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Home My WebLink AboutBuilding Permit #482-2017 - 30 MABLIN AVENUE 11/8/2016f(JA P SZ j;%rJ-w &'o ayllt� A404 �,r- BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: 117 Date Issued: 01 (o - IMPORTANT: Anblicant must LO ATiO,NI 0_ %_!d4 Cj -I rPROPERT,Yr OWNER Date Received IV' F' 2.016 wrint IMAP" W- EL,�o-3 _— ,ZO.NING ®ISTRICT: all items on this �yes� / V �S1..ED �6if•NC TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ wo or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septrc ❑ 1/Vell i ❑iFloodplain: ❑ GWetlands i.'WatershedtDistnct `Wafer/Sewer DESCRIPTION OF WORK TO BE PERFORMED: flew Kt -;R . {ems J=�ev.vr �re.9N2 Identifica 'on - OWNER: Name: •J O f0/ Address: /3� 1<49A- i)4_ Alo . kv, or Print Clearly 575---go,7-50 rAdtlress I - " /Ll l r'r� Al/() ��%P Supervisor'ssConstructior License __ C -s Ep IH'hm-PAIl'rtimnrnvamanf3l rranc:i..I Fvr . flatar f r4 ARCHITECT/ENGINEER Address: Phone: Reg. No. . FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Jotal Project Cost: $ of 0061 FEE: $ `f ® Check No.: (0l / oZ Receipt No.,.- NOTE: o.;NOTE: Persons contracting with unregistered contractors do not have: access to the guaranty fund Signature of AgentlOvvne Signature of contractor' a Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r i 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 o''.--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 VOTE: 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 limension 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 MGL Chapter 166 Section 21A —F and G min.$10041000 fine No Doe.Building Permit Revised 2014 Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TypE bF SEWERAGE DISPOSAL Public Sewer Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swu'llning Pools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ 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 COMMENTS Reviewed on Signature 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 `FIREDEPARTMENT Temp,Dumpstereonjsite yes no LQc8t0d.at 12,4'Main;Stredt ~ FireiDepartment,signature/date__. Location 3 y M L t;Y A No. a(1"% Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # (91/ r?' r 31147 �"Building Inspector Owe 0 0' 0 N CD lDD v CD U) O Z CD O CD Z rn cn O cn n 1 A < c = c g _ -Di CD nCD n O� CL C.) z o _O; N -� ql py, O Nl ,rt, (D' C '17 0 0 .� CL m -ti CD 0 N �`D-0 - CD _ CL r c � coto o Q�:�.-. _, o 03 :do Err :t00 CD _ <DCL <o � .coZ •�:w cn CD �o a CD O 0ro, % i i s 1 , f f f I , i i , f { iiif 'The Commonwealth of Massachusetts _ F Department oflndustrialAccidents M ='~ 1 Congress Sheet, ,Suite 100 ' d 0 Boston, HA 02114-2017 o�r www mass•gov/die Workers, CompensationTnsuxance Affidavit: Builders/Contractors/Electricians/lumbexs. TO BE FILED WITH THE PERMITTING AUTgORIT'i'. A lltcanz anzor�ua�x�u C[/G=rl Name (Business/Oiganization/lndividual): f7 Address- 133 rniq tAl /p - t4 b /N rT Phone #: City/State/Zip: /" ' p Y pp p Type of project ()required); Are you an em Io er. Check the ro riate box: I. ❑ I am a employer with employees (full and/or part-time).' 7. ❑ NeVdonstri G&n 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remo delliig any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Q Building addition 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 11.❑ Electrical repays or additions proprietors with no employees. lZUj-Plumbing repairs or additions 5. ❑I am a general contractor and l have hired the sub -contractors listed on the attached sheet 13•, RbOf repairs These sub -contractors have employees and have workers' comp. insurance.T 14.0. Other 6. VWe area 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.] *Any applicant that checks box #1 must also fill out the are doing elm showingrhen hire outside ctheir workers' mpensation policy ntrac ors must submit a new affidavit indicating such t Homeowners who submit•this affidavit indicating they tContractors that check this Bok must attached additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. jam an employer that is providingworkers' compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name - Expiration Date: Policy # or Self -ins. Lic. #:. _ City/State/Zip: Job Site Address: the olio number and expiration date). Attach a copy' of the workers' compensation policy declaration page (showing policy olation by a faib up to $11,5 00-00 Failure to secure coverage as required and enalties2mthe form of aSTOP25A is a criminal rWORK ORDER and as fine of up to $250.00 a and/or one-year imprisonment, as well p py of flys statement may be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A co coverage verification. I do Hereby cert under theepyaains nd/p/Qnalties o perjury that the information provided above is tru/e/lar?J correct. Official use only. Do not write in this area, to be completed by city or town offrcial. 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 Phone Contact Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ernpl6yees. 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 receivbfor 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 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 into any contract for the performance ofpublic 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 thai 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 I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia cJle Wnam IaWtvea tlb d/C� 110aavlcote/7a �L\ Office of Consumer Affairs & Business Regulation THOME IMPROVEMENT CONTRACTOR Registration:. (-1,16025 Type: Expiration:=540720_4S Private Corporation HASHEM CONS T ING:I .JOHN HASHEM ' i3 i.. 133 MAIN ST -- v N. READING, MA 01864 Undersecretary Massachusetts Department of Public Safety Board. of Building Regulations and Standards License: CS440870 v Construction Supervisor AW .t JOHN J HASHEM, JR 136 KARA DR = ii r NORTH ANDOVER MSA 01(845'' do` r—j.,nn IJL— Expiration: Commissioner 07/01/2017