HomeMy WebLinkAboutBuilding Permit #458-2017 - 53 MAY STREET 10/31/2016V06 BUILDING PERMIT %AORT#1
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TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
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Permit No#: 7 Dyo/ 7 Date Received 0
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Date issued: 0 t 0 t
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
[] One family
El Addition
0 Two or more family
0 Industrial
0 Alteration
No. of units:
0 C - ommercial
0 Repair, replacement
0 Assessory Bldg
0 Others:
0 Demolition
D Other
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OWNER: Name
AddrimczQ-
DESCRIPTIUN UI- VVL)KM I U Ut Vt:MrUM'v'r-LJ-
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Identifi t* Please Type or Print Clearly
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �Y) FEE: $
Che& No.: Receipt No.: 3146-2-1
NOTE: Persons contracting with unreg s red contractors do not have access to the guaranty fund
Signature_ of Signature of contractor
I
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 - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition N
-31anning Board Decision: Comm
Conservation Decision: Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/signature &Date
Driveway Permit
DPW Town Engineer: Signature:
FIRE. DEPAR)TMENT'=;Temp,�Dumpster.,on site yes
Located�at 124MainsSt�eet - —
Located 4 Osgood Street
Fi'r'e'Departmerit,signature/date
COMMENTS,,
- i
Dimension
Number of Stories
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location,
Electrical Inspector Yes
mast or service drop requires approval of
No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Peimait Revised 2014
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
❑ 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
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
Doe: Building Permit Revised 2014
Location 5 3 Yn 4
No. -"f5-,? - PO/-)
Date /0- 3/- P O! %►
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
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The Commonwealth of Massachusetts
Department of IndustrialAceldents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/(jrganization&dividual):.
Address:
City/State/Zip:_
Are you an employer?
;heck the appropriate box:
p rrcO
1.❑ I am a employer with employees (full and/or pari time).
2. ❑ I sin a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. 15 a homeowner doing all work myself [No workers' comp. in required.] t
4.R'I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors eitherhave workers' compensation insurance or are sole
proprietors with no enplbyees.
5.❑I am a general contractor and T gave hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. Q 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. [] NeVdonstruction
8. [] Remodeling
9. ❑ Demolition
10 [] Building addition
I1.❑ Electrical repairs or additions
III piumbiag repairs or additions
13. ER<o6frep airs
14.[] Other
*A� applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.'
I Homeowners who submit•tlus affidavit indicating they aze doing all work and then hire outside contractors must submit a new affidavit indicating such
tCcntractors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not (hose entities have
have employees, they must provide their workers' comp. policy number.
employees. If the sub -contractors
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Expiration Date:.
Policy # or Self -MS. Lic. #:. 4
Job Site Address: 5 -MCA �- _ City/State/Zip: l��`I
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration. date).
Failure to secure coverage as requited under MGL G. 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance
.10
coverage verification.
Ido hereby certJY under the
andpenalties ofperjury that the information providebove is true � correct.
Official use only. Do riotwrite in this area, to be completed by city or town official.
City or Town:
PermK License #i.
Issuing Authority (circle one):i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
Phone #:
��1,
The Commonwealth of Massachusetts
Department of IndustrialAceldents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/(jrganization&dividual):.
Address:
City/State/Zip:_
Are you an employer?
;heck the appropriate box:
p rrcO
1.❑ I am a employer with employees (full and/or pari time).
2. ❑ I sin a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. 15 a homeowner doing all work myself [No workers' comp. in required.] t
4.R'I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors eitherhave workers' compensation insurance or are sole
proprietors with no enplbyees.
5.❑I am a general contractor and T gave hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. Q 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. [] NeVdonstruction
8. [] Remodeling
9. ❑ Demolition
10 [] Building addition
I1.❑ Electrical repairs or additions
III piumbiag repairs or additions
13. ER<o6frep airs
14.[] Other
*A� applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.'
I Homeowners who submit•tlus affidavit indicating they aze doing all work and then hire outside contractors must submit a new affidavit indicating such
tCcntractors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not (hose entities have
have employees, they must provide their workers' comp. policy number.
employees. If the sub -contractors
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Expiration Date:.
Policy # or Self -MS. Lic. #:. 4
Job Site Address: 5 -MCA �- _ City/State/Zip: l��`I
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration. date).
Failure to secure coverage as requited under MGL G. 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance
.10
coverage verification.
Ido hereby certJY under the
andpenalties ofperjury that the information providebove is true � correct.
Official use only. Do riotwrite in this area, to be completed by city or town official.
City or Town:
PermK License #i.
Issuing Authority (circle one):i
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 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 emplbyees. -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 requi'red."
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 numbers) 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 maybe submitted to the Department of Industrial
Accidents for confamation 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-MA.SSAFE
Fax # 617-727-7749
Revised 02-23-I5 www.mass.gov/dia
:Irons and Stadards
=erase. CS -001821
t:0 +51"LC1ion SUPervisor
F •
DAVID P GU' EZIAN s
428 PLEASANT ST
NORTH ANDOVER.MA 04845 '
Camm,sstCA
on€r L: xr
10/0212017
mcc of C �• ! it
mtr �traira & Basinexy R�ulatioo
141E IMPROVEMENT CONTRACTOR
9 is#ration: 120199
i tIration: 11111,17 Type:
DAVID GULEZLgN Individual
DAVID GULEZIAN
42$ PLEASANT ST
Nptry ANDOVER, MA 01845
Underwrotary