HomeMy WebLinkAboutKITCHEN REMODEL (2) ORter'
14
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
a
Date Issued: A C WOO
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Ll One family
Li Addition r Two or more family Ll Industrial
Ll Alteration No. of units: n Commercial
XRepair, replacement E Assessory Bldg Ll Others:
Demolition El Other
1,7— 7'
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Identification Please Type or Print Clearly)
OWNER: Name:
Phone: Cris- R96 -;)-7,458
Address:
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons conte with nregistered contractors do not have acceWtthe g d
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Northeast Custom Kitchens Estimate
474 Main St.
Wilmington, MA 01887 Date Estimate#
1/24/2015 0424
Name/Address
Rob Levy
83 Mill Pond Rd.
N.Andover,MA 01845
Project
Description Qty Rate Total
Kith Kitchen Cabinets per design. 11,588.00 11,588.00T
Removal of existing cabinets,and countertops. 775.00 775.00
Install new cabinetry and all moldings. 2,625.00 2,625.00
Debris disposal. 300.00 300.00
In home delivery of new cabinets. 350.00 350.00
Removal of existing wall between living room and kitchen. As long 1,500.00 1,500.00
as wall is not structural and no beam is needed.
Update kitchen electrical. Basic work. 1,300.00 1,300.00
Basic plumbing and reconnection of appliances. 950.00 950.00
Subtotal $19,388.00
Sales Tax (0.0%) $0.00
Total $19,388.00
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All dimensions size designations 20 �j),I This is an original design and must Designed: 1/17/201
given are subject to verification on TECHNOLOGIES not be released or copied unless Printed:6/20/2015
job site and adjustment to fit job applicable fee has been paid or job
conditions. order placed.
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Levey,Rob All Drawing#: 1 No Scale.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02H4-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers-
TO BE FILED WITH THE PERNIITTING AUTHORITY.
AoRlicant Information Please Print Le 'bl
OJAName(Business/Organization/Individual): V
Address: b
City/State/Zip: �J�' �i Phone#:
F—am
er?Check the appropriate box: Type of project(required):
J
erwith � employees(fulland/orpart-time).* 7. ❑New construction
oprietor or partnership and have no employees working forme in $. Remodeling
[Nq1 workers'comp•insurance required.]
9. Demolition
3.E]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 11.[]Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12.Q Plumbing repairs or additions
5 Q 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 14.Q Other,
6.❑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.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'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.
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 subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: nl 1 1 Expiration Date: 10
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation 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 verification.
Ido hereby cerci der the pai andpen that the information provided above is true and correct.
Signature: Date:
Phone M
EOonly. Do not write in this area,to be completed by city or town officiaL
n• Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#•
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supersisor I &2 Family
License: CSFA-067737
GARY S mcmwiAN '
111 ARKANSAS ROAD.R. WIN' '
TEWKSBURY MA-
Expiration
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Expiration
Commissioner 08/17/2015
�e Yoa-�narza�uoealf�a;b /tcJar�
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Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration; 126257 Type: Office of Consumer Affairs and Business Regulation
xpiration: 5f7l2016 Private Corporatio 10 Park Plaza-Suite 5170
COUNTRYSIDE CUSTOM BUILDERS,INC. Boston,MA 02116
GARY MCMILLAN
111 ARKANSAS RD. �v �
TEWKSBURY,MA 01876
Undersecretary No alid without signature