HomeMy WebLinkAboutMiscellaneous - 36 PILGRIM STREET 4/30/2018'�. Location 26
No.yl:!!C / Date %-
Hoo 1 TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
,SSACHU Building/Frame Permit Fee $
Foundation Permit Fee $
o Other Permit Fee $
\ TOTAL $
Check # l:� GFS zq
18 12,* 8 8 .,a
Building Inspec,
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TOWN OF NORTH ANDOVER
4
BUILDING DEPARTMENT
AII�LICATION TO CONSTRUCT !U_AI&
RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:f
DATE ISSUED:
SIGNATURE:
Building Commissioner/I or of Buildings Datev/.
-Ute"
SECTION 1- SITE INFORMATION
1.1 Properly Address:
1.2 Assessors Map and
Map Number
Parcel Number:
'rarcJ Number
1.3 Zoning ion:
1.4 Property Dimensions:
Zonin Dislrid Use
Lot Area
Fronts 1k
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
ReqWred Provide
RecjWred Provided
ReqWred Provided
1.7 Weer Supply AG.L.C.40. 34)
13• Flood Zuue Information: 1.8 Soweraee Disposal System:
zom Outside Flood Zoos ❑ Municipal ❑ On Site Disposal System ❑
Public ❑ Private ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
'iStfiCt: Ye mo
2.1 Owner of Record
�{
Name (Print)
Address for Service
"Signature
Telephone
�.2 Owner of Record:
v
Name Print
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Constrycti Supervisor:
Not Applicable 0
5
Licensed Construction Supervisor:
C-90
License Number
%�
(
Expirki nate
Signature
Tele hone
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d
3.2 RegisteredjHome Improvement Contractor
Not Applicable ❑/
(\'`�"
Company Nam
Registration Number
6—
((Date
Expimliioon
Si re
Telephone
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SECTION 4 - WORKERS COMPENSATION (1bLG_I_ C 1142 it 2 u -m -i
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resuFt—
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... ❑
SECTION 5 Description of Proposed Workeheek as
nov&able
New Construction ❑
Existing Building ❑Repair(s)
❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. 0
Demolition ❑
Other ❑ Specify
Brief Description ofposed Work:
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SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed bypermit applicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
(o�� d d 06
3 Plumbing
Building Permit fee t+l 7(b)
0--V
4 Mechanical HVAC
5 Fine Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AG CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
I'Memby au e
My be 1 all o work authorized by this buildu to act on
ig permit application. j
Si iature of Owner Date -
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION r�
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
Land belief _I
int e _
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS iST 2ND 3FuY
SPAN
DINMNSIONS OF SILLS
DMIENSIONS OF POSTS
DRAENSIONS 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
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL 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
c11,S150A.
The debris will be disposed of '
i% + w ec,^_
I
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
E
I lie Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elects icians/Plumbers
Name (Business/Organization/Individual):
Address: ��
City/State/Zip: e Phone #: (6f 29-9 V i5 -3 5 1/
Are you an employer? Check the appropriate box:
L ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. KI am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. t
These sub -contractors have
workers' comp. insurance.
5. ❑ 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. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
. .Y UVFIJ :¢u• MUL WICU" 00x ft 1 must also nil out Ale section below showing their worker's' 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.
xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
e
Policy # or Self -ins. Lic. #:
Job Site
Expiration Date:
City/State/Zip:. t
Attach a copy of the workers' compensation 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-yearnprisonment, 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 hereb, 'cerdfy
Of Ma
t_
ofperjury that the information provided
Oficial 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
e is true and correct
U S•:
Contact Person:
Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employersrservice of another ensation under any contracet o lhire� '
Pursuant to this statute, an employee is defined as "... every pa on inthe
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 ,
foregoing engaged m a Joint enterprise, and including the legal representatives of a deceased employer, or the
of the for
receiver a trustee of ab individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having No Morethan
to do mairntenanceents nconstructioneorthrepair,or the work on suchant of the
dwelling house
dwelling house of another who employs p
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 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
r confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
Accidents fo
be returned r the city or town that the application for the permit or license is being requested, not the Department of
have any questions regarding the law or if you are required to obtain a workers'
Industrial Accidents. Should you
artment at the number listed below. Self-insured companies should enter their
compensation policy, please call the Dep
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 bo t�m
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the app
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
"Job Site Address" the applicant should write "all locations in (city or
policy information (if necessary) and under
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 thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Deparnnent'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.mass.gov/dia
GENERAL. CONTRACTORS
56 Pleasant Street
Methuen, MA 01844
Phone/Fax: 978-688-3944
Company Email: DavidReitano@comcast.net
NumbalContractor@hotmail.com
Proposal
Date: April 20, 2005
Submitted To: Mrs. Velma Wakeman
36 Pilgrim Street
North Andover, MA 01845
Home No: 978-687-0221
lob Description: Siding
We hereby submit specifications and estimates for:
*Existing siding will be removed completely. All debris will be removed from job site.
**Home will be inspected for any decay. Decay will be removed and replaced with new solid material
*Existing shutters will be removed, salvaged and reinstalled.
*Gutter located on front of property will be removed temporarily and reinstalled. Contractor will supply new
accessories such as downspouts, etc.
*Res ext or IIs Masti or W erin lid Vi/n,- idin�gc ludin yvek Ilding der
O on T o S i : Ma ' Ced i ry. Pri pae!
**AII trim including window sills, window casings, door casings, fascia boards, rake boards, etc. will be
covered with aluminum.
**AII overhangs will be covered with vinyl perforated soffit material.
*All Electrical will be removed and replaced properly prior to siding installation. Light fixture located on
rear wall will be removed and replaced with new. Existing recessed lights, in soffit area, will be
salvaged.
t
try ( appro a size, c' , will oved an aced with ne uding 2
r joi O.C. ble-�x, foists to be hung i eel joi oor str re to be s ;ft--e-d-�with4 x 4 po 1 on existing c foo
N
* air 'ng�rs will b pp�ximately 4ewide nstrucf�'w�x i e/
*� Id�ig an;staiir tre k will/4 eif. ris s.1 �niZ�Jlusf&-;--AlLAa*rial
*R g system incl a 4.x -4 -,'Vin - , 2 x 4�andr"ailsi
ar I be pr pre ted.
Standard Siding:
$ 7,200.00
*Contractor is responsible for allowances mentioned, anything that exceeds these
allowances - Homeowner is responsible for.
*Homeowner is responsible for paint and stain.
*Please review this proposal carefully for any items which may be missing. Contractor is not
responsible for items not mentioned here.
*Please do not hesitate to contact us if you have qu ti ns.
,q_.
Thank you for considering us for this project -
David Reitano
Workmanship Completely Guaranteed/Sullivan Insurance
(Please sign and return one copy)
Signature: ate:
Signature:
Date:
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