The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #023-15 - 103 SECOND STREET 5/1/2018 NORTI{ w- BUILDING PERMIT 0 �tLen 16 q r� ►°2i 070 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION H Permit No#: �� Date Received 7q ODRA7ED .FP,`.(5 SSCUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNERa Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no . _ d®. p Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ®moo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK WE PERFORMED: G4y 1r )1 m J4 e_ 6d ejp/e r "iti t-e- vatt lam' IdeutifI do - Pie a Type or Print Clearly OWNER: Name: (�J id Phone: 7 7F -�6dl 7 '?/ Address: &AfJ� Contractor Name:_ Iil4 WMVPhone-. Address: l Supervisor's Construction License: G 4 1 Exp. Date: r 5 Home Improvement License: J�-o ) q '7 Exp. Date: f r S 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: $ ( /"i ®®� FEE: $ Check No.: �-��J Receipt No.: 2 7 7 NOTE: Persons contracting with unregi t red contractors do not have access to the. ranty fund ;Signature of Agent/Owner Signature of contractor i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans El TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinnning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit (t Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No i DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building pp uildin Permit Application n ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (if Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. ��? > Date 7 //y . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# (/ ,. B4ding Inspector ciORTF� Town of a t : ,, Andover No. * _ - hver, Mass, LZ Zz�e Coc"Ic"IWICK A. ��OO Pay S lJ BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ........ ...1.<.6�.t:.Uf.... �,✓,,1�`!.![. BUILDING INSPECTOR r'' Foundation has permission to erect .......................... buildings on ..�...,.s... G... P?1... ... � . .......................... Rough to be occupied as ...... .....D�.,�vb� — .� '. ..�r� lj� ............ Chimney .... ... ................... .... ........ .....,................ provided that the person accepting this permit shall in every respect conform to t�(e terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION,,oSJARTS Rough `�-�/a� .......................... Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until. Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. NORTH Town of 2 _ Andover O �' 0 *fth ver, Mass, LAKE COCHICHIWICK 7a A�N.tTEO S U BOARD OF HEALTH r" Food/Kitchen PERMIT T LD Septic System THISCERTIFIES THAT ............................................................................................................................ BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ....................... ..................................................... � Rough to be occupied as i ..........................................................................................................:........................ irrmn y provided that the person accepting this permit shall in every respect conform to the terms of the application ina on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. P MBING INSPECTOR-` VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 4 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service .............................................. ................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises:- Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Butner Street No. Smoke Det. •11-ima _nt of PO'c . "utlding Regulations and ► flnttCllCtN !t�ltl(1CCtltut r 1 License: CS-001821 DAVID P GULE4 N . 428 PLEASANT ST " 6 N ANDOVER MA 01845 _ J . JJ ►� t�� Fxn,T, , 6orremss,log 10/02/201 e `- . office of Consumer Affairs&Business Regulation 'HOME IMPROVEMENT CONTRACTOR t Registration: V�� , �e9 120799 Type: Expiration: 11/1/2015 Individual y • DAVID GULEZIAN DAVID GULEZIAN 41 428 PLEASANT ST i...s __ NORTH ANDOVER,MA 01845 Undersecretary The Commonwealth ofMassachnsetts , _ bepartrnent o,f IndustriglAccid6nis Office oflnvesfigations 640 Njasftgton.Street .Foston,MA 02111 wwlvmass gov/ciia Workers'CompensafonbsuranceAffidavit:Buifders/Conti°actorsYIectriciansll'Xri A. heanthformation. Please Printte 'bl 'Name(Businessforganization&,Rvidual): C61 ( ! ra c (Wq --Po C Address:_ City/StafelZp: Are you anernployer?Check the appropriate box: Type of project(required): 1, am a employer with 1' 4. El am a general contractor and I s. []Now constr ction f employees(fizll.and/or pax- , 0 .* have liiredthe sub-contractors 2.[] I am a sola pxopxietor orpartnex listed on.the attached sheet. 7• El Remodeling Ship and`havena.employees These sub-contractors have 8. Q Demolition woxldng forme in any capacity. workers'comp.insurance, g, []Building addition [Nb workers'comp.insurance 5. ❑We are a corporation and its 1O.F1 Electrical repairs or additions required.] officers have exerdsed.their 3.❑ X am a homeowner doing all work right of exemptionporMGL 11=p i'lumbingrepairs or additions myself.[No workers'comp. c.152,§I(4),and we have no 12,0 Roofrepairs insurancerecluited.�i employees.[No workers' 1g,[]Other comp.insurance required.] KAny applicantthat checks box4l must also fill out the section below shovringtheir wbrkers'compensationpolicy information. f-Homeowners who submitihis affidavit indicatingthey ge doing anwork and then hire outside contractors must submit anew affidavit indicating such. TCo>tEractors that checkthis box must attached an additional sheet showingthe name of the sub.-contractors andtheir workers'comp.policy information. lain an emp7oyerthatisp�ovidingworkers,compensation irasuraneeformyemployees Relotvisthepolicyandjohsite information. n 0 InsuranceCompanyNama% C• !� Policy#or S elf'-ins.LIG.#: G L 7 (O Expiration Date: 2 S fob Site Address: d City/State/Zip: T Attach a copy of the workers'comp ensation-polley declaration page(showing the policy number and expiration-crate). Failure,to secure coverage as xequixedunder Section 25A ofMGL o.152 can lead to the imposition of crhi alpenalties of a ;Cue up to$1,50 0.00 and/or one-year imprisommnt,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 b e forwarded to the Office-of- Investigations fInvestigations of the DTA.for insurance coverage verification. X do Xtereby certffi under t ins and penal'taes of perjury that Me information provided alcove is true and eorrea - Signature: Date: �� Phone#• Cl 7Y V official use only. Do not write in Mis area,to he completed by city or town official. i City or Town: PermitlLicense# fssuing Authority(circle one): 1.Board of Health 2.BuildingDepartm.ent I City/Tom Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person M the service of another under any contract ofbixe, express or implied,oral orwxitten:' An amploydis 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 ofa•deceased em to ex'.or the red eiver ortrdstee of an individual,partnership,association or other legal entity,employing employees However the owner of a dwelling Douse having notmore than three apartments and who resides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction ox repair work on such dwelling house or onthe grounds or building appurtenant thereto shallnot because of such employment be deemed to be an employe•." MGL chapter 152,§25C(6)also states that"every state or local lio®nsing agency shall withhold the issuance or renewal of a license or permit to operate a business or to cousix•uct buildings in the commonwealth for any applicant who has not pro duced•acceptable evidence of compliance with the insurance coverage required:' Additionally,MGL chaptex 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave,beenpresentedto.the contracting authority.." Applicants Please fill out the workers'compensailou affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)and phonenumber(s)along with their certificate(s)of insurance. L' mutedLiabili Companies tY p anz s(LLC)or Limited Liability Partnerships(LLP)with no employees other than,the members ox partners,axe notrequired to cany workers'compensation insurance. If an LLC oxLLP does have employees,apolicyismquired. Be advised that-this' affidavit may be submitted to the Department of Industrial Accidents fox confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. 1ho affidavit should be returned to the city or town that the application for the permit or license is being requested,not the D eppartment of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain,a workers' compensationpolicy,please call the Department at tho number listed helow. Self insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit fox you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure to JM inthe permit/license number wbichwM be used as a reference number, fn addition,an applicant thatmust submitmultiple permit/11cense applications is any givenyear,need only submit one affidavit indicafing current policy information(ifnecessmy)and under"Job Site Address"the applicant shouldwxite"all locations in ci ( t3'or town). A`copy of the affidavit that has been officially stamped or marked by the city or town may be pxovidpd to the applicant as Pr' of that a valid affidavit-Is'on file fox future p exmits or licenses. Anew affidavit must e filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves eta)said person is NOT required to complete this affidavit. The Office of Xuvestigations 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 Department's address,telephone and fax number: T.he CaMox� at�Z ofyas aeftseli - Depa�e�� Of e offnvodt[ga-Care. 6.04 Wmbh gtm&jeet )3ostonx AM 02111 Revised 5-26-05 Fay, 617-727-7749 wt�vd?2.a�s,g9��c�ia 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 at: 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. Also, note Permits are required under Fire Prevention laws Chapter 148 Section l OA. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant -7-��/ f Date e/t• his lv 5S a e- -jAeI 61IX4,28e 4 ree-