HomeMy WebLinkAboutMiscellaneous - 28 APPLETON STREET 4/30/2018 (2)I
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No. c29 Date
TOWN OF NORTH ANDOVER
0
0
Certificate of Occupancy $
Bui Idi ng/Frame, Perm it
Fee $ /)0
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Foundation Permit Fee $
7
Other Permit Fee $
GI
TOTAL $ 1-6 0
Check #
8 12' 7 4
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
- APPLICAT - ION TO CONST , RUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
77.77.7��
Y,
BUU,DING PERNUT NUMBER- DATE ISSLTP/�
SIGNATURE:
Building COMMiSSionedln�ee6g*M&ne
SECTION I_qIT1P IN-MUMATInpi I
I - I Property Address:
,A9 _AfP/,ERA)
S �
1.2 Assessors Map and Parcel Number:
o3 �8 —06go
Map NumbeF Parcel Number
IJ,oj
1.3 Zoning Information:
Zoning Di Proposed Use
1.4 Property Dimensions:
A- Frontage (ft)
1.6 WELDING SETBA
Front Yard
Side Yard
Rear Yard
Required Provide
RNWred I Provided
Required=7, Provided
1.7 Water Supply M.G.L.CAO 54)
Public 0 private 0
1.5. Flood Zone Information:
Zone . Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHMAUTHORIZED AGENT
�Ulu
7'0
Name (Print) Address for Service:
No , 0 Vr— 14�
Signature Telephone I
2.2 Owner of Record:
Name Print
3ignarure T
SECTION 3 - CONSTRUCTION SERVICES
3.IkLicensed Construction Supervisor:
Licellsed Construction Supervisor:
Address
Signature
3.2 Registered Home Improvement Contractor
1))qvLp
Company Name
Telephone
Address tor Service:
Not Applicable El
License Number
Expirati �n Date
ss
j� 2-3 —91�ay
Not Applicable 0
Registration- Number
2 IL.�- /. 6 6
Expiration Dite '
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mn
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SECTION 4 - WORKERS COMPENSATION (NLG.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 building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check- applicable)
New Construction 0
Existing Building
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
D C
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Itern
Estimated Cost (Dollar) to be
Completed by permit applicant
14V
g
1 . Building
(a B uildi ng Permit Fee
Multiplier
2. Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (,a) x (b)
-4 Mechanical (HVAC)
-5 Fire Protection
-6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COWLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building pennit application.
Signature of Owner Date
-SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, D4V1V...C-4SrkLCQA2E —,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
DAVID s__AS7-X1CWE_
Prin � r-X_b_A-Q_.d - L. /�A 5 --
Signature of Owner/A ent Date
i low, MEN 111111011111
NO. OF STORIES SIZE
BASENIENT OR SLAB
SIZE OF FLOOR TEVMERS 2ND 3RD
-SPAN
-DMNSIONS OF SILLS
-DU\,ENSIONS OF POSTS
DINENSIONS OF GIRDERS
-HEIGHT OF FOUNDATION THICKNESS
-SIZE OF FOOTING X
-MATERIAL OF CHR\4NEY
IS BUII.DING ON SOLID OR Fff�LED LAND
F—ISBUILDING CONNECTED TO NATURAL GAS LINE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass;gov1dia
Workers' Compensation Insurance Afridavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address: ), 0 0 S 3L
City/State/Zip:
#: qS — .3 Y,2_0
Are you an employer? Check the appropriate box:
1. 2;'l am a employer with K 4. El I am a general contractor and I
eniploye6 (full and/or part-time).* have hired the, sub -contractors
2.0 1 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. E:1 We are a corporation and its
required.]
1 am a homeowner doing all work
myself [No workers' comp.
insurance requira] t
officers have exercised their
right of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F� New construction
7. Remodeling
8. Demolition
9. E] Building addition
10. El Electrical repairs or additions
11. F1 Plumbing repairs or additions
12.VRoof repairs (YM1,P)
13.[] Other
*Any applicant that checks box # I 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
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and'theiT workers' comp. policy inforrnation.
I am an employer that is providing workers compensation insurancefor my employees. Below is the policy andjob site
informatiom
Insurance Company Name:
Policy # or Self -ins. Lic. #: W. C, 1) n 9 9 0 0 112 0 A Expiration Date: J-2 6
Job Site Address: J2 2 e City/state/zip:. 30
Attach a copy of the workers'- co'nipensation 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"miiprisonnient, 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 under thff ains anoenalties ofperjury that the information provided above is true and correct
110
�.-AMAWAIE"MIM
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
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 6r 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 aii 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 miniber(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 hive 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 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 or
town)." A copy of the affidavit tha t 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 fiiture 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 peri'mit to bum 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 nurnber:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlice 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
13
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A. I
The debris will be disposed of in:
p A
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
hildi.g Itg,,It,.
BOard Of I W -&Z&
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NOINE IMPROV drd,�
EMENT CON-rRACTOR
Registratloh: 104.6.
Expiratim -
J, -,. 7�14/2006
TY Pli - CorPOration
DAVID CASTRIC6
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7 Hillside Road
BOxford, MA 01921
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MASSACHUSETTS U141FORM APPLICATIOU FOR PERMIT*��.r
(Type or Print)
Date:
NORTH ANDOVER —,Mass..'
S, ge�P permit.#
Building Location _,aLr
Owners Nam 7Z
New *0 Renovation L] Replacement 0 Plans Sybmitted
IXTURFS
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(Print or Type) Check one: Certificate
Installing Company Name
Corp.
C151
Address 1411:1, /1/ Partner.
Firm/Co.
Business Telephone
Name of Licensed Plumber:
Iz-
Insurance Coverag Indicate the type of insurance cover.age by checking the
appropriate box: Bond
Liability insurance policyJ,77r0ther type of indemnity El
Insurance Waiver: 1, the undersigned, have been made aware.,that the licensee of
this application does not have any one of the above three insurqnce coyerages.-
%
Owner Aged%
Signature of ownerlagent of property
I hemby cutify dial &Ila( die delails and infoinia lion I leavc subinif lcd (or enicicd) in Owive appliCalion age 11W MTVW&te to ON baWl of my
kmwkdp liad 1hat all plumbing wack and installa (ions lice fntnicd undcl rellitil lisucd fol this applicaliasi will be Ikk so path" Pfl, 10
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Title
City/Town:
Signature of Licensed Plumber
T of Plumbing License
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SUB-nBSMT.
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IST FLOOR
2NO FLOOR
3RD FLOOR
4TH FLOOR
6TNFLOOR
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7TH FLOOR
OTH FLOOR
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(Print or Type) Check one: Certificate
Installing Company Name
Corp.
C151
Address 1411:1, /1/ Partner.
Firm/Co.
Business Telephone
Name of Licensed Plumber:
Iz-
Insurance Coverag Indicate the type of insurance cover.age by checking the
appropriate box: Bond
Liability insurance policyJ,77r0ther type of indemnity El
Insurance Waiver: 1, the undersigned, have been made aware.,that the licensee of
this application does not have any one of the above three insurqnce coyerages.-
%
Owner Aged%
Signature of ownerlagent of property
I hemby cutify dial &Ila( die delails and infoinia lion I leavc subinif lcd (or enicicd) in Owive appliCalion age 11W MTVW&te to ON baWl of my
kmwkdp liad 1hat all plumbing wack and installa (ions lice fntnicd undcl rellitil lisucd fol this applicaliasi will be Ikk so path" Pfl, 10
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Title
City/Town:
Signature of Licensed Plumber
T of Plumbing License
Date .........
'S
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .. ..... ...........................
has permission to perform
j
plumbing in the buildings 0 ..........................
.................... North Andover, Mass.
Re� Lic. No.. . . ..............................
(I,j # PLUMBING INSPECTOR
03/06/98 11:54 30.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer