HomeMy WebLinkAboutBuilding Permit #87-16 - 310 WINTER STREET 7/22/2015BUILDING PERMIT
1 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 3 -?-r
Date Received
Date Issued: r
IMPORTANT: ADDlicant must complete all items on this t)aRe
LOCATION 3J0 \AvA JT.
Print
PROPERTY OWNER &tVVx
Print 100 Year Structure yes
MAPA)1/A PARCEL: . ZONING DISTRICT: Historic District yes
Machine Shop Village yes
`1ORTH
O�tt�.tD 16
16
i y
o
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
ne family
❑ Addition
0 Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
CAepair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic []Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
. DESCRIPTION OF WORK TOp -An f,
P[ERFO
�i f
heJ n.✓ta
Identification - Please Type or Print Clearly
OWNER: Name: Oo4; 6 Phone: � 7$ --�-175.5 771
Address: Li 1 at +n u
Contractor Name
Address:
Supervisor's Construction License: CS -0751va4 % Exp.
-Home Improvement License: / a 6Oo7 S
- 9 z < - �,V
Date: -
Date: 9)31 090)6
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED OST BASED ON $125.00 PER S.F.
"e Cost: FEE: �/ � , M
Total Project • � _ �� �Q S
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted 11 Plans Waived 11 Certified Plot Plan 0 Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer 11
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well El
Tobacco Sales ❑Food
Packaging/Sales El
Private (septic tank, etc. 11
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on
Sianature
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:
LOcatea 334 usgooci zjtreet
r- PRA " k,!Tj- - T- km- 0', —V) 6'm '0,' t -e— ,onxsite, eyes, -
at, -,1,241 M a iheSftebi,
epA Qffigh�ts�i' !I t �tj r
?I _e/d,4te-,
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
MGL Chapter 166 Section 21A —F and G min.$10041000 fine
NOTES and DATA — (For department use
❑ Notified for pickup Call Ema
Date Time Contact Name,
Doc.Building Pennit Revised 2014
No
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
TE: 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
r< 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
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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Location
No.Ul— 2-cW5
Check # 9S�
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $- jr
TOTAL $
Building Inspector
<on=� C _
O � =h <F 5: � ti
'm � m
o 0 CL C-) 3 ;uz c
O ��� N
N fl
rt= m �)
oo
h
N CD �p- N cD 2
0 CL 03 CD v
a = C
cm � CL �
o
CO
W =r CD '
S. CD -a0 to
.
CL
to
Dov', -
cD o, .a
CD
-4- �
O S S rt c a
u, :3
n � to
< COL OR ur
O O O
C CD
r
w CD
_S
VJ W
CD
CD
LA
CD .�
N
.a
=o.
-
z
o
T
m
a
-mp
m
j
•� zr
O
�,
v
CD
m
m
D
H
m
0
�,
•
D
C
G)
N
m
n
0
�,
?
3
C
o
c
o
c.
0
=$w
C
p
W
z
G1
0
m
-a
Et
n
N
f�D
o
o
CL
--
C)
N
3
O
D
m
p
O
x
_
L> CD
D =
C
O 0• ,�
O
O O
O O
SU
�
�
O
n
0
ZN
C
CD
z�
r. L
rr.r�
m�
.
�O
CC/)-
cam.
�'
Q
rn
-0
vM
Cl)
<
-im
�•
C
cn
0
Z
CDO
CD
0
O
ic
CD
n
O
CD
Z
—1
z
CL
CD
D
�
5'
=
b
N
CO
cD
I
z
CD
0
o
X
c
CD
z
y
<
n
O
<on=� C _
O � =h <F 5: � ti
'm � m
o 0 CL C-) 3 ;uz c
O ��� N
N fl
rt= m �)
oo
h
N CD �p- N cD 2
0 CL 03 CD v
a = C
cm � CL �
o
CO
W =r CD '
S. CD -a0 to
.
CL
to
Dov', -
cD o, .a
CD
-4- �
O S S rt c a
u, :3
n � to
< COL OR ur
O O O
C CD
r
w CD
_S
VJ W
CD
CD
LA
CD .�
N
.a
=o.
-
z
o
T
m
a
-mp
m
j
•� zr
O
�,
Ln
CD
m
m
D
H
m
0
�,
:33.
0 O 3.
D
C
G)
N
m
n
0
�,
?
3
C
o
c
o
c.
0
=$w
C
p
W
z
G1
0
m
-a
Et
n
N
f�D
o
o
CL
--
C)
N
3
O
D
m
p
O
x
_
L> CD
D =
C
O 0• ,�
O
O O
O O
�
3
o�,
O
rt
-
z
m
T
m
a
-mp
m
j
o
c
D
(An
Z
m
O
�,
Ln
o
c
m
m
D
H
m
0
�,
o
c
s
D
C
G)
N
m
n
0
�,
?
3
C
o
c
o
c.
0
=$w
C
p
W
z
G1
0
m
-a
Et
n
N
f�D
o
o
CL
--
C)
N
3
O
D
m
p
O
x
_
E
u
6a
ZALANSKAS CONSTRUCTION
34 BIRCH ROAD
ANDOVER NIA 01810
978-8355194
GREG.ZALANSKAS(&COMCAST. NET
QUOTE # 24
Order #
Date 7120!2015
OUOTE SUBMITTED TO: WORK TO BE PERFORMED AT:
Name Gemmell
Name SAME
Address 390 Winter Street
Address
-state Nord► Andover MA
Planned Date
Phone
email
Job Description:
Replace front entry door Doors being installed Before August 1st
Cost of door 3585,001 labor $550.001 disposal $30.001 trim $125.00 /reinstall existing storm door$50.00= $1340.00
The front door will be a Therma Tru fiberglass system with 4 fights, reuse existing storm tf possible .
Replace garage door with a 20 minute fire door.
Cost of door $588.001 labor $550.001 disoosal $30.001 trim $80.00 = $1248
work completed 6/15
repairs to house, new weather stripping on 2 doors, new weather stripping on garage door, repair cements floor in garage door, repair ceiling in garage
stain block water stains in garage, fix basement window, secure racing on basement railing.
All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and
specifications submitted for above work and completed in a substantial worlananiike manner for the sum of: $3,323.00
PLEASE MAKE CHECK OUT TO ZALANSKAS CONSTRUCTION
with payments to be as follows Due at completion $3323.00
Submitted by: GREGORY ZALANSKAS
OF ZALANSKAS CONSTRUCTION
Acceptance of Proposal
e above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized
do the work Specified above. Payments will be made as outlined above.
UL
Please note: TI# proposal may be withdm by us if not accepted within 30 days
��s
The Commonwealth of Massa. chusetts
z . Department oflndustrialAccidents
f I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual):
Address:
City/State/Zip: A- v\
Are you an employer? Check the appropriate box:
Phone #: T _t6 - 3 5' S J
1. ❑Tama employer with . employees (full and/or part-time).*
2. �1 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 employees and have workers' comp. insurance.:
6. ❑ 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. ❑ New construction
8. [-temodelirig
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12. [] Plumbing repairs or additions
13. E] Roof repairs
14.N -Other 4-,e
*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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' 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. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compepsation 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 DTA for insurance
coverage verification.
I do hereby certify under thepains andpenalties ofpetjury that the information provided above is true and correct.
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 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 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'
compensatiori 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. Anew 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 bum 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
Cllanfll- 111111"
-PAN A\�NVANA/�\INT
ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(M"s"M
SR
TYPE OF INSURANCE
PRODUCER
Doherty Insurance Agency, Inc.
P.O. Boz 1985
21 Elm Street
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
POLIO XWRATION DATE IMM1100"
Andover, MA 01810
INSURERS AFFORDING COVERAGE NAIC B
INSURED
Zalanskas Construction
Gregory Zalanskes (DBA)
34 Birch Road
Andover, MA 01810
INSURER A: Arbella Protection Ins Compan
NIStIREA B:
NNSUREA c:
wsuRER O:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
SR
TYPE OF INSURANCE
POICVNUMBEA
PO IE
POLIO XWRATION DATE IMM1100"
LIMITS
A
GENERALLIABNJTY
8500022056
01IMS115
005116
EACH OCCURRENCE A0110,000
0 i0RENTED S1100AM
)( COMMERCIAL GENERAL LIABILITY
CLAM MADE EE OCCUR
LIED EXP (A"aro poison) SS 000
PERSONAL& ADV INJURY 51 O00 000
GENERAL AGGREGATE $2,000,000
GENL AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG S2,000,000
X POLICY MPCT LOC
AUTOUGHLE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT S
(Ea )
BOOIIYWWRY S
(Pm poiea�)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY S
(Pa)
HIREDAUTOS
NONOWNEO AUTOS
PROPERTY DAMAGE S
(Potaodeed)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC S
ANY AUTO
AUTOONLY: AGC> S
EXCESSAIMBRELALIABILITY
EACHOCCURRENCE S
AGGREGATE S
OCCUR M CLAIMS MADE
S
S
DEDUCTIBLE
S
RETENTION S
WORKERS COMPENSATION ANDWC
STATU. 01H
EMPLOYERS! LIABILITY
ANY PROPRIETORNARTNERIEXECUTNE
E.L. EACH ACCIDENT S
EA_ DISEASE - EA EMPLOYE S
OFFICEPAIEMBER EXCLUDED?
O OesGlee unaar
GAL
E.L. DISEASE • POLICY LIMIT I S
OTHER
DESCRI nwu OF OPERATIONS/ LOCATIONS I VEHICLES IEXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Job: Gemmell
Covering operations usual to Zelanskas Construction...
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
I ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
IEREOF, THE ISSUING INSURER WILL ENDEAVOR YOU" —W_ DAYS TYRITTEN
TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
NO OBLIGATION OR LIANUrY OF ANY WHO UPON THE INSUREA, ITS AGENTS OR
ACORD 25 (2001M)1 of 2 NS32351AN32350 _ OML N 0 ACORD CORPORATION 1988
IMPORTANT
It the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate folder in lieu of such endorsement(s).
It 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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACDRD 25-S (2001168) 2 of 2 oS32351110=0
� L CJI�LCZ61CLCfLLC1CI�b
CJfze �aynnrnza�ruvecc� o�
Office of Consumer Affairs & Business Regulation
ME IMPROVEMENT CONTRACTOR Type.
wp!
stration: 126875ration: 813f3Ct.individual l
GREGORY J. ZALANSKAS
GREGORY ZALANS",-'
34 BIRCH RD
ANDOVER, MA 01810 Undersecretary
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS -072201
TIti
GREGORY J ZAI)kN
34 BIRCH RD
Andover MA 01810
.�
Expiration
Commissioner 03/18/2016