HomeMy WebLinkAboutBuilding Permit #775 - 1000 TURNPIKE STREET 6/2/2010 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:• tate Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION /00/ 74q,�,v�'l��
Print
PROPERTY OWNER 6,jrCR,f.P t) LLA��
Print
MAP NO:&7C PARCEL: ZONING DISTRICT: f Historic District yes n
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bid Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer A)Q Q
DESCRIPTION OF WORK TO BE PERFORMED:
--SY-.4w
IL
Identification Please Type or Print Clearly)
OWNER: NameQ Apy tL(-ACc 1-4- C Phone:22-A?7-3/UZ-
Address• Q/l/0 Ue p f4- I?Zt
CONTRACTOR Name: /lQz� j,(,��° j,tl Phone;60� fit' 2-
Address:41V2 MAW !k 'e± el"6140,W 01A 03f&'57
Supervisor's Construction License: /a'Z j3/ Exp. Date:_ 42
Home Improvement-License: �!40 A
A A407oY Exp. Date:
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.
Total Project Cost: $ FEE: $ 2,
Check No.: �DD Receipt No.: P-3 24
NOTE: Persons contracting with unregistered contractors do not have access t e uaranty fund
- .. __
signature of Agent/Owner_ Signature of contracto
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools
i
Well Tobacco Sales Food Packaging/Sales-
Private(septic tank,etc.
Permanent Dumpster on Site �
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY I
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments.
Conservation Decision:
o Comments
Water & Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT£- Temp Dumpster on site yes, . �no
Located at 12'4 Main stree
Fire Department signature/date
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 No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine f
i
NOTES and DATA— (For department use)
❑ Notified foricku - Date
p p
Doc:.Building Permit Revised 2008
I
i
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/Crossection/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
Doc: Doc.Building Permit Revised 2008
Location
No. Dates--�—
�o�TM TOWN OF NORTH ANDOVER
� 9
Certificate of Occupancy $
�'�s'••• E<�
Nus Building/Frame Permit Fee $
nc
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
232 ,:- 6 _
wilding Inspector
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
l
(Location of Facility)
Signature of Permit Applicant
1-3)16
Date
The COMMOnwe¢Zth of Massachusetts
Department o f£radustrial Accidents
Office of Investigations
600 YPashine ton Street
Bostorz, MA 02111
www.mczss govl
Workers' Compensation Insurance Affidavit: guilders/Contrac
Applicant Information tors/Electricians/Plumbers
Please Print Legibly
Name (Business/OrganizadonMdividual): C�
Address:
City/State/Zip: j
Phone
Are you an lemployer?Check the appropriate box:
1.❑ I am a employer with 4. ❑ I am a general contractor and IT
roject(required):
employees(full and/or part-time).* have hired the sub-contractors construction
2• am a sole proprietor or partner_ listed on the attached sheet $ odeling
ship and have no employees These sub-contractors have
working for me in any capacity. workers' OMP. ' g• ❑Demolition
p insurance.
[No workers' comp. insurance 5. ❑ we are a corporation and its 9. ❑Building addition
3.❑ required.] officers have exercised their 10•❑Electrical r
I am a homeowner doing all work right of ex repairs or additions
myself. exemption Per MGL 11.❑Plumbing repairs or additions
Y [No workers'comp. c. 152,§1(4),and we have no
insurance required.] t employees- [No workers 12.[]Roof repairs
comp.insurance required.] 13.0 Other
t try walicant that checks box.:ml must also nil out fue section below:.how:^...f«
Homeowners who submit This affidavit indicating the are doing » . b �worlxWs'comY oc Y t:c� c oa
'Contractors that check this box mL
,�a: a"wok and Tl1ea'hire outside contractors mmM.submit a new affidavit indicting such.
attache, additional sheet showinP the name of the sub-contractors and their workers'comp.policy information.
I am an employer that�•pronging workers'compensation insurance or
information. .f my employees, Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
. Expiration Date:
Sob Site Address:
Attach a copy of the workers,compensation policy declaration page(shoCity/State/Zip:wing the Policy number
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal matron date).
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties of a
of up to$250.00 a day against the violator. Be advised that a co Penalties a the foam of a STOP'WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification, of statement may be forwarded to the Office of
I do hereby c u er the penalties o er u
fP ! rJ thrrt the information provided above u true and correct.
Sign re-
_....
Phone#:
Official use only. Do not write in this area, to be completed bj,city or town off ciaL
City or Town:
Permit/License#
Issuing Authority(circle one):
1.Board of Healtb 2.Building Department 3. Ci /Town p
6. Other ' Clerk 4. Electrical Inspector 5.PIumbiab Inspector
Contact Person:
Phone#r:
ORTH
Town of Andover
ILL- ,
No. 7C
4 C% dower' Masso,
0 t�_ LAK
CoC1
41
CH EW
E D P? C5
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT.......... ........11��C ...........ZY4e............................................................ Foundation
has permission to erect........................................ buildings on ..... ......... ............... Rough
to be occupied as..�? ....... ....0.4..... ........ ..... Chimney
provided that the person accepting this pe mit shall in eve respect conform tdthe terms of the app ationile in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUT ARTS Rough
.... Service
BUILDING i6;i6R
71,
Final
Occupancy Permit -Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Town of North Andover 0% RTM
Building Department 20.11 E° 16�6�p
1600 Osgood Street
North Andover MA 01845 - R "
Tel: 978-688-9545 Fax: 978-688-9542
0h #
O
9A coc"Ic.k...`y1
DEMOLITION OF BUILDING AFFIDAVIT OR4TEO PPP
'9SSAC HUS��
DATE S" /
OWNER'S NAME &ADDRESS �(°���
t4 Z 1
LOCATION OF PROPERTY TO DEMOLISH .� O/
DESCRIPTION T Aw e111106 betQ ,&if9,e
CONTRACTOR'S NAME &ADDRESS
DEPA NT SIGN-OFFS
DEPT. OF PUBLIC WORKS -WATER: SEWER: 101 2�;O�
DEPT OF CONSERVATION HEALTH DEPT eptic Vel
HISTORIC COMMISSION
GAS N
ELECTRIC !-J C -/2 9,
TELEPHONE Lc S 7 Z feu
CABLE I" M -%A
t
TAXES Ct4rrtm FY I D ��Il I S�Q}{ i�n,�al d a� of - -b4Wi�e
POLICE -
FIRE Idd
EXTERMINATOR �T S
DUMPSTER- ON/OFF STREET
DIG SAFE NUMBER
DATE REC'D BLDG. INSPECTOR
Doc.form demolition of building affidavit
ivlussachusetts- Department of Public Safety
Board of Building; Regulations and Standards
Construction Supervisor License
License: CS 102931
Restricted to: 1 G
ROBERT MESSINA
44 GREAT POND DRIVE
BOXFORD, MA 01921
Expiration: 8/31/2012
('unmiis'sit)nell Tr#: 102931
SPO ✓�ze -�an�meo,zurea/� o���aaaac�ivae�
�\ Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration `1,,84829
Expiratlgtt11}9J 011 Tr# 290708
ulp
TYPe+ I �YaCo
0: tion
MESSINA DEVE Q i
4 - PANY INC.
ROBERT MESStDIA-' €_— i
44 GREAT PONDER
BOXFORD,MA 0192 ."'':�'l
t.-`i: Undersecretary
PROPOSAL 4245
KIDDER BUILDING &WRECKING, INC.
247 Main Street
PLAISTOW, NEW HAMPSHIRE 03865
Ph: (603) 382-1422 Fax: (603) 382-3697
PHONE DATE
TO: MESSINA DEVELOPMENT 978-887-3102 5/14/2009
ATTN: BOB MESS INA JOB NAME/LOCATION
HOUSE / (2) STALL GARAGE / SHED
44 GREAT POND DRIVE 1001 TURNPIKE STREET
BOXFORD MA 01921 N. ANDOVER, MA
JOB NUMBER JOB PHONE
978-887-3103
We.hereby submit specifications and estimates for:
>
COMPLETE DEMOLITION OF STRUCTURES AT THE ABOVE REFERENCED LOCATION.
FRACTURE SLABS AND COLLAPSE FOUNDATIONS IN PLACE.
REMOVAL AND DISPOSAL OF ALL RELATED DEBRIS TO AN APPROVED DISPOSAL/RECYCLING FACILITY.
PRICE DOES NOT INCLUDE ANY SITE PREP. , BACK FILL, COMPACTION, ASPHALT PAVING REMOVAL.
NOTIFICATION BY KBW.
PERMITS BY GC.
CUTTING AND CAPPING OF UTILITIES BY GC.
POLICE AND FIRE DETAILS BY GC.
SITE FENCING AND SECURITY BY GC.
SAFETY AND EROSION CONTROL BY GC.
DUST CONTROL BY KBW. SUFFICIENT WATER HOOKUP FOR DUST CONTROL BY GC.
PRICE IS BASED ON SALVAGE, AND CURRENT DISPOSAL/FUEL COSTS.
KIDDER WRECKING IS NOT RESPONSIBLE FOR TESTING (ASBESTOS SURVEY) , REMOVAL OR DISPOSAL OF ANY
ASBESTOS, HAZARDOUS WASTE, OIL TANKS, FREON RECLAIM, FLORESCENT LIGHT TUBES AND BALLASTS.
We ose hereby to furnis
PCO h material and labor—complete in accordance with the above specifications,for the sum of:
p
12, 450.00
Twelve Thousand Four Hundred Fifty and 00/100 Dollars dollars
)
Payment to be made as follows:
PAYMENT TERMS TO BE NEGOTIATED.
IF PROPOSAL IS ACCEPTED, PLEASE SIGN AND RETURN COPY. THANK YOU.
All material is guaranteed to be as specified.All work to be completed in a professional
manner according to standard practices.Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders,and will become an extra Signature
charge over and above the estimate.All agreements contingent upon strikes,accidents or
delays beyond our control.Owner to carry fire,tomado,and other necessary insurance.Our Note:This proposal may be
workers are fully covered by Worker's Compensation insurance. withdrawn by us if not accepted within 4 5 days.
Acce tance f Proposal—The above prices,specifications and con-
dions area satisfactory
ti �and are hereby accepted.You are authorized to do the work as
specified.Payment will be made as outlined above. Signature
Signature
Date of Acceptances
a^a
MESSINADEVELOP
DATE
Acn. INSURANCE BINDER 05/13/10
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
_ _ _.._ --- - _.`.-_ _. -__'--_-_... _.
PRODUCER - PHONC 978-47S-OZtiO -COMPANY -- BiNOER o
f.aA1C _0_..-,.-"_......- ._.—.__ EFFECTIVE 'TBD
EXPIRJ.710N —_
FAX.
a+{ c:N,��_ 9784750303 Western World Insurance _
Doherty Insurance Agency,Inc. _DATE___._ . •., TIME
P.O.Box 198505/13110 X A+.t
— 12 01 � 06/13110
21 Elm Street Pill _ Laor+
Andover,MA 01810 - ._. T HISBINDER IS ISSUED TO EXTEND COVt_IiACE.IN THE ABOVE NAMED C01 PANv
CODE: SUB CODE: PcR^XPIRC7G POLICY g.
AGE" 9 )
AGENCY _ 4034 DESCRIPTION OF OPERATIONS(VEHICLES+PitOPERTY{Includin location
CUSTOMER ID' - - -
INSURED Messina Development Co.Inc.-& Empire Drive,North Andover,MA 01845
Orchard Village.LLC
44 Great Pond Drive
Boxford,MA011921
COVERAGES' LIMITS
TYPE OF INSURANCE COVERAGOFORMS I DEDUCTIBLE- COINS AMOUNT
PROPERTY CAUSE";OF LOSS l i
UASIC- UROAD SPEC i
i
GENERAL LIABILITY E I�AcII rrcuF,ii_;`�E :1,000.000
X C,OG4dERCIAt.3Er+F:Y.,L.LIABILITY DAMAGE TO s 100,000
_ REP;TED.!'i"IEaISES__ "
---j @Lt,Ife5 r.V.OL j.X }OCCUR MED LXr (Mr cne Person) )s.1,000`PERSONAL&ADV INJURY G 1.,000,000
X BIIPD Ded;1000 GE F AL GGR GATE S Z,000,OOO
.---_ 'QETRO0:.T'EFOR C,;]MS"'!AC_. ..PRODUCiS•CO!S-iGE;.GG s2,000,000____.._
AUTOMOBILE LIABILITY
COMBI-NED SRUGLE U!.IIT 5
_ ANY.id!TO ' BODILY 1111URY(Per person) 'S
' ALL O'h:JED AUIGS BODILY INJURY iPer nmetent) s
SCHEDULEDAOTOS _PROPERTY DAMAGE _f s_
egRED AUTOSi EDfCAL PAYMENTS.
RSON.'.L U=JURY FOOT__,_
� J - U.`43:SURQD'.1CTOR4T 4..J 5
AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES ` I SCHEDUL'r.0 VEHICLES ACTUAL CASH VALUE
COLLISIOti- ..__-_— ; i SIA TED AMOUNT '.is
s OTFi_R TIlA:';i:(:L."
GARAGE LIABILITY A
+
U+G C.•:LY•EA ACCIJEt:T !a
IYL-1
AGGREGATE 15
EXCESS LIABILITY
_ EACII OCCURRENCE_ 15
UMBRELU FORM AGGREf;A7-
7 OTHER Ti".';U%1HREl1.A*C7.'.! !RETRO DATE FC7 Cl;,l!.1S+JAtiE. �5"eLF-Q:51:R_D RETECi'IOt 'S .
L:%STATUTORY UGt1T5
VJORKER'S COMPENSATION E.L.:ACH ACCIDENT i 5
--- .__.t. ..
AND
-
EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE $
E L.DISEASE-POLICY LVAII 5
SPECIAL FEES .5
.CONDITIONS
OTHER iAxlls is
COVERAGES
ESTI!.it.JEsTO TAL PRE%IIU:.I i 5 ""
NAME&ADDRESS
MORTGAGEE ADDITIONAL.INSURED
Enterprise Bank&Trust Co. (--
8 High,,Street ---� _. ----- -- _.
I LOAN
Andover,MA 01810 19549&,19551
AUTHORIZED REPRESENTATIVE
ACORD 75(2001!01)1 of 2 #21315 NOTE:IMPORTANT STATE INFORMATION 0
N}2EV .SE SIDt L 0 AC.249" ORPORATION 1993
\ The Commorzt neaft of hfessachuse&r
"� Deartmerzt ofindustrial Accidents i
f
6 , Q91ce of Investigations
11.14� ' 600 a,"ashhWion Street
BQstorn, MA 02111
- c� r7�rnas,�gov/die
Workers' Compensation fnsizrance.AHidavit: Ruilde
Applicant nformattion
rsJCuntractors/Eiecfrici$as/PiQmbers
I .
/ Please Print Le-`biv
N�1e(BuscnesslOrgaaizafion/[ndivi3¢aI); 1-9
!� /L L ( /"
Addmss: --
CityL �- LZ� M l�•a L( Hone#:
��--Sg�- 3/o Z -
FIA8reyoum i FP Priate.boz:
PEoyer Cheek.t3ze s rnmployer with 4: �] I am a F70
Project(regnb*:general cor&aetor and Iees(furland/or part-time).* have hired the sub-contractors °v'cons�trvction .
. m.asole.proprietor or p�cr_. . listed M the attached sheet.3emodeling
M*and have no employees'. ThMe St6- ontracsnts have
wanking for me in emtiiitian
�t any capacity. workers' comp.insurance.
[No workers'oom ' [] are a corporation and its uilding addition
p mato arrrce 5. We
d-] nf6ce have excreised their ` iectritall repairs or addib ris3.0 I sin a homeowner doing all work right of exem on MCIL Ph P°C umbinrequire
nrysrl£[No-work= comp. 1S2, §1(4),;snd we have nog repaus or additionsinsurance•required.].t etnlwor3 oof repairs
gip. inauranccrrquirad] th
r.may eppumr het ebecks bo>L#1 mart elan fist out the=Chan below showing their watkett'o
ptwho=Ennit this ewidevit indjt"tt th an ompeesatton Policy infomtetion
that cheek this box roust a3' 9wB an wozk&end then hae auuHda contrettots must submit a new affidavit ind'
etteoh�ser rdd.�tiaasl shefltshowing the name of the a&-coatraatoa and.the works' 6 such'
�'�.PoFi J tNntamtion.
t arx�.ert en�lo,per that is prm:tauag:w�r 'awr- 'IM durance or
uiforraaotanrt ' � n'mpIwem. Bzk�w.ir Else pv , job site
Insurance Company Name:
Policy#or$elf-ins.Lie.# y
Egwzbon Date:
--------------
job.Site Address:
ny irdelZ'
Attach a copy of the workers'con tion
d
P� dee
fix
Fara
bion pave showiraa the
� b h number Failure Po c3' her and e '
to trattoa da
set%rlre cOverB t as xP. fe
g required irTt )•
� under Sedan?5A of l�1CiL c. l52 can lead to the imposition of crlatitral
fine up to Ii:1,500.00 and/or one-year imprisonmean as well as civil penalties in the form of a S717P WORK ORDER F a rine
of up to$250.00 a day against the violator. Be advised that a copy.of this statement may be forwarded to the Office of,
Investigations of the DIA-for insraar�coverage venin"cation.
I do hereby cerfi under the pains and penarliim of perjury"J*az the in armadioa ro '
f p voted abo cr is bw and Correct
Date: (�
Pham#: — O
FIBuIrd
only. Do not write n this avis,m he co
►1et�if h eery or town ofj:riQ(
n: Permit/Lirease#
ority(circle one):
ealth Z Soi'Idittg DePw1snent 3.City/Tcrvva Clerk 4.Electrical Inspector 5, Plambing Iuspecfor
6 Ofhei
Contact Person:
Phone#: