HomeMy WebLinkAboutBuilding Permit #824-13 - 72 JEFFERSON STREET 5/31/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION3i
Permit NO: gA Date Received
,An—
Date Issued:
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
)(One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
)(Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
r ❑ISeptic� ®Weill _}Floodplain
` ®�Wetlands�
�t Watershedpistnci
❑}Water/Sewer_,. _ .
- -
DESCRIPTION OF /1JWORK TO BE PERFORM
u:
n i- - —
OWNER: Name:
Address
Please
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97$-6%-2-(, -1
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dd7 l �,v�`�a )'C'" fIir-1-� /-v►[xt� r� ons c� r>
-5-bpe Construction L-e
Homelm FrovementL'icense _
_ Exp, Dates
ARCHITECT/ENGINEER Phone: '
Address: Reg. No. A
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.: aL��
NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund
Signature of Agent/Owner -r_ '',1 f V�d:. ` Sig nature of contractor
Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ St mped Plans ❑
Building Department
The folmwing is a list of the required forms to be filled out for the appropriate.permit to be obtained.
Roofi! ,g, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L: Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpsterpermits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
❑ 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
o. 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)
o 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 appy al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm:kted with the building application
Doc: Doc.Building permit Revised 2012
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE.DISPOSAL
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
,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
N
Reviewed o
ianature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . _
Planning Board Decision: Commen
s
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
IDPH' ToNv;s ]Engineer: Signature:
FIRE DEPARTME'' T - Temp Dumpster on site
Located at'124 Main Street
Fire Dep" A er t�sigriature/date
COMMENTS
Located 384 Osgood Street
yes no
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.$10041000 fine
NOTES and UA TA — (1 -or crrepartment use
B Notified for pickup - Date
Doc.Building Permit Revised 2010
Location
v(
No.—,F-,2 41 - /2 Date �3l
Check #--Z 7 4//
26458
TOWN OF NORTH ANDOVE`i
Certificate of Occupancy $
Building/Frame Permit Fee $ A
Foundation Permit Fee $
Other Permit Fee $
TOTAL $�
Building nspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 129000.00
m
$ -
$ '1144.00
Plumbing Fee
$ 18.00
Gas Fee 100 comm.
$ 100.00
Electrical Fee
$ 18.00
Total fees collected
$ 280.00
72 Jefferson Street
824-13 on 5/31/13
Kitchen Remodel, Upgrade Electrical and Plumbing,
New Floor
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Page #
of
7xye hereby submit specifications and estimates for:
... ...... .-
loci
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V e propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of:
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs
will be executed only upon written order, and will become an extra charge
over and above the estimate. All agreements contingent upon strikes,
accidents, or delays beyond our control.
Dollars
f
Respectfully
submitted
Note — this proposal may be withdrawn by us if not accepted within days. j
'ACCeptance of propo.5al
The above prices, specifications and conditions are satisfactory and are /�
hereby accepted. You are authorized to do the work as specified. u �� �� S • 02 c�
Payments will be made as outlined above. Signature
Date of Acceptance
i+-rv�soiai rsaou ua-n
Signature
I. Nil work shall be completed in a professional manner and in compliance il'I rill building code,
and other applicable laws.
2. to tho e,, cru rt.. -q,- rcd by lm , all be pcl-fotmed hN "ildi� iduall Jl 11
authori/ed b�, lave to p,:rform s+.ict+vo l+_
3. t c ltraclor nia,, W d...1s%;iggti'1:, ogi ,gam til}-,c,)z-,tt.tiir,s trr,'1*r"orin wofl, hL -Lt- A.c, pit -ded
Cwttractor )',il! t,Jl, tray s;.ui Vd M Ldl lnstinces ri,,na'n ":�pUll�iblc 1(ir' I li
proper completion of thiti Contract.
4. C'Ontractor s;iall fu-nis: appiopraIc rclea�es or wai%crs alien for i'l iici _61-ri,d or
materials provicicd'atlfi tinct! the next pe.`Odic payment shall' be due.
5. All Chant, Orders and or Additior:al `yotk.Authcu, tttions shall be 1 "ritjv- and slyvied by both
Owner and Contractor.
6. Contractor warrants it adequately insured `oinju4•y to itsromployees and otlitr's incurring lois
or injury as a result of the acts of Contractor or its employees and subcontractors.
7. Contractor shall, at its own expense, obtain all permits necessary for the work to be performed.
8. Contractor agrees to remove all debris and leave the premises in broom -clean condition.
9. In the event Owner shall fail to pay any periodic or instdllment,payment due hereunder, Contractor
may cease work without breach pending payment or resolution of any dispute. Failure to make
payment within days from the due date of payment shall be deemed a material breach
of this contract.
10. All disputes hereunder shall be resolved by binding arbitration in accordance with the ruled of the
American Arbitration Association.
11. Contractor shall not be liable for any delay due to circumstances beyond its control including
strikes, casualty or general unavailability of materials.
12. , Contractor warrants all work"for a period of days following completion.
Note: This form is not a substitute for the advice of an attorney. Legal advice of any nature should be sought from competent,
independent, legal counsel in the relfevant jurisdiction. Absolutely no warranties are made regarding the suitability of this form
for any particular purpose.
f
The Commonwealth ofMassachusetts
Department of lndustriglAccidents
Office o fInvestigations
600 Washington Street
_ Boston, MA 02111
www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
n fi,5
Address: > -� C 0,-, -C r—
f a�, -�. MJ
c., r Phone #•_ �/ r
City/State/Zip: " G'l/,1'�
r
17
Are you an employer? Check the appropriate box:
Type of project (required):
1. [l I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New consfiraction
employees (full and/or part-time) *
2.A I am a soleproprietor orpartner-
have, neathe sub -contractors
listed on the attached sheet.
7. [] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
,
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
g, [I Building addition
10.[] Electrical repairs or additions
required.]
3. ❑ Z emu homeowner doing allwork
officers have exercised their
right of exemption or MGL
p p
11. ❑Plumbing repairs or additions
myself. [No workers' comp.
c.152, §1(4), and wehave, no
12.[]Roofrepairs
insurance required.] t
employees. [No workers'
13.0 Other
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 indicatingthey tie doing allworlc and then hire outside contractors must submit anew 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and joh site
information.
Insurance Company
Policy A or Self -ins. Lic. #: ExpirationDate:
lob Site Address:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dote).
Failure to secure coverage as requiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of
'Investigations of the DTA- for insurance coverage verification.
pity/State/Zip:
I do hereby cerfiAzinder the pins and enaltles ofperjury that the information provided above, true an1correct.
7,Y C o
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: permitMeense#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical inspector 5. Plumbing inspector
6. Other - -
Information and
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 ofhire,
express or implied, oral or written."
An em,ployer 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 ofpublic 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 certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no empIoyees other than the
members or partners, are not required to carry workers' compensation insurance. If an LL C or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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 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 orpermit to bum leaves etc.) said person is NOTrequired 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: r
Tho Corx onwaalthofmassachuseits
Dep.artmelit ofTadu dEd Acoldc? its
Q?fte of hive.8tigWo
E04 Washington Stxoet
BostwMA02111
TQJ, # 61.7-727-4900 oxt 406 or 1-877-MA.SS.AF9
R
��e o�avr�zooacueaLG� a�C�/�aaoac�c�el,7i I
Office of Consumer Affairs & Business Regulation
Q — OME IMPROVEMENT CONTRACTOR j
egistration: 169543 Type:
�r
Expiration 7/5/2015:; DBA j
JOHN MORRISSEY, REMODELING -4
JOHN MORR18SEY `
57 CONCORD ST 1
NORTH ANDOVER, MA 01845 Undersecretary
__ --
lic Sit
ti7,tti�:trliu�ctt� - Delt.ulm nuns �e�rs(?S�t nd it tls .
Board Of Buil(!'ing Rote
Construction Supervisor•. License
t_icense:+CS 105236,,'
JOHN MORRISSEY
•57 CONCORD ST
I NORTH ANDOVER, MA 01845
f,
Expiration: 11 /2612013
Tl#: 105236
1 ,
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