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HomeMy WebLinkAboutMiscellaneous - 15 WENTWORTH AVENUE 4/30/2018•_. l.A 1 a r Location-x---�^^`�"�` No. `7 Date O "�? `au •. �oRT►, TOWN OF NORTH ANDOVER 10- p ' 1 i ^ • Certificate of Occupancy $ a JACMU� Building/Frame Permit Fee $ Foundation Permit Fee $ ✓ Other Permit Fee $ TOTAL $ Check # a, 18437 Building Inspect ( r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: 2 SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 1�G✓� hl % Giv /Z f i-i C-) Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dis d Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred Provide Regpired Provided RecjWred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zane Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic lstrict: Yes NO 2.1 Owner of Record J�/9✓yiM/a�/9 ,2v ✓ / s /,, � nt : Ctiv fc[—rt Name (Print) Address for Service: y rJl- Stgnature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ t Q Licensed Construction Supervisor: 6 License Number Address %cJ ✓ L t2t rc. — G-P / f�ii7iPr•�t�f 7c (a �S 3 9 V1 Expiration Date Signa Telephone 3.22 Regi ed Home Improvement Contractor Not Applicable ❑ /0 0 C Z Company Name Registration Number O Address Expiration Date Expiration � C ?-,N-r� Q. Si nature Tele hone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin rmit. Signed affidavit Attached Yes ...... No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: .... ' 1•C- 3e0 < SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applican �i y�? a01�U O�i8j' Ygt✓ ., 1. Building j J (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I </ Yr.111 G N dJ 1p_;- 41� ism ice/-/ o v'J ! ,as Owner/Authorized _Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print 1,Lame Si atur f Owner/A ent Date 06 W."MIZ NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 RD SPAN DRAENSIONS OF SILLS DIN ENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND - IS BUILDING CONNECTED TO NATURAL GAS LINE ra Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aunlicant Information Please Print Legibly Name (Business/orpnizatiodlndividual): -5,7,� Address: J :� Lr'—' i '�y2 •Ir L �r City/State/Zip:Phone #: 9 % FJ Are you an employer? Check the appropriate box: 1. E1,1 -a -m a employer with 4. ❑ I am a general contractor and I employee's (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t 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. ❑ 1 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 s. ❑ Demolition 9. ❑ Building addition 100 Electrical repairs or additions 11 -El Phlmbing repairs or additions 12.❑ Roof repairs 13.❑ Otter -Any awncan imn rumcm cox w i tmsa ase, mr mm me semen oerow suOwtns their workea' compensation policy infornation- t Homeowners who submit this affidavit n4csting they are doing all work and ton bite outside eonhsctors must submit a new s@"idsva indicating suck tConb ectw tot chock this box must attached an additional sheet showilS *cum= of the sub -contactors and 8rcir wo&=, comp• policy inf msetioa lam ion -_employer Is providing workers' compensation insurance for my e�nploym Below Is the p llcy and job alas information. Insurance Company Name: lard 2 J Policy # or Self -ins. Lic. #: 6- o 43 -6 0 If Expiration Date: �r--.,)-L Job Site Address: %S— C,.1� �P `�,VA'T'M t city/State/Zip:N lJ•�� a �r�2 �iy Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as MqUIref 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-yenbV isonment, 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 herebyIWO) under the pales and�e of perjury that the lnjormatlon provided above b frac and correct Phone #: T/ 1� 6 Y.3 z4/ j K !�- Offlcial use only. Do not write In this area, to be compkted by city or town of j?ciaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other PermWLiceuse 3. Cky/Town Clerk 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone #: iniormaitun unu mau ul tivlla 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 ab 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() 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 sip and date the aflldavlL 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' compensationpolicy, please call die Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Offlctals 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 has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid afvit is on file for future permits or licenses. A new affidavit most 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 wwwmass.gov/dia s RAYMOND E. DAM PROUSSE, A AN SONS °1100FIN CO., IHC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE. MA 01842 SUPERVISOR LIC. #046636 TEL: (978) 683-4588 HOME IMPROVEMENT REG. #101862 ROOFING — SIDING — INSULATION j Date ;From: _d/ i� !� i /� �C C'J / (c,� remit (Name) (Address) 4O: UTEM L DAVIOU9, A. AND SONS .1OOFDI6 CO., IMC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 I (we) hereby authorize the Contractor to furnish all materials and labor necessary to install, construct and place the Improvements described bel.ow_io,on building located at No. —/—w Street, City /%�� h I 12 6 ki!'1? state �� r i/ in accordance with the following specifications: 1 / , !� �-' // /' rJ F" �� ! /Y (r �. C - l�d ^i L 1-6-1 -Y hr r \ �1 ✓' �"" % n i ,�' L 1 L � O 1� f'►��z�� - /?'< �L-.�1C � s'� �! 1 � �� o �-�l ,2 �� J" ✓,.� � C G s r-- 11c i C) Ci TLC7 T ��,� �./ �-"'•' �-rG G /�/. ,tel• - All of the jbove work to be one in Wgood and workman like manner. All men and equipment Insured. Premises to be left clean upon completion of work. ���� v f For the total sum of Entire Sum to be paid immediately upon completion in accordance with pla dollars. as shown below. TOTAL CASH SELLING PRICE .......... i J DOWN PAYMENT IN CASH ..... :....... DEFERRED BALANCE UPON COMPLETION ................. . The undersigned agrees to keep property mentioned in this agreement properly insured against loss by fire including the Contractor's interest therein. This agreement shall become binding only upon the written acceptance hereof by said Contractor, and upon such acceptance this shall constitute the entire contract and be binding upon the parties hereto, there being no covenants, promises or agreements, written or:elral except as herein set forth. It is the intention of the parties hereto thafthis contract shall be binding upon their respective' heirs, executors, administrators, successors and assigns. Customer agrees to pay a reasonable sum as attorney's fees and Court Costs if placed in hands of attorney. for"tollection. The owner further agrees that in event of cancellation of this contract after acceptance by the contractor and before the work is commenced the OWNER agrees to pay 20% of the total consideration herein named as liquidated damages for breach of contract. Said contractor shall not be responsible for damage or delay due to strikes, fires, accidents, or other causes beyond his reasonable control. - We, the undersigned, certify that we are the sole owners of the property herein described on which said work or repairs are to be performed. IN WITNESS WHEREOF, the undersigned has (have) hereunto set his (their) hand(s) and seal(s) the day and�year written above..