811 `—9tlOtl/
—6611 / �11
All dimensionq size doignations i (This 14 an original design and must Designed: 7/4
given are subject to verification on ; not be released or copdbd unless Printed 7/412
job site and adjUstm nt to tltejob applicable tee haq been paid or job
conditions, ander placed,
f d A cf�i I -Range Nall �D.rawing#s t INo
94 9 qs
B24_B30 2F'1111T BUT71 DB24
9e 2411 /1 301111184
All dimensions size designations This Is an original design and statist Designed: 7/4
given tire subject to verification on not be releaiscdor cooled unIms. Printed.- 7/4/2
job Site and adjustment to Iit,job applicable Pee hes been paid or,job
conditions. order planed.
[Flet Screen Wall I'Draawing#, 1 �NO
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Filb nam,e: 61303c#b.kit
Desciiption: DC MAGNOLIA AVE DESIGN,6.13
CATALOG AWCHOICE
Supplier)
AWCHOICE tray 20,15
'waft doors: Btiorebrook Painted Linen 48MPS Drawer fronts.:
Tall doors: Drawer pelts:
Base doors: Door putts:
moor sfyte: SHO BROOK PAINTED
item Description User Code Manuf.Code Frr. Side �
11 2 Deep Woad Tato End Panel DVVTEP96 DWTI EP96 B
DWTEP96
Nfod'd"icaf ens: width= d 3W
widfh2'= T
height= X9T,
depth= 29"
7 1 Finished Parlefrng FP4896 FP4896 FP4896
3 .1 Dom For Decorative Use DR. 1830 DRI 830 ND(LJ, DR1830 ND[Lj B
ND(L}
4 11 3 Drawer Base DB24. OB24 D824 B
4.1 11 Leif Base Decorator Door DMDB DMDB j DMDB{Q B
5 1 Base WMI 2 DR:Q 'B30 2FWT BUTT B30 2FIVVT BUTT B3G 2FWT BUTT B
6 11 Door For Decorative:Use DR1830 DC1834'NfCfI R) DR 1830,NDfR f B
N0fRj
7' 1 Finished'F'ane{ing FP4834 FP4834 FP4834I B
Modifications:, width= 36"
width2= Q",
l e4ht:= 34117'
depth= 8 3/16-
8 1 3.Drawer Base DB24 0824 D924 B
8.7; 1 fi'Uht Base'Decorator Door DMDB CMEYB{R.j DMOB tR) B
g 1 Base VM 2 DROT B24 2F7VVTi BUTT B24 2FWT BUTT B2:4 2FV T BUTT B
9.11 1 Field Installed:Wood Tiered Cary VVTCOK24, WTCDt�24 B
Divider tfi Wrl,CDK24
1G 1 3Drawer, Base=DB'30 D0301 DB30 B
11 2 Base Super Susan BSS36L BSS36L ESS36L B
12 1 Base Cabinet BI 5L 0115aL BI SL B,
13 1 Base Cabinet B18R. ataR B18R R
14 1 Base P'ant'ry Pull Out BPP9 8PP9 8IPP9 B
14.,1 1 Right BaseDecorator Door DMDB DMDB(R) Dl OS, .I a
is 1 Leat Ease(Dec:Matching Door DMOB DtVEDB{Lk D IDB fLI B
16 1 Blind Corner Base BLB41488 fl. BLB45f4'8,R(Fj1 RLB45r4-&R, €�, B.
16.1 1 Furniture Ends option FE-Base FE FE B
Mile:name: 61303cfab.lcit
DescrEption: DC MA-GIOLIIA.AVE DESIGN 6.13
�item Ref My Descrfptib.ni User, Code Manuf.Code Fin. Side,
16.2 1 Recessed Toe Kck Botta RTKB RTKB B
16_3 1 Blind Base Filler UF6 UF6 UF6 B
1T 1 SInkfRange,With FR TO,TRAY SB36 S836 BUTTTO SB36 BUTT TO S
BUTT TO,
16. 1 WlWIastebasket Cabinet.B,WBTi8 2 BWlW BT18-2 BWBT118 2 R
19 1 Left Dishwasher Return DWR3 DWR3{L} DVVR3(Ll fL
2t7 1 Wait Cabinet W2730 BUTT WtWl2730 BUTT W2730 BUTT B
2.1 2 Wait Cabinet W3030 BUTT W3030 BUTT W3030 BUTT B
22 .1 Wall Cabinet 11W12436 BRITT W2436;.BUTT WlV2436 BUTT B
23 1 WGWIatf Cabinet WIWf2436 BUTT W2436 BUTT W2436 BUTT B
23..1 1 Right Wall Decorator Door OMDW36 DMDW36(R.) DMDWiWl36{ftp), B
24 1 W/WFalf Cabinet W3636 BUTT W3636 BUTT WtV3636 BUTT 8
24.1 1 Right Wall Decorator Door OMEYW36 CMDW36 fR) OMOW36[R) 8
242 1 Left Wag Decorator Door DMDW36 DMDW1Wf36 Lj DMDW36,{Lj B
251 11 W1Wfalf Cabinet W 1236L W1236L WtW I,2 6iL B
26 1 Refrigerator WiWfaff Cabinet W3312 X 'NIWt3312 X 24 DP BUTT Ti W-3312:X 24 DP BL B
24 DP BUTTI
26.11 1 VDO Offledl For H"rnges Option!% VDG-DFH VDO-DFHI B
VDD-DFH
26.2 1 Matching Interior option°lay ME ME ME B
27 11 WIVaU Cabinet W3336 BRITT W3336,BUTT' W3336 BUTT B
Nlodifi°catx-ms: width= 33"
widthi2= 9
he ght= 36 1f8'
depth= 2C
2:7.1 1 VD0 Drily For Rnges OpY'im% VOOLDFH VDO-DFH 6
VDO- FH,
2:7.2: 1 IWllatchfng tnterio OpVcm%Ml Iii ml B
27.3 1 Increase.To 247'Deep %ID 2.4> ID 24 tD-24 B
28 1 Refrigerator Wall Cabinet WfW,3318 X W3318 X 2.4 DP BUTT WlW13310 X 24 DP BL B
24 DP BUT
28.1 1 VDO,Dril edi For Hkiges Option]% VOO-DFH V0O-DFH E
VDO-CFH
2.8.2: 1 Matching,interior Option %MI Mn [Wilt a
29? 1 Refrigerator Wall Cabinet.WtWat3315 X W3315 X 24 DP BUTT W3315 X.24 DP BL B.
24 DP BUTT
3:1G 2 WiWIa(0 Easy Reach WfWfER2436L WER2..436xL WLW BR2436'L B
311 1 Reftiger°ator Wall Cabinet:WtWri3618 X WtW/3618 X 24 OP BUTT W3'618 X 2:4 OR BL B
24 OP BUTT'
32 1 V tICabinetW1536L WtWf1536SL W1536L B
33 4 Base Toe Krck BTK8. BTK8 BTKS
Fite name: 61303efb.kit
Desed"p>tiom; UQ M.AGOLlA.AVE DESIGN 6.13
;iter, Ref Qty Description User Code Manuf.Code Fin.aide.
34 4 Ogee Pilaster Molklingl OOPS QQP8 OGP'8
35 5 Finished Salid!Stack:(Verffrai}6" FSS696M, F 96,
FSS696
36 6 Angte Crown Molding ACM8 ACM8, AGM8
37 4, Single Bead Molding SBM8 SBMg sBM!8
38 11 Universat Base Filler UF3> UF3 UF3. B
39 11 Universall Base!FillerUF3 UF3 UF3 E
40 11 Universal]Tall Fitter 3"X 92"UF392 UF392 UF392 B
"41 11 Pafhted Linen % UNEN LINEN LINEN,
*42 28 Shoreorook.P'akited-Limen 48MPS 48MPS Shorebrock.Pain u
`43 1i One Pint Stairs STAIN PINT STAIN PINT
''44 1 Putty Slick Exterior Qty2: PUTTYSTICK FXT2 PUTTYSTICK B(T
*45 4 Scribe MoMing Sim WD, M8 WD
'48 1 Tall End Panel Ti EP96 TE 96,
"47 1 Tducft,Up,Marker Exterior Qty2 TU MARKER EXT 2 TU MARKER EXT
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The Commonwealth of Massa chusetts
.z Department of IndustrialAccidents
w n d 1 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.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): O&Lr p V) X. ..,5 C e,
Address: m a 5 ,�y l%-, ✓Q- lv;tf- . 6-30
"7
City/State/Zip:�,Uew, A11140307 'e? Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I a mployer with employees(full and/or part-time).# 7. ❑New construction
2. am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ['demolition
3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4. 1 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 11.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.F1 Roof repairs
• These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ther
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i 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.
I am an employer that is piovidhig workers'compensation insurance for my employees. Below is the policy and job site
i formation.
surance Company Name:
licy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
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 violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verificatio
I O hereby cer ' i o fy that the information provided above is true and correct
ature: Date:
hone#• b� d 3 ® 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#:
i
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'
compensatioii'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 pennit/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
Massachusetts-Department Of,Public Safety
Board of Building Regulations and Standards
a Construction Sunen-isor 1 cSc 2 Family
License: CSFA-096462
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