HomeMy WebLinkAboutBuilding Permit #402-2011 - 25 PETERS STREET 11/12/2010 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: —.2 e//- Date Received
,
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION 5toe, 1+ �n� d✓
Print
PROPERTY OWNER 5 4iii3
y rint
MAP NO: 10 d PARCEL: �1 ZONING DISTRICT: Historic District yes z
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition i'(wo or more family ❑ Industrial
A-Ateration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic Vil1 �h ®Floodpl 0 Wetland p® �W atershe
d_Distret y
a ,
®W'afer Sewer w
DES CRIPT ON OF WORK TO BE PERFORMED:
I y �d-Q-0o V0 Vie. I' f r) CA� JA f 5, q-tt U-4*r3
i-�i 6a rd pf&C �e w lib uv \n �Ivj rov" w I`A
`fid� Ig q vimag w ko tii Zed
Identification Please Type or Print Clearly 7 T/ V006 Pb
OWNER: Name: V'"CC7 0 Phone:
Address: 60 t_vl Lie- izi
CONTRACTOR Name: "ba Phone:
Address: 7
' ld�1(
Supervisor's Construction License: C .f�2) Exp. Date:
Home Improvement License: Exp. Date: ' T
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: $ ��JC-0 0.C56 FEE: $ .;P .2 —
Check No.: Receipt No.: -':2. 1 (f 65
NOTE: Persons contracting with unregistered contractors do not have access to the u anty fund
=:i,�+Ws^ �
Signature of,Aant/Ownerr a. ature ofcontractor
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL E
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales
❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ 1
z
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
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DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑ +
COMMENTS
I
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH- Reviewed on Signature
COMMENTS VV
1
1
D
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
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
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® Notified for pickup - Date
Doc:.Building Permit Revised 2008
I
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
❑ Flo or/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable) 1
❑ 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) g
❑ 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
( ) p
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
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Doc: Doc.Building Permit Revised 2008mi
Location
No. .?aii Date /o
NORT► TOWN OF NORTH ANDOVER
3 O�
a y
Certificate of Occupancy $
��s••"°''�<�
Building/Frame/Frame Permit Fee
s aMust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # L�2G d
2 �
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"' BuildinSpector
NORTH
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Town Andover of �: 6 F
tt
AK dover, Mass., 2/i0
COC H IC HE WICK �� 1
- A�RATED
`S U BOARD OF HEALTH i
Food/Kitchen S
T D
PERMIT
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Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT...............................................s G ��S
... ................................................................... Foundation
has permission to erect......................................... buildingss......r.1............................................. Rough
Ch
p' � � � ti
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Chimney
to be occupied as......... ..........�..........:............r... .��.�F..........:- ........ .�� . 4..�.-.....r.'...... ..............................
provided that the person accepting this permit shall in eve respect conform to the terms of thea licatiah on file in
p p p g p every p PP 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 `
Final y
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION TARTS
Rough
.................E...... . �� �'••✓�t,.n,-.-............................................ 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 Smoke Det.
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428,PLEASANT;ST
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HOME IMPROVEMENT CONTRACTOR
iRegistration ;120199 .
Expiatn1/1/2011 7r# 290224
Type s -Incl vI S Mf,a ■
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IDAVID GUL'EZIAIJ i
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DAVID GUL`LIAfiI
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428 PLEASANT STS ' o t, t
1 NORTH ANDOVER M- -8, +,Undersecre nary'
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08127/2010 11:5Z I'AA I aro 000 ---
ACCP CERTIFICATE OF LiA�i�.ITY iM URAiVCE �"'�`'att
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! THIS CERTIFICATE 1S MUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC HOLDER.TH15
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*9(t acate hntder 16 are ADDITIONAL INURED,the jRkRias)rnrrd be . If SUBROGATION IS WAIVED,suWC-f to
the term and condtNons of the policy csRain policies nuy require an andotserrmiL A stent an this eattticate does rot wafer rlphts to the
rertl iam her•oldin Neu of such endorsesn®rt(s)-
r °Rowccre MacDonald&Pangione Insurance Agency
non (978)fi66 9921
P.O.Box 428
104 Main Street EAM
North Andover,IMA 01645 DA050T12172516
APlDRQiI%I SAS! MAIC it
m tw G Ontr2( tng,Mt: ; TRAVELERS CA5UAl.TYBSURETY CO OF IL 19046
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D f' tSt. IIRER6c SAFETY iN[ MNITY!N IURANM CA ' 83618
N Andover,AAA 01645 c: RICAN HOME ASstJRANt�:COMPANY _ 16360
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COVERAGES CERTIFICATE NUMBER.- REVISION NUtI4aER:
THIS IS Td CERTIFY THAT THE P (CIES OF INSURANCE LISTED BELOW HAVI"gE13V ISSUED TQ THE INSURED A1AM�ABOVE FOR TiiE PdtICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR=4DITION OF ANY CONTRACT OR OTHER DOGUMEhfT wrrH RESPECT TO WHICH T1dis
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TmE POLICIES DESCHBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM'S.
WF POLlcvexl'w TTm OF ui "°" 100000
A sera aLUAesmr I.660.1553RIO-1 ACJ-10 05117 10 05J9712011 �FMEN� s
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CLANSMAot 10 OGWR �100000tt
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-- FRL1pI1CTS-CO DPAr c $ 20OMW
DENL AWKGATE UM APPUM PM $
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3116536 07112121}10 07/12/2011 r�IN�slNote u►art $ 1 oD0000
g AUT B►ELUAK" (Ea i)
AW AUTO RMLY M1URY MwALL OWNED AUTOS SLY INJURY(Far atddwll 3
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CEtRTi TE HO ER
CANCELLATION
SHOULD ANY OF THE AWO DIIISCRISED pMK4 6®E CANCELLED BEFORE
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TEXPMAMN OM IWENEop, MOTH wILL me OELIIIRRED W
ACCORDANCE Wff"THE POLICY PWMKML
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go-MeACORD CORPORATION. All rights r gs®rvAd.
ACORD 25(2` ) TIM ACORO ram and loge aro@ rag"tst "id 1naft of ACORD
D.G. Contracting Inc.
Additions, Kitchens, Baths , Decks , Home repairs ,Excavation work
Commercial fit ups* finished basements* Dumpsters
paved C-tu(.eziavL. T>resLdewt
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 and Alexandra lappas
25 peters st
n Andover. Ma
Nov. 5, 10
j Remove and dispose of existing cabinets in the kitchen, Install new cabinets and
counter per Doyle lumber proposal.
Remove and dispose of tub, install new fiberglass tub and wall set. Sheet rock around
the tub and paint the walls.
Remove one picture window in the bedroom, install one double hung window that meets the
egress code. Build one closet in the bedroom and build a 11 foot wall to make the
bedroom smaller by 4 feet. Open up the archway from the bedroom to the living room,
sand the hardwood floor where the wall was and poly that area.
Total cost $18, 500. 00
I authorize David to do the above work X DateX P_
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Aar,
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print`Le ibl
--pn Legib
Name (Business/Organization/Individual): Iry l wl�`i'F
Address: °N--V � eu �
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City/State/Zip: Ad ve 0)//h_Phone#: q7 G F?V 9 7
Are you an employer?Check the appropriate box: Type of project(required):
1.EU-fam a employer with 2 4. ❑ I ain a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.E:] I am a sole proprietor or partner- '
listed on the attached sheet. t ❑ 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.❑ 1 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.]f employees. [No workers' 13.❑ Other
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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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: Q "Y'I,.eL h g vre,(1.55 v V qW-e (d
Policy#or Self-ins. Lic.#: c-1 4 a4 9 S7 y 107 Expiration Date: 7 /�
Job Site Address: 9"I / e k 7 �j / City/State/Zip: Yoduye V ywq
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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 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 be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I
I do hereby certify underth p ins and penalties of peijury that the information provided above is true and correct.'
Si nature: 0� �I ( Id
Date:
ly
Phone#:
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#•
L
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 apartments 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-contractor(s)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 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 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 permit 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.
I
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 pen-nit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pen-nit/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 proof that a valid affidavit is on file for future pen-nits 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 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,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia