HomeMy WebLinkAboutBuilding Permit #651-16 - 30 AMBERVILLE ROAD 11/24/2015,fill /;r,,/,ve-- D / --> - / - /-S
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BUILDING PERMIT
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
'qMPORTA-NT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
El Addition
0A.0ne family
0 Two or more family
El Industrial
0 Alteration
No. of units:
0 Commercial
0 Repair, replacement
0 Assessor v Bid.
El Others:
Ll Demolition
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Ydentification - Please Type or Print Clearly -73
OWNER: Name: rat-AE)s Phone:
Address: a&>`� A�f PVIA
ARCH ITECT/ENGINEE
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 contracting ivith unregiWered contractors do naa
ot have access to the gurntyfund
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No. Date O�
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee'
TOTAL $
Check #6 W
29732 Building Inspector
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Plans Submitted ❑ Plans Waived.[] 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 m U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes
a
Planning Board Decision: Comments
1
Conservation Decision: Comments
Water & Sewer Connection Permit
DPW Town Engineer: Signature:
Umension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: lies No
MGL Chapter 166 Section 21A —F and G rnin.$100-$1000 fine
NOTES and DATA. — (For department apse)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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
o Building Permit Application
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
u Certified Surveyed Plot Plan -
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
DTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o 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
ATE: 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
Doe: Building Permit Revised 2014
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Carlos Guzman
30 Amberville Road
North Andover, MA 01845
Account Number 10034
Quote Number 100342575
Issue Date 11/20/2015
Due Date 5/18/2016
11/20/2015
11/20/2015
Install Timber Wolf TPI35 PEllet Insert in to existing manufactured fireplace (insert supplied by
customer)
4" pellet liner kit with lower end double wall connections
None
None
1
1
500.00
675.00
500.00
675.00
11/20/2015
INstall Englander PDVC freestanding pellet stove in basement w/ OAK (stove supplied by customer)
None
1
650.00
650.00
11/20/2015
3" PEllet venting for basement install
None
1
450.00
450.00
-
Sub -Total:
$2,275.00
Total:
$2,275.00
Balance Owing,
$2,275.00
QUOTE ONLY
Permit to be paid for by customer
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Page 1 of 1
32av< j"
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
,F Boston, MA 02114-2017
y�; >•` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Name (Business/Organization/IInndiividL'al)):
Address: W v
City/State/Zip: 0_��
Are you an employer? Cheek the appropriate box:
� vl�
ov, A 07-7&6( Phone #:
am a employer with __,._% : employees (full and/or part-time). x
2. FJ I am a sole proprietor or partnership and have no employees working for me in
any capacity_ [No workers' comp. insurance required.]
3.. ❑ I am a homeowner doing all work myself, [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have ernployees and have workers' comp. insurance.t
6.FJ 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.]
Type of project (required):
7. C] New construction
8. EI Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12. F-1 Plumbing repairs or additions
13. [] Roof repairs
14. ❑ Other
' Any applicant that checks box 41 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 state whether or not, those entities have
employees. Ifthe sub-cbi&aci6rs have employees,'ttiey must provide their workeis' 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. Lie. #: 1�'J d7s� Expiration Date: fl�7
Job Site Address: -0 , (�� �� City/State/Zip: M�
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.
I do hereby certify under
]t�l�i ains and penalties of pej jury that the information provided above is true and cot rect.
-- - Date: I — 2.O — i -_
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
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 o-1 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 -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 cant' 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 fok 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
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 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 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 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-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
KIM
CERTIFICATE OF LIABILITY INSUPRAN CE Rooi
[1117120i f
rAISCERTIFICATEISISWED ASA MATTER OF INFORMATION ONLY AND CONFERS No RIGHTS UPON THE CERTIFICATE 14OLDM THIS
M71FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, EXTEND OR ALTM THE COVERAGE AFFORDED BY 7REPOUCIES
REPREWNTATIVE OR PRODUCER, AND THE CERVFICATE HOLDER.
terms and conditions of the poll cy, cortal n poUd 9 a may to quire an ondor earn art, A statement on tNa "Mil Cate does not,confor dahts to the
"I'"ficAtO holder In lieu of wch ondarsemort(s).
COMPLETE BENEFIT SOLUTTONS/PAC
PO BOX 33015
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PAINTCRAFT INC DSA PELLET STOVE SERVICE
51 WINTHROP ST UNTIT 6
REHOBOTH KA 021E9
ClAy"'IrATE — Se ISSUED OR MAY PEPTAINTHE INSURANCE AFFORDED uy THE POUCIES DESCPJBED HEREIN IS
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The ACCIRO nem. 4nd logo am registered memo of Acogo
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Massachusetts Department of Public
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of Building Regulations and Standards
License: CSSL,_105742
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TREMOIYT STREET p '
REHOSOTH MA 02769
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