HomeMy WebLinkAboutBuilding Permit #55 - 85 WEYLAND CIRCLE 7/25/2007Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
v��T�.av,*6• ryO�
® ,/ DESCRIPTION OF WORK TO BE PREFORMED:
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ARCHITECT/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: $ 1,x,5 d �` FEE: $_ 40Wi- 0"s
f
Check No.: Receipt No.: 6 V7
NOTE: Persons contracting with unregistered contractors do not have access to the guar ty fund
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Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
IN
DATE REJECTED
Stamped Plans ❑
DATE APPROVED
❑
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Privatt (septic tank, etc. ❑
Permanent Dumpster on Site ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connectio
Located at 384 Osgood Street
Dimension !�
Number of Stories: Total square feet of floor area, based on Exterior dimensions. f
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 2 1 A —F and G min.$100-$1000 fine
NU i t5 and DATA — (For department use
❑ Notified for pickup - Date
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
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
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 DEPARTMENT:BPFORM07
Revised 2.2007
Location
No. Date
Check # C�3 3
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ 2
Other Permit Fee $
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TOTAL $
2G4JJ ",K
Building Inspector
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JUL-25-2007 WED 10:04 AM WYZE BUS CTRS INC
FAX NO, 16038931050 P, 01/01
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FRI
ROMD OF ISUILDfNG
Llconfic: CONSTRUCTION SUPS 'OR
Number: CS 072449
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il ixplr* 11;2008 Tr, no: 21677
Restrtew., 00,
CARL G GRENER,
HOME IMPROVEVirNT Coi,!,rFt.kc*roa
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www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
DDlicant Information ploova P«:nt T .-:hl,
Name (Business/Organization/Individual
Address:
L"
City/State/Zip: �j „� _ .z� Phone me
The Commonwealth of Massachusetts
1. ❑ I am a employer with
Department of Industrial Accidents
�.
LIOffice
A
of Investigations
U ,'
600 Washington Street
ship and have no employees
These sub -contractors have
working for me in any capacity.
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
DDlicant Information ploova P«:nt T .-:hl,
Name (Business/Organization/Individual
Address:
L"
City/State/Zip: �j „� _ .z� Phone me
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. ❑ 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
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill 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 the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: `�/� 4 ,0 —4,4/l L �� �t s J 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 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 undeoe pains and 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 #
MAI
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 pen-nit/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 5-26-05
www.mass.gov(dia
PROPOSAL
GC Contracting
52 Stiles Rd. Suite 101, Salem, NH, 03079
..Full Service Woodworking
Carl Grenier
Licensed Insured
Tel: (603) 870-9000 Fax (603) 893-1050
Proposal Submitted To:
Date:
Kell
6-26-07
Street:
Job name: 01
85 We land Circle
City, State Zip Code:
Job Location:
North Andover
Telephone:
All prices are based on estimated stock price,
(617) 407-7814
1 availability and quantities.
We hereby submit specifications and estimates for:
Carpentry* Carpenters responsibilities
Paint
Additional Bed Room
• 1 Entrance door $6,000.00
• Interior walls
• Closet with shelf and pole
• Closet door
• Wainscoting on outside of bed room only
• Prime and paint
• Adjust heat vent
• Additional closet work
Note: Window and Electrical works are not included in price, but
costs should be in these price ranges (electrical $500.00)
(Window $1,000.00)
Shutters
Cedar with Stainless Fasteners were possible $900.00
(per set,paint not included)
TOTAL LABOR FEES $6,900.00
We propose hereby to furnish labor and materials — complete in accordance with Massachusetts and or
New Hampshire Building Codes and in a manner compliant with standard Practice. Materials supplied by
customer, contractor will not be responsible for condition or warranties of installation
Estimated Completion Date: working days
Payment to be made as follows: First payment upon acceptance of proposal $3,000.00 Second payment
$.00. Final payment upon completion $3,900.00(prior to punch list)
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according
to specifications submitted, per standard practices. Any alteration or deviation from the above
specifications involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond the
means of the contractor. , Proposal price estimated on current lumber and material prices. Changes in stock
prices will the responsibility of the customer and will be reflected in the final bill. Balances unpaid for
period of (30) days will have a finance charge assessed, computed at a periodic rate of 1.5% per month,
which is an APR of 18%. Legal fees and costs accrued from unpaid balances in an attempt to resolve
monies owed will be added to assessed charges and balances entailed all to be responsibility of customer.
Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by liability
insurance.
Authorized
Note: This proposal may be withdrawn by us if not accepted within 30 days.
Acceptance of Proposal: The above prices, specification and conditions are satisfactory and are hereby
accepted. You are authorized to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signatuq� -"e -
Signature