HomeMy WebLinkAboutBuilding Permit # 9/29/2015 t%ORTH ^
BUILDING P IT
TOWN OF NORTH AV
APPLICATION FOR PLAN EXAMINATION _
Permit No#: Date Received �p�
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Date Issued:
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
P� Identif cation- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
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ARCHITECT/ENGINEER Phone:
Address: Reg. No. j
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ � , Itel-
q ,)3
Check No.: Receipt No.: I
NOTE! PPrvnn.v rnntrarthi r with unrPoi.vtPred rnTntpartnry do vent have arrP.v.v to the frlL/Jlpanty fund
The Commonwealth of Massachusetts
Department of IndustrialAceldents
" = I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): - �- �w
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Address: � � t ` ej, ( '
City/State/Zip: S e,11 :`: .. Phone#: GC>
Are you an employer?Check the appropriate box: Type of project Orequired):
1.iJ 1 am a employer with .. : employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑DemoIition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.F1 Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
X am an employer that is providing workers'compensation iusurance for•nzy employees.' Beloiv is the policy and job site
information. r
Insurance Company Name: ...
_
Policy#or Self-ins.Lie.#: ^ � �� 1� , �-• Expiration Date: � -
Job Site Address: . �'° i "� City/State/Zip
: At t✓
Attach a copy of the workers'compe• sation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific do '"" "
I do hereby cf t' u the airs andpenalties ofperjury that the infor^inationprovided above is true and correct.
Si nature: / � Date
Phone#: r° ( f u
Official use onl lib'/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#: