HomeMy WebLinkAboutBuilding Permit #711 - 855 WINTER STREET 5/14/2010TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Buildingi
Cow
Additio
or more family
Industrial
A tion
No. of units:
Commercial
Repair eplacemen
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
OWNER: Name: 1� r� H� X e.e v1k^ Phone: �6 t 7, 3
Address:
CONTRACTOR Name: Phone: —7f t
Address: ` 54.4,4w- - N A 0.)-1-1,7V
Supervisor's Construction License: a� Exp. Date: t y ?cap/ -
Home Improvement License: j a c cy 3 Exp, Date: 16 - z
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: $� ..,a4-6� 1 5, 606 FEE: $ ( d v
Check No.: td Receipt No.:
NOTE: Persons contrractipigith u eg red contractors do not have access to the guqqntyfund
n
I
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Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools ,1
Well
Tobacco Sales
Food Packaging/Sales
rivate (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
ti
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
.FIRE DEPARTMENT - Temp Durnpster on site yes no
Located at 124 Main Street r"
Fire Department signature/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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
No
Doc.Building Permit Revised 2010
;C
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
❑ 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 DepartmjZnt 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
❑ 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: Building Permit Revised 2008
Location S7 [ r—
No. Date t v
fSORT►, TOWN OF NORTH ANDOVER
i .• OL
Certificate of Occupancy $,.�j*
' • __1f�—
s^CNUsEt� Building/Frame Permit Fee $
Foundation Permit Fee $ '
Other Permit Fee $
TOTAL $
Check # 16 /0U
231
I
Building Inspector
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proposal 4y .
HOMEWORK UNLIMITED .CO.
329 Mlll STREET
BELMONT, MA 02478
617 689 3220
PROPOSAL SUBMITTED TO PHONE .
G hh ` DATE
SREST i TY�3
JOB NAME
—J
S �--„moi
CITY, STATE and ZIP CODAJ A
E JOB LOCATION
165 Al, A aj
"ARCHITECT :IDATE=PLANS1
We hereby submit specifications and estimates for.
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JOB PHONE
it 7 55
Wt' Propt1199 hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
_� _ ($ L �G� 1
Fment to be made as follows: dollars c
All material is guaranteed to, �s, specfied. All work to be completed in a workmanlike
manner according to standanf p2c6's. Any alteration or deviation from above specifications Authorized
involving extra costs will be'execu” only upon written orders, and will become an extra Signature
charge over and above the "Imate. All agreements contingent upon strikes, accidents
or delays beyond our control, Ownei to carry fire, tomado and other necessary insurance. Note: This proposal may be
Our workers are fully covered by W"man's Compensation Insurance. withdrawn by us if not accepted within
Arreptaure of raposal —The above prices, specifications
and conditions are satisfact* and are hereby accepted. You are authorized Signature
to do the work as specified .",Pa nt will be made as outlined above.
Date of Acceptance: Signature
4
days.
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The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office OfLnvesiigations
600 Washington Street
Boston, M4 02111
www.snassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electri
Mlicant Informtion cians/Plumbers
a
v. Z!a MA L
Name (Business/organization/lndivid W):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
------_
1. ❑ I am a employer with
4. ❑ I am acontractor
TyEf project (required):
employees (full and/or part-time).*
2.52lam a sole proprietor or partner_
and I
have hired the ubc ntractors
listed
6• Neu+ construction
ship and have no employees
on the attached sheet x
These sub -contractors have
❑ Remodeling
working for me in any capacity,
[No workers' comp..
i nsur-dnce
workers insurance
com . '
P
5.❑ We are a corporation
g Demolition
9• ❑ Building addition
3. Elrequired_]
I am a homeowner doing
and its
officers have exercised their
1Q•❑ Electrical r epairs or additions
all work
myself. [No workers' comp.
right of exemption per MGL
C. 152, § 1(4) and we have
11-11 Plumbing
g repairs or additions
insurance required.]t
no
employees - [No workers
12•❑Roof repairs
comp• insurance required ] 13.❑ Other
. e A -Y EPPlirvnt that checks bm ia7 nn3t 8130 ill! Crit t.CC Se On L�rQI'.' ah442^�
liomeowuers who submit this affidavit indicating tha are do b worltte s' COmr - 3- a Yo;_;c ���
'Contractors that check this box must attached an additional sheets owing and® outside contractors must submit a new affidavit indicating such.
the
t name of the sub -contractors and their
workers' coma „tet: R, ; _,__
o G"`rmation, P"'�'er agar Is provuting workers' compensation i
infonsurance for my employees. Below is the policy and job site
Insurance Company Name.
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declaration page sho City/State/Zip:
Failure to secure coverage as required under Section 25A ofMGL cp 152canlead to ththe policy
imposition os number
and expiration date).
fine up to $1,500.00 and/or one-year imprisonment, as well as civil P criminal Penalties of a
of up to $250.00 a day against the violator. Be advised that a co Penalizes in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. PY of this statement may be forwarded to the Office of
I do hereby under the '�andenalties of perjury thrzt the formation provided above is true and correct
Signature:
Phone #: —ZZ
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town:
Permit/License #
Issuing Authority (circle one):
- Board of Health 2. Buildinb Department 3. City/Town Clerk 4. Electrical Inspector 5. plum
6. Other a inspector
Contact Person:
Phone #:
Information an- d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or tiny two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association o$ other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartmLents 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 it license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coimpliance 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 urrtg 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 certificates) 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 inaura�,ce. 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 stare to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pert or license is being requested I , not the .Department of
Industrial Accidents. Should you have any questions regardixxg 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 p=niVlicense 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 Office of Investigations would like to than 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 lmdustrial Accidents
Office Gf lnvest igatiGns
600 Washington Street
Boston, MA 0.2111
Tel. # 617-72.7-4300 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fw, # 617-72.7-7749
umm,.mass._gov/dia.