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HomeMy WebLinkAboutBuilding Permit #761 - 1135 GREAT POND ROAD 5/18/2007 NORTH BUILDING PERMIT 0 .1"Ut° 06 q�o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �4"oqTo SPP`�y �SSACHl1S�� Date Issued: IMPORTANT: Applicant must complete all items on this page ms'sAMR w L ? l4r 3 � rr • �5 � �� �xt �' ':5' � s� ac ' aim 3 r��' -. n A ' In 'b - "_ %Qo .... .i.,�:. ....K•z u..:'u... .:�......e'. ova...::,.. .. ., -... > :.: . ' ......�4 &'. x1?e ..L i.., .,.,�^.�, 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 Bldg ❑ Others: ❑ Demolition ❑ Other dOla� ate S't #Ct E DESCRIPTION OF WORK TO BE PREFORMED: I i Identification Please Type or rent Clearly) OWNER: Name: '�4%�/c1_ �rCLtc c, Phone: Address: All 0;11 ko 4ddr'�✓stW S ofIR 61 64W duns),' + "' 4 fT b ^ Supe► rr d�' CQ�s rt12 n _V 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: $ _57,3 0,2,� a FEE- $ 99 �� Check No.: � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have ace s to he aJi 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 D Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ r THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS i i DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 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 j Located at 384 Osgood Street FIR © pAR �»TO�n� #eIt � s I toted X 757 124 Dimension I 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 NOTES and DATA— For department use I ❑ Notified for pickup - Date 1 ........................................................................................ ......................................................................... ................................................... ..................................................................................................................... ................................................................................ .. . . Doc.Building Permit Revised 2007 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 Rehabilitati ermits l Workers ilding Permit ApplicatiComp Affidavi . . r C.S.L. Lice s ❑ ❑ r Work I avl s or 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 I ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 %!3 S yam.•+r d��a''V, ,,�':_ -� �.--� -: _.. s. Location �a .S'c 0 u("-T #vuy--�- No. Date M NaRT� TOWN OF NORTH ANDOVER F - p Certificate of Occupancy $ s •Eta' Building/Frame Permit Fee $ — ACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � 20227 ..�-------_._ Building Inspector Certificate of L.iabili Insurance Dam ofiseue041ame'r Producer 7Thls CerdricAe Is Issued as s matter of information Apptetree Inaura3noe only and coMefs no 710hts upon the csKNkate holder. This owi ficAte dose not afnend,extend or alter the 1 Campbell Ave 1c;wreraSe afforded by the policies bel". I Hudson,NH 03051 Companies Afford! --... rte,.,CoverageROUP _—..—.—_. CONCOR 6038819900 Company D G .—.—..—_.V.._._._.- ---------• � VE ��,...._._. FMNOR INSURANCE �..., �Ineur9d sore CONeTRUC7 8GM CONSTRUCTION Canparq 2 TATE ST Company HUDSON,NH 0300iiy _-- 8T PAUL TRAVF.LER8 �+Coveraps Is Is toh ft ponds of kta+ranee IkNed below have been"W to the i&MM rid above far the pofiry Pedod hWIMWd, notwWwWOne any requirement term or csndieon of any contract or other dommant vAM reaped to wldoh this cer011cote may be Issued a may paAaln,the Insumoo afforded by the policies deoribed harem is subject to all the teams.erockalons and ooh lkm of such policies.IirnNS show may have been reduced by paid Balms. — Co Type of tra~ee — Panty Wuneer —' Policy EBactive Polio Ex01ra11or► LAW Lt► DatO Det9 UabNlty =2.0001'eswoll Commercial Ooneml Wlbility 91111071109 03121000'/ 03f21f2000 MeksxrCanMOp An S 000 ❑Clalms Mad 65 ocou mmco rarwrl A Ads W" S1,otm coo ❑Owners a Comracws Prot Each t)oourrerhoe 31.000.9001 i-,1 Fere Onrwpe(ary � oro ar _i50,ON Iotrol EEE ar v xp ...sQ1,�0 L o�o ety ABY717�10600 oll1ZI P o3n2rAM CamtimdStrodeU"A >I9o0A90 �' 9 All trwrled Autos { Bad "WY (Ver Person) Soboduled Aulm I -- []Nlred&An Q bion-owned Autos —^ _...`.—.._ .—._—•�verg!Qanwos _�— S. _ _ J C Games ueblaty Auto hmiy•Ea Aceldalt,.1.� — L. Any AutoI A'a OMy .__— Each to —J rixesert Llablmy i �Owwrer�ee —� tJ Q Umbrella Foran — [�01her Than Umbrella Form Workers Compenoaeon — MIX115147C05s0 tWtar00ba t14/1JIMW 0 wtw� oVror esr��e "dE C�lertAarident t o 000 The PMP%%d WMwd Ind tem DlasHo• Umit Eawcurrw CW"ft 4161 P.EAd EL ohpeMEe EMC10Ylr Oe N Ohre —. ..._....,. .. _ .�_---.—. ..._..._.— �... S7e9t7ApCrOn M Operallon;llocalbna/VatMdoaf6peaol items FAXED TO-14711-725-0293can ----- Ceditete Holder ftlatlan 19hoildtdd any of the abav®deaoAbed poitcies be cancelled before 9►e I 13RWKS SCHOOL eaplraeM thereof,the lowng company wet endeavor to moa 10 days w illan(109"le Ins 0WOCadr h0kder named 10 the ISH.but 1 11®D GREAT POND RD fallum to mad such no0oe shell ImFese no ob ftatlon or liOW&of any ANDOVER,MA01845-1298 kind upon the company,its agents or represarKstivee• 1.� 10/10 39dd S3IlI-1I0VJ SA00da 96Z99LL8L6 t'0:ZT L00Z/8T/90 �ORTIy Town of Andover No. o "A - ,. � � � IL o y dover, Mass., .ter- 4�- ' �— �IPICOCHiCHEWICK V A0RA TE O P?*t �y `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System J� ' / /- BUILDING INSPECTOR THIS CERTIFIES THAT d A.F ..... f�li 0. .. ..................... Foundation has permission to erect........................................ buildings on ..,//. .,/.!f....... ,,c Q.�..................... Rough to be occupied as...... ✓..�1...l v ........ .............�X7.. ..1......;rl ................................................... Chimney provided that the person accepting this permit every resect conform to the terms of the application on file 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 CONSTRU S TS Rough ........ .... .......... ................ .........: .....- - service . ... .... . ... . . ............. ........ . BUILDING INSPECTOR 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. The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations 600 Washington Street kvi Boston,MA 02111 1dta Workers' Compensation Insurance Affidavit: Bui lders/Contractors/Electricians/Plumbers Awl clnt Information Please Print Le 'bl Name(Business/Organization/Individual): ,j C..417 �G�✓j f, Address: s�--- City/State/Zip:—z "U9 f-v� Phone#: 6 C J .0 Are you an employer?Check the appropriate box: 1.1Tf am a employer with a 4. ❑ I am a general contractor and IFE] ject(required): employees(full and/or p�ime .• have hired the sub-contractors6. 11 New ew 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 odel miction ship and have no employees These sub-contractors havegworking for me in any capacity, workers'com olition [No workers'com , i pinsurance.P nsurance 5. ❑ We are a corporation and its ing addition required.] officers have exercised their3.❑ I am a homeowner doing all work right of exemptibti per MGL 1 ❑Pl iElectrical repairs or additions myself.[No workers'comp. C.right ht 1(4), g epairs or additions insurance required.]t employees., and we have no airs [No workers, 12.[]Roof rep comp.insurance required.] 13.U,6ther U' ,t r' r *Any applicant that checks box#I must also fill out the section below showing their workers'com t Homeowners who submit this affidavit indicatPensation ing they are doing al work and then hire outside con tom must submit a new !Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their worsubmit a new oro affidavit indicating such. � I am an employer that is providing workers'compensation insurance jor my employees. Be/ow is the comp.Policy information. information. ` policy and job site Insurance Company Name:- Policy#or Self-ins. Lic. Expiration Date:_c� �/G--- — Job Site Address: //_11 J— -,4 / GZt CS .�•.G, Attach a copy of the workers'compensation policy declaration page(showingt�hetatpnumber Failure to secure coverage as required under Section 25A of MGL 1? 52can lead to the imposition o fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties policy and expiration datea Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be f criminal penalties of a Pe stn the form of a STOP Wpm ORDER and a fine Investigations of the DIA for insurance coverage verification. Y forwarded to the Office of � Ido hereby certify pnd�'-t/i�iains and ena/ties o era that the informalio ,� -� _ fP J r!' n provided above is true and eorrec� Phone#: L off' Yl'=G, Ste.3,, D O,J)Icia!use only. Do not write in this area,to be completed by city J,j?ciai: City or Town: or town o Issuing Authors Permit/License# ty(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. 6.Other Plumbing Inspector j Contact Person: j Phone#: Ii I PROPOSAL SGM CONSTRUCTION 2 TATE ST HUDSON, NH 03051 1-603-595-6923 5/7/07 BROOKS SCHOOL GOELET HOUSE 1160 GREAT POND RD ANDOVER,MA 01845-1298 978-725-6284 Scope of work to be performed on Goelet House: Install Styrofoam insulation _ Wrap all windows and house trim with white aluminum Install white vinyl soffit Install white vinyl siding $33,025.00 I' Signed by Serge Michaud Owner Location No. W/ Date 40WTh TOWN OF NORTH ANMVER F 9 S Certificate of Occupancy Building/Frame Permit Fee $ ` ssAC-1. : Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # `"�— 20-186 Building Inspec&