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HomeMy WebLinkAboutMiscellaneous - 330 WAVERLY ROAD 4/30/2018f WA 0-0 At Y ��e Location No. Date TOWN OF NORTH ANDOVER 'A Certificate of Occupancy $ S Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 17496 C-1 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: q k( SIGNATURE: Building Commissio er/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: V G(' 1.2 Assessors Map and Parcel Number: / - Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Re4pired Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record M 2s `Y'{t a A) r+s�I iYp 1r3 0 Name (Print Address for Service Signature Telephone 2.2 Owner of Record: r Name Print Address for Service: t Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed C ruction Supervisor: _,�'77-- License Number Ad " l!/ %✓ (� io St natureV Telephone Expiration Date al 3.2 Registered Home Improvement Contractor Not Applicable ❑ ComNam // Registration Number G� Addr Expiration Date Si nature Telephone TT ■ . ■ ic z O OR SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2506) 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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check au a 8cable New Construction ❑ Existing Building ❑ Repair(s) ElAlterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descriptions of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b rnut a licant x (3FFICIALUSE ONLY• 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction Eke 3 Plumbin Building Permit fee (a) x (b) , (� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number 3 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT, OR CONTRACTOR FOR BUILDING PERMIT /APPLIES I, as Owner/Authorized Agent of subject property Hereby authorize iz"' d� 'lo act on My behalf, in a e tow k,au o y this building permit application. 7';;?7 Signature of Owner t— Date SECTION" OWNE AUTHORIZED AGENT DECLARATION I, 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 Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DMIENSIONS OF POSTS DMENSIONS 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 sy The Commonwealth of Massachusetts Department of Industrial Accidents Office atinuestigatinns 600 Washington Street, 7thFloor B, a� Boston, Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors name: f 2ho !�) < n� /� d� address: x.33 vhf . 6V 00 r 4 (1 Y 1m4 city /Vy /Teri! d (� L le state• /"-9 zin o phone # work site location (full address): ❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel ❑�I am a sole proprietor and have no one working in any capacity. ❑ Building Addition L j I am an employer providi for on this i I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have r anus c w sccare coverage as requirea unuer 6ecn0n ion of MUL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cer under the pains andpenalties er.ury that the information provided above is true and crrect. Signature _ Date �G Print name / "" _J, a/k t7 EQ= Phone # 7 re -6 73 / official use only do not write in this area to be completed by city or town official city or town: permit/license # []Building Department ❑Licensing Board ❑ check if immediate response is required ❑Selectmen s Office ❑Health Department contact person: phone #; ❑Other (revised Sept. 2003) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns' 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. ttj— The Department's address, telephone and fax number:77 The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`' Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 E �:l ii, C C C Q MA•— 'r0 CD CD m m CD c o M o a cma co cc CL C2 as Co Z CD V y O C C C cc y W W W U) w c o W a ' c � C ti O a w° -c, U Cc a a W x WW z V)cn v ii, C C C Q MA•— 'r0 CD CD m m CD c o M o a cma co cc CL C2 as Co Z CD V y O C C C cc y W W W U) c o ' c � C ti O G CO aG W p CE\o mD O 3 a c E w 0 0 ~2 0 ice! m G CL mm � C4qm v,3 o► . g. y m = �� to G p ` c p �: .n�` �� m cc m; • p � CIO C : o, C2 m a��qp 0 Z o ` m .- G o ca G Q = m m ` m C dam" QCQ N p h W G C p t m � •.. G r=as ... �=WC Z d h m� o� :� O =tea.-mF ii, C C C Q MA•— 'r0 CD CD m m CD c o M o a cma co cc CL C2 as Co Z CD V y O C C C cc y W W W U) A.J. Walsh & Sons Inc. 55 Hcasaw S I rcc-I North AMovcr, MA 01;5 Mass. LICENSE' d 022090 Mass. Rl--Gltil'12A*HON H I0.13513 RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. Notice: All home Improvement contractors and subcontractors engaged In home improvement contracting, unless specifically exempt from registration by provisionsof Chapter 142a of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108. Designated Registrant's Name: Registration Number: Salesperson's Name: This agreement is made on of 6 hereinafter called "Contractor" and 0 - hereinafter called "Owner". / 0 (COWMACroa) l 71- 'S - 6 73 7 (PHONE NUMBER) DETAILED DESCRIPTION OF WORK TO BE PERFORMED Contractor agrees to perform in a good and workmanlike manner all work detailed helow. Such work consists of the following: DETAILED DESCRIPTION OF MATERIALS TO BE USED 11. PRICE Contractor agrees to do all work described in Section I for the total price of S ���� W. PAYMENT Payment will be made as follows: 133 11-11 % (S C(W ) upon signing Contract, f°o (S ) upon completion of --' upon completion of . and the rcmaininV4'%(S ) upon verification of the work by Owner and Contractor as having been satisfactorily completed, which verification shall take place promptly after completion. Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwi%e obtain delivery of special order materials and equipment, whichever amount is ereater. IV. COMMENCEMENT AND COMPLETION OF WORK Contractor will not begin the work or order the materials befor�e�e third day following the signing of this Agreement, unless specified herein writing. Contractor will begin t wo ot�pr abo t I d� — (date). Barring delay caused by circumstances beyond Contractor's control. the work will be completed by (date). The Owner hereby aclotowicdges and aerecs that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violadoms of this Agreement.