HomeMy WebLinkAboutBuilding Permit #735-14 - 82 MILLPOND 4/22/2014Date Issued: 'I I -LL I (_
must complete all items on this
LOCATION aZ)- WA tLI k0,4JC)
Print
PROPERTY OWNER G AAA?, 04, U
Print
MAP NO: C'S- PARCEL -606Z ZONING DISTRICT: Historic District yes no
Machine Shop Village ves no
TYPE OF IMPROVEMENT
PROPOSED USE
BUILDING PERMIT
3i 4•';f_ *"'
Pennit NO: �J�
Non- Residential
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
i e
Date Issued: 'I I -LL I (_
must complete all items on this
LOCATION aZ)- WA tLI k0,4JC)
Print
PROPERTY OWNER G AAA?, 04, U
Print
MAP NO: C'S- PARCEL -606Z ZONING DISTRICT: Historic District yes no
Machine Shop Village ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
)(One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
0 Commercial
WRepair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
Water/Sewer
fZQAWA1- Of- GXVM� A- \4VA-ak
CAS w-� ow -10 ���� 1�
Identification Please Type or Print Clearly)
OWNER: Name: CIMQX C OLv_4C" ��6 0 F',43Phone:
Address: 6-z VAli U&,0b
CONTRACTOR Name: Phone: C,0 0 H T>c k a 3
Address:
j%A A O vsi y
Supervisor's Construction LicenC�01760(b Exp. Date: � � I O G U (g—_
Home Improvement License:Exp. Date:
to66sn -7 ley. l --Z614
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: $ a $
Check No. Receipt No.:
NOTE: Per ns Antracting with unregisterepj conoactors do not have access to the Juarantyfunit
SignatVre of Age
re of.
If . I
A._
Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
.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
0$e ptic ❑ Well _
❑ Floodplain ❑ Wetlands
Watershed District
Water;/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Ari riracc-
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
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: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
'Signa' �reot�Agent/Qwner.; _ . _ .: __ S�g�ature of contractor;. __ _ ��.
Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
l-
Building Department
'''The fold-pwing is allist of,the retluired.forms to be -filled outfor:the appropriate. permit to`.b.e obtained.
Roofii,g, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
Li 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
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
❑ 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
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 apo•,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
- -Plans Submitted ❑ Plans Waived ❑ .
_.Certified Plot Plan ❑ . Stamped Plans-' ti
'TYPEOYSI wERAGE.DiSROSAL-
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
well ❑
Tobacco Sales 0
Food Packaging/Sales ❑
Pxivate :(septic tank, etc.- ❑ .- - :
-Permanent pampster on Site ❑
THE-..FOLLOI. ING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
r,
J
DATE. REJECTED DATE:APPROVED
PLANNING & DEVELOPMENT ❑
COMMENTS
,CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Com
:Com
"dVater & Sewer Connection/Signature & Date Driveway Permit
,,.DPW Tows Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT ..= Tertip Dumpst�r onsite .yes.... no
Located at.124iMair.Street
Fire'Departme►it
~�
COMMENTS` 1:
_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 :fin.e
Doc.Building Permit Revised 2010
P ■
Location 2• d V, Cf
tt
No. t Date
ru4.to'��+
Check #�
27477
TOWN OF NORTH ANDOVER
Certificate of Occupancy I
Building/Frame Permit Fee 07?12 •—
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Building Inspector
The Commonwealth ofMassachusetts
Department of IndtcstrialAccMiks
Office offnvestigations
600 Washington Street
.Boston, MA 02111
www.mass.govIdla
Workers' Compensation. )insurance Affidavit: Builders/Contractors/ER.
Name(Busimsiorganization&da'vidual): q -t� • C-9-4AV+v(�OL q—
Address: �,� ( (�V��C►� Sr�
City/Siaie/Zip:tMviUS��''� U� ov-LPhone #: �-i� L[ 3:1 IUB
Are you an employer? Check the appropriate box:
Type of project (required.):
1. [( I am a employer with
4. ❑ I am a general contractor and I
6. ❑ Now construction
employees (full and/or part-time).*
have hired the sub -contractors
listed on the attached sheet.
'i. ❑ Remodeling
2. I am a sole proprietor or partner-
ship and1ave no. employees
These sub -contractors have
8. E]Demolition
working forme in any capacity.
workers' comp. insurance.
9. [I Building addition
[No workers, comp. insurance
5. ❑ We are a corporation and its
10.[] Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised.their
right of exemption per MGL
1111 Plumbing repairs or additions
myself. [Eo workers' comp.
c.152, §1(4), and wehave no
12.❑ Roofrepairs
insuraucere ed
�' . �
employees. [No workers'
13.[] Other
comp. insurance required.]
'Any applicantthat checks box#1 must also fill outthe section brldw showingtheir Workers' compensattonpohay mrormaion.
i "Homeowners who submit this affidavit indicatingthq Rio doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis box must attached as additional sheet showingthe name of the sub -contractors and their workers' comp. policy information.
I am an emyloyer that isproviding workers' compensation insurancefor ray employees Below is thepolicy andjoh site
information.
Insuxanco Company
Policy # or Self, ins. Lic. #: Expiration Date:
rob Site Address: City/State/Zip:
Attach a copy of the workers' comp ensation-polley declaration page (showing the policy number and expiration date).
failure to secure coverage as requiredunder Section 25A ofMGL 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 may be forwarded to the Office of
Investigations of the DIA. for insurance coverage verification.
I do liereby cer ,iv under the pains andpenalties ofperjury that the information provided above is true and correct.
Ri�,afi,r2//z�x. Date:
Official use orzly..Do not write in tliis area, to be completed by city or town official.
City or Town: Permit/License 0
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other -
ContactPerson: Phone
Information and Instrnctions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuazii to this statute, an ernployee is defined as "...every person tri the service of another under any contract ofhire,-
express or implied, oral or wxitten.,,
An emPloyei xs defined as "an individual, partnership, association, corporation or other legal entity, or anyiwo or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a• deceased employer, or the
reeeivex orir6tee 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
ox 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, McL 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 boxesthat apply to your situation and, if
necessary, supply sub-contractor(q) name(s), address(es) andphomenumber(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members orpartners, arenotrequiredto carry workers' compensationiusurance. IfanLLC orLLP doeshave
employees, a policy is required. Do advised thatthis affidavit maybe submitted to the Department of industrial
Accidents fox coniumation 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 Offtcials
Please be sure that the affidavit is complete andpriated 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 Min the permit/license number which will be used as a reference number. 1h addition, an applicant
thatmust submit multiple permit/license applications in any*given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or
towb)" A copy of the affidavit that has been officially stamped ox 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. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves eta.) said person is NOT required to complete this affidavit.
The Office of Investigations would Uo to thank you in advance for your cooperation and should you have any ciuestions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho CQwj on.w.oaTtktofA4assaehvsP
Depaftmt of fadustrial .El ccldonta
Off oe of Investiga.-tone
6.9() Wasbigtan Sl7reet
Boston, MA 021 It
`E`er, # 617-7.27-4900 W 406 or. 1-877-
MASSAk�
Revised 5-26-05 Fax # 617-727-7749
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name: zj4ww-r-S (-j! V" k)",2 7S -K
Location: W Lu— kFb1^�
'�?
City �{) AVQC AZA MA Phone --76 1 —t Z:- :7AS Z
E-1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone #:
Insurance Co. Policv #
Company name:
Address
City: Phone #:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1700.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. 1
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify un the pains and penalties of p 'ury that th information provided above is true and correct.
Signatur-11'4Date_4� t
Print name 6AwuS G- V"ku Mw k q " l Phone # CDO L( --1130k b 2�
Official use only do not write in this area to be completed by city or town official' E] Building Dept
[]Check if immediate response is required Building Dept p Licensing Board
0 Selectman's Office
Contact person: Phone #: 0 Health Department
0 Other
FORM WORKMAN'S COMPENSATION
P&M CONSTRUCTION LLC
183 OLD FERRY DRIVE
METHUEN, MA 01844
Name / Address
GAYNOR CHECKOWAY
82 MILLPOND RD.
NORTH ANDOVER ,MA
Estimate
Date
Estimate #
4/18/2014
2013-75
Project
Item
Description
AMOUNT
Amount
Markup
Qty
Total
KITCHEN
REMOVE EXISTING COUNTERS
15,000.00
15,000.00
15,000.00
,UPPER AND LOWER CABINETS AND
REINSTALL NEW CABINETS
ACCORDING TO LAYOUT BY
PLAISTOW CABINET COMPANY
DATED APRIL 8 2014.
DEBRIS
OLD CABINETS AND COUNTERS
0.00
0.00
0.00
WILL BE REMOVED FROM JOB SITE
NOTE
ALL PLUMBING AND ELECTRICAL
0.00
0.00
0.00
WORK BY OTHERS
NOTE
RANGE IS SHOWN AS GAS ON PLAN
0.00
0.00
0.00
BY ERROR IS TO REMAIN ELECTRIC
IN SAME LOCATION
NOTE
GRANITE COUNTERS BY OTHERS
0.00
0.00
0.00
G
4v (141-17 t
Total $15,000.00
Massachusetts - Department of Public.Safety,_
Board of Building Regulations and Standards
Construction Supervisor
License: CS -037698,
Is
JAMES G MUNR0)E JR -
131 WASHINGTON
METHUEN MA 81844
`'bxpiratioh ,
Commissioner .11108/2015
✓hQ L�omvmaittaefa a� F'iaJauciru�e+t
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
j Registration:. -106658 Type:
Expiration: _7/24/2014 DBA
MUNROE BUILDERS
James Munroe
131 Washington St `
Methuen, MA 01844 '
Undersecretary
IN 1 11 1 No
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