HomeMy WebLinkAboutBuilding Permit #802-2017 - 325 BOSTON STREET 2/27/2017BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR.PLAN EXAMINATION
'--
Permit No#:�09-a-ul7
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
ResiOtial
Non- Residential
0 New Building
YOne family
11ion
0 Two or more family
0 Industrial
1, Alteration
No. of units:
0 Commercial
0 Repair, replacement
0 Assessory Bldg
0 Others:
0 Demolition
El Other
Septic
0 71.66 d"plairi ❑Wetlands
"Va't'rsRed Disirf1f6t
_D_Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly'
OWNER: Name: A21C.,,K ;1e 01 4-;w-J:&A —Phone:
Address: 32 5- 'SOS-/V/I/ Ste 4, Vp 0
A714t
66ntraid-t& Phone . %7f.A 0.
Address:
5
Supervisor ,t 7,7- D
7
Home Imp n s
- Qqt6.
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Y"
.,__,rotal Project Cost:$ Z� FEE: $
Check No.: 36 7? Receipt No,: I
NOTE: Persons contracting with unregistered contractors do not have: access to the guaranty fund
Si "natiae_of�Agerit/Owner F
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Plans Submitted ❑
Plans Waived El Certified Plot Plan ❑ Stamped Plans ❑
' yPFbF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Private
Tobacco Sales ❑
_
Food Packaging/Sales ❑
(septic tank, etc.
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature_
CONSERVATION Reviewed on Signature
COMMENTS
TH
COMMENTS
Reviewed on 2
46. cdM�La4Q_ seQ�- c
t&.r9A 0 CC��
5 V 5� Cry
`1 C C �-
r 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:
FF�IRE DEPARTMENT - Temp Dumpster on site yes
ted at 124. Main Street
Fire Department signatureldate
COMMENTS-
Locatea jd41
no_
Street
dimension
Number of Stories: 3 Total square feet of floor area, 'based on Exterior dimensions.
Total land area, sq. ft.:
f
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
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.
r
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
of 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
40TE: 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
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 7038550.00
m
$ -
$
850.20
Plumbing Fee
$
106.28
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
106.28
Total fees collected
$
1,162.75
325 Boston Street
802-2017 on 2/27/2017
finish walk up third floor
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10 �j r-
Wil.
The Commonwealth of Massachusetts
_ r . Department of IntiustrialAccidents
1 Congt'ess Sheet, Suite 100
Boston, MA. 02114-2017
www mass.gov/dia
Wot:kere Compensation Insurance.A,ffidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMIT'�G ,A.UTSORITY.
9, S
A I1carLElIlJluxLua�xv,a f��
Name (Business/Organization/Individual): �/���
<< //1� iJ1
A ddress: Y' b 13011 19
City/State/Zip' 1 1Jr}� !'� &1 kO Phone #:
Are you an employer? Check the appropriate box:
1.❑ lam a employer with employees (full and/or part-time)."'
2. ❑ I am a sole proprietor or Partnership and have no employees working for me in
any capacity. [No Workes' comp. insurance required.]
3.[] I am a homeowner doing all work myself [No workers' comp. insurance required] t
4.F]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-coutractos listed on the attached sheet
These sub -contractors have employees and have workers' comp. insurauce.t
6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c.
1 4 and vde have no empldyees. [No workers' comp. insurance required.]
,9(d9F6
Type of project (required);
7. X60,Modelhig
�'donstraction
8.
9. ❑ Demolition
10 ❑ Building addition
11.❑ Electrical repays or additions
12TQ:Ptumbiftg repairs or additions
13-. [] Rb6f repairs
14.[] Other
*Any applicant that checks b1.ox #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who sub�this atfiiaaviindicatingched do shehey are eeett showing the,ame of thall work and then hire e outside
c ntra to s and state wtors must heth t a r or not thseow affidavit en ties have
al
TContractors that checkinas
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
X am an employer tlaat is providing7vorker�s' compensation insurance for° my employees. Below is the policy and job site
information. C.
Insurance Company Name- Q
La Ex-1.1�1g
�� � (,P � piraiionDate:
Policy # or Self ins. Lic. #:
Job Site Address:
? 7 t! ta,��'('Dt.� City/State/Zip: 1 b �1�1 PP
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
by a flAb up to
Failure to secure coverage as required as ivil enalties?m the form ofra STOPal violation
WORK ORDER and. a fine of up to $200.00 a
and/or
one imprisonment, as well P
cat may be forwarded to the Office of Investigations of the DIA. for insurance
day against the violator. A copy of this statem
coverage verification.
pains an ofperjury that the information provided above is true and correct
X do Iiereby certify under tlle.
official use only. Do notwrite in tlsis area, to be completed by city or town official.
Permit/License #
City or Town:
issuing Authority (circle One
1. Board of Ifealth 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 enterprise, and including the legal representatives of a deceased employer, or the
receivet'or trustee d 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 opdrate 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 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. B e 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
Iudustrial-Accidenis. Should you have any questions regarding the law or if you are requured to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self -insura'nc'e license number on the appropriate Trod.
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
ACC>RV® CERTIFICATE OF LIABILITY INSURANCE
DTE(MMMo
17
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(les) 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
NAME: Peter Bevelaqua
Norwood Insurance Agency, Inc.PNONE
(978)372-5921 F No: (978)521-0242
293 Main Street
ADDRESSyeterbevelaqua@comeast.net
INSURERS AFFORDING COVERAGE NAIC d
EACH OCCURRENCE $
INSURERA:Safety Insurance Company 39454
Groveland MA 01834
INSURED
INSURER s Hartford Underwriters Ins. -ARWC 80411
INSURERC:
Gmelch Industries, Inc.
61 Lamoile Ave
INSURER 0:
INSURER E:
AUTOMOBILE
Bradford MA 01835
INSURER F.
COVERAGES CERTIFICATE NUMBER:CL1722102703 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.
N R
L
TYPE OF INSURANCE
L
5 SR
POLICY NUMBER
POLICY EFF
MIDD
POLICY EXP
M
LIMITS
A
X COMMERCIAL GENERAL LIABILnY1,000,000
CLAIMS -MADE Fx_1 OCCUR
12411,0022238
6/10/2016
6/10/2017
EACH OCCURRENCE $
DAMAGE TO RENTED
PREMISES Ea occurrence $ 50,000
MED EXP (Any one person) S 10,000
PERSONAL & ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ JEOT F1 LOC
OTHER:
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OP AGG '$ 2,000,000
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS TOS
COMBINED SLE LIMIT $
Ea ac 'dent
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
pR�OPER DAMAGE $
$
UMBRELLA LIAB
EXCESS UAB
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTIONS
$
8
WORKERS COMPENSATION
AND EMPLOYERS' LIABILI Y
ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
OBNECCH1743
1/11/2017
1/11/2018
P OTH-
STATUTE ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE $ 100,000
E.L. DISEASE --POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required)
in ".VI
mjkphoenixhomes@comcast.ne
Town of North Andover
Building Inspector
North Andover, MA 01945
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Bevelaqua/PB
01988-2014 ACORD CORPORATION. All riahts rpservnd
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 (2ouol )
Massachusetts Department of Public Safety
�® Board of Building Regulations and Standards
License: CS -079450
Construction Supervisor
MICHAEL J KOULOHERAS
77 PLEASANT VALLEY, Fbi
AMESBURY MA 01913 !�
Commissioner
Expiration:
08/06/2018
'. - ��e rpry��z�ua�r[aralfl9o����aasnc�r�a
Office of Consumer Affairs & Business Regulation
�9 —=AOME IMPROVEMENT CONTRACTOR
egistr'ation169157 Type:
Expiration 5120#2047. Individual
MIC HAELKOULOHERASL4
TI
MICHAEL KOULOHERAS#-,,="
77 PLEASANT VALLEY, RD.
AMESBURY; MA 01913 Undersecretary
i