HomeMy WebLinkAboutMiscellaneous - 287 DALE STREET 4/30/2018 (2)Vol J�
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Occuparicy & Fees Ch ecked
APPUCA71ONFOR PERMIT 70 PERFORM ELEMICAL WORK
ALL woRK To BE PERFORMED IN ACCORDANCE WnM THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRDff IN M OR TYPE ALL INFORMATION)
Town of North Andover To the Inspector of Wires:
Tile undersigned applies for a pennriit to perform the electrical work described below.
,,*� C\
Location (Stmet & Number) ry-S q Ne
Owner or TenaW C -y (),I t'�4,(JqSc � ^0
owner's Address -qme - ---
Ls this permit in conjunction with a building permit Yes " No (Check Appmpdate Box)
purpose of BuildinS Utility Authorization No.
Existing Service Amps
....L..Volts 11 Underground 1:3 No. of Meters
N&M Lejadm Ampg_..L.Volts Ovedwad Undeqmund No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work ("rCc-1, JAA -4 Qr-ll Not
No. R 1.1511ti" Outhu
No. of He Tube
NO. of Thwahmnen
Total
KVA
No, of Ughting Fixturn
Swinuning Pod- Above
0
Below
n
KVA
No. of Itneptocle 0141011
No. of Oil Butuers zround
ground
No. of Emergency Lighting Battery Units
No. of Switcb 0010692
No. of Go Burners
FIRE ALARM
No. of Zones
No. of RwL90
No. of Air Cond. Told
Too
No. of DeNction and
No. of Dispoula
No. of Had Total Total
Ponys
TOM
KW
Inidaft Devices
No. of Sounding Devices
No. o(Dishwashen
Space Arm Heating KW
No. of Self Contained
Dmodonnoomaug Dnicn
Local Municipal
connectiong
ED Other
No. of Drym
Hoeft DoWan KW
No. of Won Heaten KW
NIL Of No. of
SIVA
Balleals
No. Hydra Massage TW*
of motows
Total HP
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jrdftffWdgrwancnftpw& 11605% Vlonst
(Plasm check one) OwnaV C3 Agent Talephone No.
33SHEM or Owner or Agent ARM FEE
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hin'to
plz�le
Location t IF S-4-
,-/ -
No. VC/ Date
40RT;l
TOWN OF NORTH ANDOVER
'A
Certificate of Occupancy
$
'S CHU
Building/Frame Permit Fe e
$
Foundation Permit Fee
$
Other Permit Fee
$
A�
TOTAL
$
Check #
184-17
Building Inspector
TON" OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT E!A_a RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUELDING PERMIT NUMBER- DATE ISSUED:
SIGNATURE:
Building Commi ioner/Inspector of BuildingS Date
sEcTiON I -SITE INFORMATION
1.1 PropedyAddress:
1.2 Assessors Map and Parcel Number -
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Am (af) Frontage (fi)
1.6 BUUMING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Reqwred Provide ReqWred Provided Regaired Provided
1.7 Wdeg Supply M.G.1-C.40. § 54) 1-5. Flood Zan Infoundion: 1.8 Sewersp Disposal System
Public 0 ftivate a zoss, Outside Fh)od Zone 0 Mkw 0 OnSiteDisposal System 0
SXCn0N 2 - pRopERTY OWNERSE[UP/AUT1101tMED AGENT 1,7; UiStriCt: X,/P3 NO
2.1 Owner of Record
&ULY AreDA-5611JC) 'DA t e- 5-r AJ, 1471016 Vl� "A - 61
Name (Print) Address for Service
C/
Signature Telephone
2.2 Owner bf Record:
r &-LAV _6,4P-d,145e-'170 -0,41e -57-, /U And6ill-1-
Name Prinf Address for Service:
Signature Telephone
SEC17ON 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
&u�
Licensed Construction Supervisor:
Address
,)- 8 -� jo,�(- 7; Ale,lfn d6 ve,' -6 F -ell
Signature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
, t�g—
Not Applicable o
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
LbF(I* 0 � 114)
M -
I
SECTION 4 - WORKERS COMPENSATION (MG.1, C 152
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 buildina Permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Descrigtion o Provosed Work kh�ftk avWkebb I
New Construction 0 Existing Building. 0 Repair(s) 0 on E!�'
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
-7LA 74 49el-,r
i qRrTioN fs - VATTMATwn rnvQTDrTo-irrf%w fnere i
item Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICL4L USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
SPAN zs-_"4 rlool
3 Plumbing
Building Permit fee (a) x (b)
/S
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
FOR BURDINc PYRN
L 6- tA.X ILI 19 0 A 5� t 1"-76) as Owner/Authorized Agent of subject property
Hereby authorize 1�a 46,49 to act on
My behalf, in all matters re'lative to work authorized by this building permit application.
--.14 .1. -1
Signature ot Mv-ier -611 Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, - 4!5�- C.." ::4 r, e- 1 ---0— as Owner/Au
property I Ic I thorized Agent of subject
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
S
nt N
Pri Xe
-e�� �- --, /// 70-
Sianature of (bafer/Agent Date
NO. OF STORIES
SIZE_
BASEMENT OR SLAB 'oe a"'e
SIZE OF FLOOR TRVIBERS &W" , ffcp,
3 RD
SPAN zs-_"4 rlool
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIC,HT OF FOUNDATION
THICKNESS
SIZE OF FOOIING
X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FELLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
I
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or l.andowner from compliance with any applicable or requirements.
*****APPLICANT FILLS OUT THIS SECTIOW,**"
APPLICANT LU
—L/Z >CPHONE_f 2jL—Z5-F-9-6 6`0
LOCATION: Assessor's Map Number PARCELO 0 /-S�-
SUBDIVISION LOT (3)
STREET__�= 4e le :57-74- BER
OFFICIAL USE ON -------
DATE APPROVED
DATE REJECTED
I UVVN VEAMMM DATE APPROVED 7
DATE REJEMED
e%.
COMMENTS �,Na ,,, -,,� ~ A-- / 3 4, 7. &�
,etAf
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR TE
RevIoW OW Jm
it
DALE STREET
PROPOSED ADDITION
cuoin BARDASCINO . 90F
LOCATION: 287 DALE sT.,mo.AmDovERmA.
L
&
DA TE.- 618105 SCA LE.- I 2�-- 60 8 A "Vk"ll"A 1.
PROFMIONAL ENGINEERS
CHRISTIANSEN &SERGI LAND SURVEYORS
160 SUMMER ST. HAVERH"MA. 01850 TrL. 978-373-0510
@2005 BY CHRIS77ANSEN & SERGI INC.
DWG.NO.:04082001
I he Commonwealth ofMassachuselts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, M-4 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibi
$4 Name (Business/Orgariization/Individual):_(9 U y—A6A tz 0 A 5 C_ / r) el
Address: _D�qte _-5 77
City/State/Zip: No, " Ver; t -7A 0 / SL/ C - Phone #: cf-7F .,5-8'0 t4l
,"Are you an employer? Check the appropriate box:
1 - EJ I am a employer with 4. El I am a general contractor and I
,_erriployee§ (full and/or part-time).* have hired the sub -contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
3. eleaqmutehdomeowner doing all work
myself [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance,
5. El We are a corporation and its
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. New construction
7. Remodeling
8. Demolition
9. E] Building addition
10. El Electrical repairs or additions
II-OPlumbing repairs or additions
12 -El Roof repairs
13.0 Other
t�iy UpiJIMMIL LIJUL UJIUc" DOX ff I MUST also 1111 out Me section below showing their w-kers'compezisation policy information:
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 their workers' comp. policy inforrnation.
I am an employer that is providing workers I compensation insurancefor my employees. B
f elow is the policy andjob site
3141 4
ormatin.
usurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date: / 00
zzll��
Job Site Address:— 2 9") 4q Ae , SY City/State/Zip: -41 1 d
Attach a copy of the workers' compensation p Ik
olicy 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 cerrift under the pains andpenalties ofperjur th the information provi
.0�1 y at ded above is true and correct
Simature: I's — —11, N
Date- A.,
z XI C.—
Oricial use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1 -Board of Health 2. Building Department
6. Other
kiermit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #:
1nformation and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers, compensation for their employees.
pursuant to this statate9 an employee is defined as,,... every person in the service of another under any contract of hire-,
express or irriplied, oral orwritten."
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 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 perinit 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 orkers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
Please fill out the w dress(es) and phone number(s) along with their certificate(s) of
necessary, supply sub-contractor(s) name(s), ad
insurance. Limited Liability Companies (LLQ 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 OfficiRls
tto
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bo in
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 permittlicense nurnber 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 pen I nit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would lile 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.niass.gov/dia
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 IVIGL
c 11, S 150 A.
The debris will be disposed of in:
MI a 7' A4 -s- 4iloi e - /1-40 4�y *"Ojkll
(Location of Facility) &'Cf
"gignature of Permit Applicant
�7 IlZle
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
4 TOWN OF NORTH ANDOVER
0
OFFICE OF
BUILDING DEPARTMENT
400 Osgood Street
North Andover, Massachusetts 0 1845
D. Robert Nicetta,
Building Commissioner
HOMEOWNER LICENSE EXEM[PTION
Please print
DATE:
JOB LOCATION: J. Anctwev,
/4
Number Sireet Address
HOMEOWNER Giw e) t7
,+ o, evr
Telephone (978) 688-95454
Fax (978) 688-9542
Map/Lot
Home Phone . Work Phone
PRESENT MAILING ADDRESS �0---r)aje-
6), A-lu-00 vcr- "A C) / rzlz
City Town State Zip Code
0,6 /_�—
(p r4l
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5. 1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNA
APPROVAL OF BUILDING OFFICIAL
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
CHRISTIANSEN & SERGI, INC.
PRbFU.9IONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830-6318 (978) 373-0310 FAX: (978) 372-3960
June 20, 2005
Lincoln Daley
400 Osgood Street
North Andover,Ma. 0 1845
Re: 287 Dale Street
Dear Mr.Daley,
We have prepared a proposed addition plan on the above property. Based on our site walk
the property is greater than 400 feet from Lake Cochichewick and all wetland resource
areas. Therefore the property is located within the "General Zone" of the Watershed
Overlay District. The allowed uses in this zone are per 4.13 6.3.a.i. 1. of the North
Andover Zoning Ordinance which is "All permitted uses allowed in section 1. 121
"permitted Uses residence 1,2 and 3 Districf 'of the Zoning Bylaw.
If you have any questions or I may be of further assistance please call ay anytime.
Sincerely yours, 0 11*1
00" llv� C!�
Q .
Michael J, Se
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Date ..... 7-/
TOWN OF NORTH ANDOVER
0 -
PERMIT FOR WIRING
This certifies that--,-�. �D ........... ....................................................
, has permission to perform ...... . ......................................................................
wiring in the building of ...... &.. ............ . ;".4.e14 ...................................
at,:71,F7. � .... ....... ...... ............. . .... . North Andover, Mass.
Fee..t� . .......... Lic. NA.-OA49A.-I., ... ........ ............ ...........
Check # / ZZ -3 K";' x .-- ELECTRICAL INSPECTOR
[ey i, V, igl,7el irc, J� Ir � I
Ml =
7 1 , =7f s7t
IPennit No. MNEEEENWWW�
Occupancy & Fees Checked ��, CS...
WWEMEMWEWWW�
APPUCA71ONFORPERMITTOPERFORMELEcnz[CAL WORK
ALL wORK To BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL coDE, 527 CMR 12:00
(pLEASE PRINT IN INK OR TYPE ALL INFORMATION)
Town of North Andover To the Inspector of Wires:
lie undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
owner or Tenant (-y (),I J-�Qr-jq& � ^0
Owner's Address �CLme W
rMIMA
Is this permit in conjunction with a building permit: Yes LVJ No [:3
(Check Approprija Box)
purpose of Building k--- Utility Authorization No.
Amps
Existing Service ...�.Volts Overhead Underground No. of Meters
Amps__..L.Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
L,ocation and Nam of Proposed Electrical Work ('�rCOJAA 4 (Jr -t POCik
No. of LAghting Outlets
No. of Hat Tube
No. of Tranallonneni
Total
KVA
No. of Ughting Fixtum
Swinuning Pool Above
1:1
KVA
Vaund
g1krolm"id
Receptacle Outlets
No. of OU Burness
NO. of Emergency Ughting Battesy Units
No. of Switcb Outlets
No. of On Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
TOM
No. ofDelecdon and
No. of Disposals
No. of Had Total Told
Purn"
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashm
Space Arcs Heating KW
No. of Self Contained
DetectionlSounding Devices
LOCRI Municipal
connections
Other
No. of Dryers
Heating Devices KW
No. of wam Hasten KW
No. of No. of
signs
Bailask
No. Hydro Mossage Tabe
No of Motors
Total HP
6 OTUER-
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FEMNAME cu,� T NQ A aw al
C,r�
Lk=Nb P ��aO5
BudlinTdNO,
Arkirpon Ave, Q)Ar\ AAV 0,,,qo�\
AXTdNa
0WMVS24SL?-AbMWAMIamw=dWftL=wd=wt
(Pleasecheckone) Owner ED Agent Te I lephone No.
....PMvff FU
ailglanife oi Owner or Ageng
--) 0 r) IDA)
Location 6X
No. 4P !�- — Date CD s—
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $ -3 0
-3 C1.411*'
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #
'18366
$ 7:5 9.0
�'Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLI�ATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
uq
se 0iiii:
BUILDfNG PERNUT NUNMER:
ISSUED:
SIGNATURE:
Building Comni-issioner/Inspector of Buildings Date
SECTION I- SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parvl Number:
D *� e- 0 & 00115-
ck) Map Number Parcel Number
1.3 Zoning In -formation: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (so Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Required Provide Required ::=Provided ReqWred Provided
I i e' P� .4- 1
1.7 Water Suppfy M.G.L.C.40. �1 34 Zone 1.5. Flood
public 0 Private 0
SECTION 2 - PROPERTY OWNERSFIIP/ Tf
2.1 Owner of',gecord
I -.ignarure
�2.2 Owner of'Record:
�,mc Print
1.8 Sewerage Disposal System:
O.t.ide Flood Z.;!'%� 0 Municipal 0 On Site Dispoial System
:D AGENT
At-"
Address for Service L)
-?,T<- - �3 q o —
Address for Service:
SF6TION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable 0
Licensed Construction Supervisor:
Address
Signature
Telephone
3.2 Registered Home Improvement Contractor
-r-�C�CAmSLAPC cov-APN�-)
,6nv Name
,
Address
k -a- G") fz:�,Vet— )�j -e-
Signature 11 — \�- Telephone
01
License Number
Expiration Date
Not Applicable 0
1 q -� c)t
Registration Number
gitb�OG
Expiration Date
"D
il
I SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 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 cheeck applicable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition El
Other X Specify ��fui u
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to
Completed by permit applil
Cit., 4
- Mr. s
I . Building
(a) Building 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 Tb BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUaDING PERMIT
1, 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
1, as Owner/Authorized Agent of subject
property
Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print NZ
Signature of q4nZr/Age_nt Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TTMBERS 2 NU 3RD
SPAN
DIMENSIONS OF SILLS
D12vENSJONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
OF FOOTING X
-SIZE
MATERIAL OF CHININEY
BUILDING ON SOLD) OR FMLED LAND
-IS
IS BUILDING CONNECTED TO NATURAL GAS LINE
FORM - U - LOT RELEASE FORM
INSTRUCTIONS:. This form is used to venify that all -necessary approval / permits from
Boards and Departments having junisdiction have been obtained. Ibis does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT Q)� SC 1 �3 (5 —PHONE
ASSESSORS MAP NUMBER 'P �
SUBDIVISION
LOTNUMBER C) C) —
LOTNUMBER
0) `3� -7
STREEND Doe��e- 5 STREET NUMBER 0
OFFICIAL USE ONLY
I 9N F rOWN
................. .......
DATE APPROVED ±M95
0_�
WCS VA7U0N(A:DMMSTRAT0R
DATE REJECTED
TOWN PLANNER
CONMIENTS
FOOD INSPECTOR - HFALTH
SEPTIC INSPECTOR - BEALTH
COMWN'I'S
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERIVIIT
FIRE DEPARTNIENT
COMNIENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
RECEIVED BY BUILDING INSPECTOR DATE
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I tie Commonwealth ofMassachuselts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www-mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibl
Name (Business/Organization/Individual):
Address: A
el _,
City/State/Zip: e
00(",_7
Are you an employer? Check the appropriate box: '
I - A I am a employer with 2-
4. El I am a general contractor and I
employees (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. El We are a corporation and its
required.]
officers have exercised their
3. El 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.i
*Anv annficant that checks box #I must a]— All mit tu
— -1
FAMI
t
Type of project (required):
6. El New construction
7. E] Remodeling
8. [:] Demolition
9. El Building addition
10 -El Electrical repairs or additions
11.0flumbing repairs or additions
12.0 Roof repairs
l3.[2"er'1::)J G D
, se on ow showing their workers' compensation policy information:
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subtr1it a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infibirtriation.
I am an employer that isproviding workers'compensation insurancefor my employee& Below is thepolky andjob site
information
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: �&Zn 020rle_ City/State/Zip: �) - /) C) \,) \kiq�,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as require ' d 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"6iprisonment, 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 cenify u rthepain ofperjury that theinformation provided above *0 true and correct
Signa -is M� -Z f 5
Date- , f
I
Official use only. Do not write in this area, to be completed by city or town offwial
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 M
1nformation 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 hi I re,
express or implied, oral OT 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 all 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."
chapter 152, §25C(7) states "Neither the connnonwealth nor any of its political subdivisions shall
Additionally, MGL Ii ce with the s ance
enter into any contract for the performance of public work until acceptable evidence of comp an in ur
requirements of this chapter have been presented to the contracting authority."
Applicants ation affidavit completely, by checking the boxes that apply to your situation and, if
Please fill out the workers' conVens dress(es) and phone number(s) along with their certificate(s) of
necessary, supply sub-coutractor(s) narne(s), ad
insurance. Limited Liability Companies (LLQ 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
a fir it Th ffi vi
Accidents for confirmation of insurance coverage. Also be sure to sign and d te the a idav . e a da t 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
you to fill out in the event the Office of Investigations has to contact you regarding the applicant
of the affidavit for er which will be used as a reference number. In addition, an applicant
Please be sure to fill in the Permit/license numb ent
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating curr
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 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 number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of InvestigatiOUS
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
L40 k
36'
320
I
)POSE 20
x 1
r 32\,
A
30 -
se�� C-
LOT 4
NERD PL. 8763
L = 150-00'
DALE STREET
PROPOSED ADDITION
cuENT.- BARDASCINO
LOW10N.- 287 DALE ST.,No.ANDoVERMA.
DA M 618105 SCALE: 1'�--60'
PROFrSSIONA ENGINEERS
CHRISTIANSEN &SERGI UMO SURVEYORS
160 SUMMER ST. 1"VERH"MA. 01WO TEL 978-375-0310
02WS BY CHRIS77ANSEN & SERGI INC.
0
DWG.NO.:04082001
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