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HomeMy WebLinkAboutBuilding Permit #411-2017 - 14 WALKER ROAD 10/18/2016 V A�p ' r10RTF� '/�Atu,` BUILDING PE�.�rilT �`��LE° bq�o TOWN OF NORTH ANDOVER ,6 °L APPLICATION FOR PLAN EXAMINATION L� �J] � ^O Permit No#: —1 ' l �©�� Date Received ��°0 ATED cy �SS9CHU5�� Date Issued: /e Zc IMPORTANT:Applicant must complete all items on this page Y-V- - al L0CATIiON s m: PROPEF2fTY OWNER` . _v. __ Orin#: �IGO"Year Structure yes no. MAP',_-_ ___ _ PARCEL: ZONING DISTR1CTrHist'onc District' yes; no _ . _= Machine,Shop Village yesF nog TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition El Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other 4 Septic D 1%Vell�- I=loodplam ❑Vl/eflands. � Watershed'Distriet DESCRIPTION OF WORK TO BE PERFORMED' a Rylj Uq�e �6 a7 ? Identification- Please Type or Print Clearly (_�� .� 1 �' OWNER: Name: i f M Phone: IQ � Address: t 'Jlie� _Contractor Na e: y . -- _ Phone ._ _ Adtlress -- v'_- vy\r - d D _ Ex Date - p Supervisor s Construction L-_icense _ __ _ j_ Fp -A _-- aCl Jie( n. Ex Horne lm ,rovem:en;t License:-. _- _�.._ ._ �A_-_ � _ �__- .-T .P' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ 4�1 — Check No.: �� Receipt No.: :;10':4 NOTE: Persons contracting with egistered contractors do not have access to the guaranty fund Signature of�Agent/Ovvner Signature of contractor Plans Submitted ❑ Plans Waived-0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL, Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE�DEPARTMENT 'Temp eron�site eyes � A$ - - - -� _anon Fir.`e�Departmentsignature/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 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 Permit 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 o 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 a 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 offrom 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 C Location 1 wit', No.441,7-4 ! � - Date 1019wz�7- • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 00 Foundation Permit Fee $ Other Permit Fee $ r i TOTAL $ Check# A ti 'j J u �i� Building Inspector " !/ %40 T#1 Town of � _ 6 ndover lad y h ver, Mass, CONIC NlwKK ��' S U BOARD OF HEALTH Food/Kitchen PERMIT. L D Septic System + THIS CERTIFIES THAT .............1_ .�.�.�I......... ... BUILDING INSPECTOR..�../�,l .�C.. .. ............................. has permission to erect .. ..............Ppperm�itsha buildings o .�. ,�0..... �� Foundation ..... .... ...... ........... . Rough j to be occupied as ..... . . ...... . ..�1!1�,�, .�.'r....... t/k`Jr ,. ReappliczItion E Chimney provided that the person accepting thin every respect conform to the terms oft Final 1 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 CONSTR IONS Rough Service .. . ............. 207 .. .... . Final BUILDING IN..SP TOR 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. i The Commonwealth of Massaehusetts { Department ofjndustx^ial Accidents M = 1 Congress Street,S�rte 100 tl Boston,MA 02114-2017 • �� www mass.gov/dia Workers'Compensation Insurance Affidavit,Builders/Contxactoxs/Electriciaus/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY- please Print Legibly A ' licant Information G qc ( h Name(Business/O /Indi`n rganizationdual): 1 Address: Phone, n,I�(�IJ�P d AMU Q �{`J e City/State/Zip: (1 K. 7 . Type of project(required): Areyou an employer?Checkttie a PP P ro riafe box: em to yeas full and/or part-time).* 7. F]NeV+''donstruotion l, am a employer with P Y 2.F]I am a sole proprietor or partnership and have no employees Working forme in $, ri emo deXi2lg any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Elecixial repor additions ensure that all contractors either have workers'compensation insurance or are sole cays proprietors with no employees. 12�D l?�umbing xepairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors hav6 employees and have workers'comp.inmrancel 14 Other 6.❑We are a corporation and its•officers have exercised their right of exemption per MGL c- ave workers'comp.insurance required.] e no em to ees.[N 152 1(4),and we hav P Y . ,§ 'compensation olicy information: . workers' P . indicating *Any applicant that check's bbic#1 must also fill out the section below showing their w Homeowners who sub.-'. is affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit ttesh such tContractors that check this Box must attaclied'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. tliat is rovidingworkeNs'compensation insurancefor my employees. Below is tree policy and job site manemployerp lam , �, information. �(�GlC{ ( f� ill,l� � �—�"�Ye-T✓1 5 5 Insurance Company Name: 1, /, / 7 /y C�Q (� 7� Expiration Date: Policy#or Self-ins.Lie.#: y `I Job Site Address: I q wC4 4 r (zA City/State/Zip: compensation policy declaration page(showioag the policy number and expiration date). Attach a copy of the workers' Failure to secure coverage as required under il enaltiesMGL c. 2m§he form of25A is a S TOPal rolation WORK ORDERIe by a fiftib up to$1,500-00 and a fine of up to $250.00 a and/or one-year imprisonment,as well p day against the violator.A copy of this statement maybe forwarded to the Office of Investigdtions of the DIA for insurance coverage verification. X do hereby certify er thepains andpenalties ofperjury that the information provided above is true and correct. ,6 Date: Signature- Phone i ature:Phone#: 7 0 �I S official use only. Do not-write in this area,to be completed by city or town official. Permit/License City or Town: # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Person' 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 enferprise,and including the legal representatives of a deceased employer,or the receivet'or trustee 6f an individual,partnership,association or other legal entity,employing employed.-However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant ofthe' 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 b6 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 intp 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry 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 confirmation 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 permit or license is being requested,not the Department of IndustrialAccidenis. 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(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 proofthat 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 permit 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-A4ASSAFE Fax# 617-727-7749 Revised 02-23-15 wwwmass.gov/dia I i OP ID:GOGL A16.R V CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 08/24/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone:978-688-6921 ROME: Hannah Courtemanche,AAI,CISR Macdonald&Pangione Insurance NE 104 Main Street Fax:978-688-5350 C No,EMI:978-688-6921 (FAX, /c No): 978-688-5350 North Andover,MA 01845 E-MAILI hannah@mpins.net Donald Schemack PRODUCER CUSTOMER ID#.DGCON-1 INSURER(S)AFFORDING COVERAGE NAIC# INSURED D G Contracting,Inc ID 646648 INSURER A:Travelers Prop&Casualty CL 25674 428 Pleasant St INSURERS:Safety Insurance Company 39454 North Andover,MA 01845 INSURER C:National Liability&Fire Ins INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN IR TYPE OF INSURANCE D L POLICY NUMBER MMIDDY EFF MOMIDICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE ToRENTED A X COMMERCIAL GENERAL LIABILITY 680-1553R18 05/17/2016 05/17/2017 PREMISES Ea occurrence $ 300,00 CLAIMS-MADE FXI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X JE,PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 ANY AUTO (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS B X SCHEDULED AUTOS 3116538 07112/2016 07/12/2017 BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,00 A CUP-0090153321 05/17/2016 05/17/2017 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER C ANY PROPRIETORIPARTNER/EXECUTIVEN/A V9WC704542 03/31/2016 03131/2017 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 A Property 680-1553R18 05/17/201605117/2017 Lsd/Rent 20,00 Equip DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Fax: 978-688-9542 i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover,MA 01845 ct �. ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Y y * . .>Oitire oft"onsumet•Afrairs&8nsiness Regulation $ur _,t'ons and Sta dards ME IMPROVEMENT CONTRACTOR t istration: tense: CS-001821 120199 Type: .Co.ittruction 5upervisOr. <� �. Eacpltation: 11/1/2017 indivicivai ' DAVID GULEZIAN DAVID P Gu,-tZIAN r '428 PLEASANT ST ' DAVID GULEZIAN NORTH ANDOVER MA 01846 ,,,;,, , 428 PLEASANT ST i NORTH ANDOVER,MA 01845 ,4 Undersecretary Kx irat+Cri' Commissioner 10102/2017 i i I I i I , of -'� officeotConsumcrAffairs&BusinesvRrgniatiaa ! i. Bus �, ,� �� •.t,ons and Sta dards { � OME IMPROVEMENT CONTRACTOR cense: CS-001821 -" egistratfon: 120198 Typo: �.;�-truction Supervisor. i "� Euplration: 11!1/2017 IndEVual r DAVID GULEZIAN DAVID P GULEZIAN j '428 PLEASANT ST DAVID GULEZIAN NORTH ANDOVER MA 01845 t 428 PLEASANT ST I NORTH ANDOVER,MA 01845 tlnderstcrebry 1 f�t.,�.�. �.,,/1,,...... 'Expirationi Comm�s5loner 1010212017 l