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Home My WebLink AboutBuilding Permit #548-11 - 133 MAIN STREET 2/1/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:-5;�L'g Date Received Date Issued: J ORTANT:Applicant must complete all items on this page ` 4 LOCATION vAo Printf - PROPERTY OWNER. Nfint MAP NO: PARCEL: ZONING DISTRICT: Historic District ye Machine Shop Village y"10 TYPE OF IMPROVEMENT PROPOSED USE P Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Other f - - ❑ Demolition Floodplain4 ®Wetlands �,®1Watershed;DJstrict' i J - t[7 Septlq ❑IWell� ,�� t�. I }�:f _ k , V DESCRIPTION O WORK T0,13E P gr I I vv I +Idenra cation Please Type or Print CIearly) OWNER: Name: �"'1 ffAPhone: Address: C� `� 1 110 c7p `e 2� - I >?�15 CONTR-ACTOR Name: �G/y (� � Phone: (� yvvq' Address: Supervisor's Construction License: �� Exp. Date: Home Improvement License: ( � Exp. Date: I I �'C) p ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000-,o 1000 00OF HE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cast: $ Q� FEE: $ Check No.: Receipt No.:e�7 3a :7— NOTE: Persons contracting with unregistered contractors do not have access to the guara ty fund Sinafure'ofcontracfor> 117 Signature:of A`ent/Ownerx, ::: = Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tamun assa eBod Art ❑ Swimming Pools ❑ - 1� g Y � Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS S FOR OFFICE O C USE ONLY E INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS I a 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date I COMMENTS i 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 DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I Ll Notified for pickup - Date Doc:.Building Permit Revised 2008 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 Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ - Copy Of Contract ❑ Floor/Crossection/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 N.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 . OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals lit the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording is be submitted with the building application Doc. Doc-Building Permit Revised 2008mi Locationzg? S� No. _ Date NORTIy TOWN OF NORTH ANDOVER F w ♦ i , Certificate of Occupancy $ sCHU Building/Frame Permit Fee $ c3 00 �� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # „�-41� 23bi3 V� Building NORTH ,9 TO" of a 6Andover oti .. . .? �� LAS OL lover, Mass.,C2 l O COCMICMEWICK t `s BOARD OF HEALTH Food/Kitchen .PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .......... ............ ..!�. K............................................................................................... Foundation has permission to erect........................................ buildings on .....1.. ....Mor.ty1........... .......................... Rough N 6 ( C�. Q.!!..�. !41.1. Chimney to be occupied as...... ch provided that the person accepting this permit s all In every respect conform torthe terms of the application on file in Final 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 �-� PERMIT EXPIRES IN 6 MONTHS Final Ute' / UNLESS CONSTRU ON STARTS ELECTRICAL INSPECTOR Rough ... ........................................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE j Smoke Det. i Stateline Electrical, INC 110 Jackson Street— Rear Methuen, MA 01844 Telephone: (978)-682-5395 Fax: (978)-682-8563 E- Mail: StatelineElec a-)_aol.com D.G. Building, INC January 31, 2011 428 Pleasant Street North Andover, MA 01845 Attention: David RE: 133 Main Street North Andover, MA David, Please note that of this afternoon Stateline Electrical has replaced the emergency battery unit cabinet& charger, this unit supplied power the remote heads located in the Back Entrance, Stairwell and 2"d Floor Hallway. At this time all heads are functioning properly. If you have any questions please feel free to call at anytime. Sincerely, Stateline Electrical, INC Philip J. lannazzi C6ns,IX n r1`iSOhs`anif�C¢lt7fl ,r t tion,S� . RFfe#sse,""CS :1821 N _ LttTSe 77, EAVIbp� GULEZIAN '~ 428 PLEASANT . : . . . :ST , 1 N ANDOVER � MA 01845. . - .. 607Ece ti COn iiypRQyEMEyT tfairs&Business r - > gists 10 `r COM Regulation EXPiratiort 'ar`. 20199 TOR TYPe err 1�-�112D11 DAVIDGVLEZIq;j d�v1dual - Tr#'290224 DAVID GUL 428EZIgN7 . NDRTLEASgNTS :� } HANDpVER, o f _ r Undelleeretary „� The Commonwealth of Massachusetts r F Department of Industrial Accidents 72 Office of Investigations 1 1 1 Y•f 1 600 Washington Street •�� Illdlf ; Boston,MA 02111 =; www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Le ibl I6JName(Business/Organization/Individual): U( J Address: t,(01 ��-4 City/State/Zip: V Q�( �6( (1405—Phone#: 9, y7 q 7 Are yo n employer?Check the appropriate box: Type of project(required): 1. I am a employer with 9— 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. I � E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] employees.[No workers' comp. insurance required.] 13.n Other *Any applicant that checks box#I 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors alid 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: r «h �dm ash N c Policy#or Self-ins. Lie.#: W (—Ad 7 (11/-)7 Expiration Date: Job Site Address: ?] VYQ�46� City/State/Zip: �l 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-year imprisonment,as well as civil penalties in the fonn 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t pains and penalties ofpeijuiy that the information provided above is true and correct.' Signature: Date: ^b l Phone# q 7 ,T l ,�Q f7 q7 Official 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 Contact Person: Phone#: 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 in the service of another under any contract of hire, 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 of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three aparhnents and.who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house 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-contractors)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 cavy 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 Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen-nit or license is being requested,not the Department of Industrial Accidents. Should you have any,questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. 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 and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple•,pennit/license applications in.any given year,need only submit one affidavit indicating current policy infonnation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or 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 pen-nit 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial accidents Office of Investigations 600 Washington Street Boston,MBIA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749- www.mass.gov/dia www.mass.gov/dia 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: 6M (Location of Facility) Signature of Permit Applicant Date erf hqs Iv �5sde. D.G. Contracting Inc. Additions, Kitchens, Baths , Decks , Home repairs ,Excavation work Commercial fit ups* finished basements* Dumpsters 1�-6iVW CIULeZLOIA, PrESWEMIC 428 Pleasant st. N Andover Ma. 01845 Office 978 689 4797 Home 978 683 0397 Fax 978 686 6337 Cell 978 815 7745 Ma. License # 001821 * Insured * Home improvement # 120199 Dgbuilding@aol.com James Lappas 133 Main st N Andover Ma Jan 29, 11 I authorize David Gulezian to install a double hung window at 133 Main st N Andover at an estimated cost of $950. 00. XDate