HomeMy WebLinkAboutBuilding Permit #480-13 - 67 MEADOW LANE 12/20/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
WO -13
Date Issued:
J p -la 6 /t
IMPORTANT:
LOCATION 67 / ' 1 e6�ow Lane
Date Received
must complete all items on this
PROPERTY OWNER oh aTr! /"
Print J 100 Year Old Structure yes no
MAP NO: ,S/= PARCEL:,2/ ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Re idential
Non- Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
❑ Industrial
No. of units:
El Commercial
$Alteration
Repair, replacement
El Bldg
El Others:
Demolition
❑ Other
❑ Septic ❑ Well
D Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Wl
rc
Identification Please Type or Print Cldirly)
OWNER: Name: Phone:
A.drlroe �•
CONTRACTOR Name:
-745- 536
Address: SBrltAol 'F4lC6 ��yn A nl qua
Supervisor's Construction License: t 21 Q3 Exp. Date:
Home Improvement License: 16 a7aa
Date: X14
ARCHITECT/ENGINEER N�� Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDINGP RMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ r 6 — FEE: $ TO
Check No.: A ;2 OA RbW10v /G 2 Receipt No.: ;26 6 yy
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner, gA,1 C Signature of contract
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
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 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:
Comme
Conservation Decision: Comments
1
Water & Sewer Connection/Signature & Date Drivewav Permit
DPW 'Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at'124 MainStreet
Fire Departinent•siignature/date
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.$100-$1000 fine
NOTES and DATA — (For department use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
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
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
Li Floor Plan Or Proposed Interior Work
o 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
o Certified Surveyed Plot Plan
o 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)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
o 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
NOTE: 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: Doc.Building Permit Revised 2012
Location
No. y& — /-?
1<
Date l22n �IL
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
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The Commonwealth of Massachusetts
T ,fi 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 A Please Print Legibly
Name (Business/Organization/Individual):]
Address:
1tyi3tateiLIp: DQ I_JT) l"IH
011lu Phone #•II
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.1 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance)
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] f
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance reouired_1
5-534
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
f 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 providing workers' compensation insurance for my employees. Below is thepolicy and job site
information. ,
Insurance Company Name: NorWikrld —_Ty
Policy # or Self -ins. Lic. #: \A/ S 0'4 5724 S
Expiration Date: It /3
Job Site Address: 67 Du) L an City/State/Zip: Tong+hey /Ju U
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dAly
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 ains , penalties 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 #
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 -contractors) 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 apphcanf
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicuat
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
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
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MICHAEL'T DEMILLE
5 BPtSTOL ST
SALEM, MA 01970
officito 0 r
-.940ME IMPROVEMENT CONTRACTOR
t`_rl Z4 F"iultnd ort: 162772 Type -
Exp
iratlow. 4162013 Individual
BiAEL THOMAS, DlEitLLE
EL DEWLLE
TOL ST
M, MA 01970 Undersecrelmy
Uicesse or registration valid for individul we ani
before the expiration date. If found retum.to:
Office of Consumer Affairs and Business Reguliation
10 Park Plaza - Suite 5170
Boston, MA 02116 -
Not valid without signatm
Pf7p.: f
8010290169 02011, RR Donnelley. All rights reserved. - 0221 —_
[Co NTRACT# 0004 I
MASSACHUSETTS EXTERIOR SOLUTIONS INSTALLED SALES CONTRACT
INSTALLED SALES SPECIALIST
NUMBER
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TELEPHONE
DATE
LOWE'S HOME CENTERS, INC.'S MA HIC NO.: 148688
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FEIN: 56-0748358
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CLI TOMER
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TELEPHONE
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REG
. CASH CHARGE - _
This is only a quote for the merchandise and services printed below. This becomes an agreement uponpaymant Upon payment, the entire agreement, inclutling thespedfcally completedpages of this _
document the Terms and Conditions included with this document and any other addenda and attachments hereto. shall be referred to herein as thls'Contma.-
PLEASEREAD ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF -THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING,
INSTALLATION STREET ADDRESSCIN ZIP- _
�'� `{�.3 ,. c' ,€ �: t. .. 6'1 €!'�' • J "'t 6^"`'i. iZ{ -", 1
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Are permits required for this installation?: [' )Yes [ ] No
Contract Total
*applicable tax included
rr reywrea owes to provlae you wnn me pampiet menovate Leight. By signing this Contract, Customer
acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure
PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this
Contract, and irrevocably grants to Lowe's all right, title and interest in and to the photographs for use in all markets and media, worldwide, in perpetuity.
Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such
photographs for any lawful purpose, including, but not limited to, marketing, advertising, publicity, illustration, training and Web content. By initialing
here, Customer agrees to the foregoing.,__ [Customer to initial to the left].
Work into commence upon reasonable availability of Contractor and/or any special order or customer made Good(s) which is anticipated to be
[fille in date]. Estimated completion date is � — 1 [fill in date].
Said estimated substantial completion date is not of the essence. A statement of any contingencies that would materially change said estimated substantial
completion date is as follows:
(if applicable, insert -a statment of such contingencies).
IF THE CONTRACT TOTAL IS $1,000.00 OR LESS Customer must pay in full.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00:
(Customer to Pay in Full; OR [ ] Customer to use the following payment schedule:
(1) Deposit $ to be paid upon siging contract. Deposit should be 1/3 the total contract price; and
(2) Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's
to do one of the following (check appropriate box below):
[ ] Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed;
or
( j Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and
(3) Final payment of $100.00 to be paid upon completion of the installation and both parties' satisfaction.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. 042
LOWE'S AND OWNER HEREBY MUTUALLYAGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS DISPUTE CONCERNING THIS CONTRACT, THAT
LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT-
IVE OFFICE OIq CONSUMER AFFAIRS AND BUISNESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
AS PROVIDED IN Iv1.G.L. c'€142A. ;yr �, V
By: d '/ r i i s % �o /t �F r� Date: / G <�b J
Lowes Home Centers,'Inc.� // r
By: r, +u�yt.<., _I� •,— - C,--- Date' "I�. •-°" i'r / `,�
Owner Signature
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED
BY LOWE'S PURSUANT TO M.G.L. c. 142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE.RESOLUTION EVEN WHERE THE
SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND
CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.
BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE
TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
CONTRACT. YOU ARE ENTITLED TO A COPY OF THIS CONTRJIjCT AT THE TIME OF SIGR4TURE.
WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS % DAY OF
Low,6's Horqe Centers, Inc. f
Specialist or Above z, Owner v Co-owner or Witness
�4
cancel this transaction at any time prior to
.ram. vrru�n waa .."'j --y ..ueu u. prior to L ustomers execution nereot. YOU, the buyer, may
o midnight of the third business day after date of this transaction. See the attached notice of cancellation
e
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