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HomeMy WebLinkAboutMiscellaneous - 8 BELMONT STREET 4/30/2018l X31 Location No. `tr Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ S Foundation Permit Fee $ Other Permit Fee TOTAL Check # a� q'o mu 15369 Building Inspector TOWN OF NORTH ANDOVER. 1.2 Assessors Map and Parcel Number: BUILDING DEPARTMENT )r 6 Map Number APPLICATION TO CONSTRUCT REPAIR, RENOVATE,. OR DEMOLISH A ONE OR TWO FAMILY. DWELLING aw t '. $... fix.. BUILDING PERMIT NUMBER- DATE ISSUED: Zoning District Proposed Use SIGNATURE: Frontage, R Building Commissioner/Inspeadr of Buildings Date SECTION I- SITE INFORMATION I 1.1 Property Address: 1.2 Assessors Map and Parcel Number: &- `►gin o,ni 5` (-e c+ )r 6 Map Number a Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sf) Frontage, R 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided ReqWred Provided 1.7 Water Supply M.G.LC.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone - Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal Sysient ❑ SECTION 2 - PROPERTY OWNERSE IP/AUTHORIZED AGENT 2.1 Owner of Record —Toh n J- Name (Print) Address for Service: W) (,,kL&c,� 685 -6 ir-7 d i 8cl S Signature of Telephone 2.2 v�hc;�tet 5eh� . 31A s Gur-W—O @ me Print Address for Service: 50� - 6 Oy-� CA Signature Telephone . SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: Address i f e Signature License Number Expiration Date 3.2 Registered Home Improvement Contractor Not ?applicable 0- �M�4 2 // Q� Company Name b U 3, ` J C I 1 Registration Number \� D- C—SCA -71SL 11U ll Expiration Dat L z M 0 a® M SECTION 4 - WORKERS COMPENSATION (NLG.L C 1'52 § 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 buildingpermit. Signed affidavit Attached Yes ....... No ....... ❑., SECTION 5 DesciiptiddofPrdp6s6dWork'(checkaU'appficablej New Construction ❑ Existing Building ❑ 1 Repair(s) ❑ Alteratioris(s) Addition 0 Accessory Bldg, ❑ I Demolition . ❑ I Other. ❑ Specify Brief Descri tion of Proposed Work: V-\ 141 Lv , q 0, AJ s v cju C 6 - F.STYMATRn CONSTRurTION rn-,TC Item Estimated Cost (Dollar) to be aimew C� tNllY Com leted b rmit a licant� `No. Fr 1. Building (a) Building Permit Fee CV7-Z Z • 0 o Multiplier 2 Electrical -(b) Estimated Total Cost of Construction - ' 3 Plumbin Build Building Permit fee (a) .X (b� 4 Mechanical. HVAC 5 Fire Protection 6 Total1+2+3+4+$ "7 b 0 Check'Niiiib'er ' .7L`1,11%J1`I /a "VV114:Cd(AU1r1V1i1/.A11111V lV tfL l.'(lMME-1 Ell WH IN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUnDING 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 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 Name Signature of BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 sr SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Dat- e f SIZE THICKNESS X The Commonwealth of Massachusetts Department of Industrial Accidents Office Of I/IYeSGf8U0ilS 600 Washington ,Street Boston, Mars. 02111 Workers' Compensation Insurance Affidavit Failure to secure coverage as required under Section 25A 'o MGL 152 can lead to the Imposition of criadnal penalties of a tine up to 51,500.00 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 (hat a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification Ido hereby ce under the pains and penallies of pepury that the information provided abm,e is true and correct Signature - "I Date Print name official use only do not write in this area to be completed by city or town official city or town: permit./license # ❑Building Departrnent ❑ check if immediatt response is required ❑Licensing Board ❑Selectmen's Office contact person: ❑health Department phone #;' ❑Other Information and Instructions Massachusetts Uenc ra 7:-aws-c idPPT-F-52-'-'scctlon 25YeqWie­s1 -dill emplove 1to provide workers ,.,compensation for their cmployces'i As quoted' from tieemploveels&fi-ni'-�das'ever-v..Oei.,s,bn..ii1'theserOcc�6another` j finder any contract of hire, express or implied oral or x\"Ti c- "n - An employer is defined as an individual, partnership, association, corporation or i offier'legA entity, or anv .two or more of the foregoing engaged in a joint enterprjsc, -and including the legal representatives of a deceased employer. or the receiver or trustee of an individual , partnerslup,association or other legal entity, eniplo'yu-'ig cmployees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupantth! f 0 e dwelling house of another who employs'' persons to dd in'a-l.ntehance:lc,construction oT,3yelp,41T NyqLk,!j d 'welling house or on the grounds :�, , or building appurtenant thereto 'shall not. because, of such employment be deemed W be an employer.',, e �41 MIA I 12 I*biO ln)zoll MGL chapter 152 section 25 o stat iic'*' 0� ensingLagency s�fiall'wfthhold the issuance or renewal of a license or permit to operate a business or to -construct buildings in the commonwealth for a . ny applicant who has not produced acceptable evi den ce,o f,compliance with the insurance coverage required. Additionally, neither the .1 1-a"1011 Ev41.lj ij .�, - - I commonwealth nor any of its polit-ical subdivisions shall enter mtd-,iny contract for &'-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 66hipleiely,",by, checking the boxthatapplies to your situation and supplying com;p'an*'y"name*sz-address and phone numbers along, �ija.ceitificate - o f insurance as '. all, affidavits maybe ep�rtment of IndustrialAtc submitted to the D ;' ideiks fbifcokifinination of msurance coverage. Also be sure to sign and date the atfidavit. The affi&vit should 'bojeturned to the city or town that the application for -the permit or license is being requ 0�� not the Department of Industrial. Accidents. Should you have any questions regarding the "law" or if you ensa 6 are required to obtain a workers' cbrnpi ' �ti­npolicy,.pea�,ecaff theDepartment-at the number. Iisted, below. City or Towns Please be:sure-that .,the ,,,a6,v-rt'I p e"t y­� 'e, Department a space at the bottom of the _jscpMp ",' ' 'ed legibly "61" n— D artmerithas.provi _g you out the the Office -q!', 114'17 '- regarding eg affidavit'f�i Y' ce, of Investigati o*ns' ha�s to contact you ' arding 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 Lnvestigatidns would like to ihhnk, you in advance for you cooperation and.should you have any questions, please do not hesitate to give us a call.. 4 The Department's .address' :telephone: and fax number: 1 The CornrnonweAth,Of Massachbskk "V Department of i'd Office NjuveskalJons:­7 600 Washington Street Boston, Ma. 02111 fax 4: (617) 727-7749 phone fl: (617) 727-4900 ext. 406, 409 or 375 I -AME IRi!'RONIE,,IEN-l' INSI'ALLA'I'ION CONTRACT Sold, Furnished & Installed t t Sales The Horstt: Depot 345 Greenwood Street, Unit I Worcester, MA 01607 Toll Free (80o) 657-5182; (508) 756-6686; Fax: 508-756-2859 Federal iDa 27 CT Lie# 465522 MA Home improvement Conti co Reg. 0126893 Branch Name: !U tL__?•— Uate: a d3 '2 -�� �„'• Branch Number: �.t•--•-- Job #: Installation Address: City State work. Phone:_. Ionic Phone:— 5S#: f IDit Lr s License:: �._ -- 1 it - Y'�' e r{t'TV dome Address: ----------- J, s? State zIp r�eL�� ZL90 (ifdiffercnt from it, stallation Ad les Fruiect TnforDl ctliane UepatliUliomerDrptrt') to f In"), tile owners as thdeliver and perty larratngc fod at httu nstallatiorove �tof all materiaisras described �9 ® contraCt +'ith �_ 7r Incorporated f:erein by reference and made a part hereof. ea 6,G• olI ;lie attached Spec Sheet #- d } 'fIt ,y on re -lass ection of the job, Boyne Depot determines that b try r• * . �t n Ilonle I)epot reserves tl+e right to cancel this contract if, up P calwot perform its abllgalions clue to a structural problem vrith the home or because work required to coluplete the jD was out included in the contract. DEPOSIT PA C'N]ENT OPTIONS f d verification, andlor.creda apProvalJ SALE ANIOUNT S CONTRACT ARIOUNT S.—_—_----- C�c,LKf' �l""DEPOSIT S_o rj BALANCE DUE ON COMPLETION S-- j -q_7 .15%of Contract Amount due upon execution of tills contract (unless project is financed Through 111,cry Chase, in tt'hich case no deposit is rcquircd). totlicaie Payment Method For ItsI.ANC'F. 1)t1E ON COMPLETION r � Subject to un 1' Check. C LVers Clicck or US Postal Service Money OI r rn ayab{e tu'fhe home Depot). 2. Credit Card• and/or other payment options • Circle One Belot., Visa Mastercard Discover American Express ,ionic Improvement loan Bane Depot Credit Card Areliahle Credit; S _,_.-- I III L & IIUCC ONLY) Acct#: Name as it appears un c" tBy my/our signature below, 1/We agree to allow 'Ilie Home Depot to charge the above referenced credit card for the amount indicawd above. fardholdrrs Signature---- _ l-ht1C C 1 If this is a finance transaction, the agreclncllt for financing is contained in a separate document, which is incorporated herein by Reference, and made a part hereof: At-Hotlle Services Credit/Loan Application Ref. # aser on rtificate and bPurcltaser alance duaay grees tis t, iljonedialieanc upon n atii actory casecup nllIPi submion ission of the exece work, luted ComlpieliolCert Certificate, itlomeeDepot will beppaid rin Nil by the lender}. Purchaser also agrees to be jointly and severally obligated and liable hereunder. law as follows: Owners who Fur bless �s;dient`rm�ts.tvC Contractor, exor, at tdtliom tlet guaranty funde, shall rprovesaanseot' MSL Chapter rmits required yI4 A. Unless otherwise noted secure their p within this document, this contract shall not imply that any lienor other security interest has been placed on the residence• etsincluding any lcntiteneat nLenetsigned by bPhparties eeded ormodifedunlessn rii ng it asepa between t)eparties and can tbea Wen NOTICE, TO PURCIIASER rilled-iDo t to ot)Our o rights. Do not signtan), Completion Ctllid to a complete ertiflcale or agreeme slatting tthatfyou aretile tsaco completrnct at file Iliion entire project igd protect before this project 9s colnptee. Law prohibits home repair contractors from requesting m• accepting a Completion Certificate Signed by the owner prior to the actual emnpletion of the work to be performed under the contract. e date or is contract. ht the d business day ater I You mayon elthis an transa ti onaof Ihistice of llrnighlrlofhcre tdgE anyvillbe Iiservice rcharge equal tof25%hof the contract amount sefthe /job b is explan ('ancellat r cancelled by Porcbaser AFTER the third business day. OF TIIIS RMS RBy NIY/OURECEIPT OF AiCOPY OF THBELOW, I/WE AGREETO BEIS CONTRACT AND TWO COMOPLETED UNDCOPIESCOF THE NOTICE OF, CANCELLATION. BY MY;pUR SIGNATURE BELOW, I/WE UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MY/OUR 10MF-- DEPOT AUTHORIZED CRE ONTRACI'ORRTO ViLR fY Aix[)IREV IEWORIZE OMY/OR CREW T RECORD ME Drpar AND RMA FWITH IANSINDEPENDENT CREDIT REPORTING L AGENCY AND RE1-EAnnSE Tf hf At LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS. 0?-26=02An390g-1Rfi"ir Rc Date: Ut, SUBMi'TTED BY: ACCEPTED NOTICE: AUu1TIONAL Date: 02-26-02A] cI:19 CFMIJ r-ric, CONVII IONS AND WARRANTIES ARE STATED ON Tt1E REVERSE SIDE AND ARE PANT UP TIIIS IX1N 1'RAC wl,iic-nnrch Pik Yell.,-C,go- r Yin,: -Saks C—""'t t e6 7O 4 0 i W x o W -a u W. v T � u CL VO cn O z � •� v w p v Ca -a U C ii O U W � O rx C CiiW u. O W U ,�.� to p PG V� y cn C w F a C7 s O cG C ti W w ami co z cn o E cn ui s-, �I 0 0 A 0 co cn w w crw 0 v: o .`c c v C) 0 ' C L H w C C� � vJ: C., a c CO : 'co.... cLv 2 �1 3 Ea . L C, 0C �oa . E c 1.4 30 3 O � 2; U Q1 a E CD a o L L � 3 H N z N m � C m Amo N m ; = o a coQ ��Ho m 0 z ��o c L ya m c o Q = m :a©r=„p N ~• S N m« H m W CG •N fir. Ry=, ♦+ � �... OC E as C ca�o Q N Z O V m p� C CO) a N •� CD = A 'C'L 'C' L s-, �I 0 0 A 0 co cn w w crw 0 f ✓J!C iOd�t�BpX�/g�� fls i./NG(IQ6�id�!!d®/,(6 1 Beard a(Building Re`ulatons and Standards HOME IMPROVEMENT CONTRACTOR Reqk&adon: 928883 EXP :08!03/2002 i Type: Supplement Card Home Depot At-home Servlow + PAUL VENTRE 3200 COSS GALLERIA PKWY 026 ALTANTA, GA 30339 nsp" °� i Administrator ®FyVl�S License124846124"1 M S- p � nob of bra. cam_ - -