HomeMy WebLinkAboutBuilding Permit #749-15 - 1160 GREAT POND ROAD 4/2/2015 4
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
IMPORTANT:A licant must complete all items on this page
LOCATION ._
'Print.,
OWN UO
�I?ROzPERTY ER
Print 100�Year®Id,Stl _ yes;
�� � cture, no
MAP NO: _ PARCEL: _ ZONING DISTRICT:._ Historic District yes fno,
v
= b_ - _ ?MachmeyShop 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 Bldg Ithers����
❑ Demolition ❑ Other
Septic ❑`UVell ❑ Floodplain { �Wetlands " ❑:`Watershed District
_A_PiWatef/S:ewer
DESCRIPTIO OF WORK TO BE PERIORP4EP� L�
Identification Please Type or Print Clearly)
OWNER: Name: ;3,44,445, Phone:c�'
Address: 14 �
C,ON, !RACTOR Name:. �'/r/1ST/ /'l Ylt- _ - Ieta�Lp'..hone
4 `
Address:.1
i '
M ►�.ha-e-1 C:���h�
-Superulsors::Constructlon License: CS —= o67Yf.y -:E Fate: .ZZ /' ��_ y
Home Mproyemerit-'LicenseDater._ _
A ( �� e5�00 /a Phone: lolly-23Y-y74 a
� l � o3�y9
Address: 19 L//�� � Dk'+VC l�/1/S //�f 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: $ 40 DSD ! FEE: $
Check No.: Receipt No.: Z�-(.Pb 3
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
C
signature of A_gent/Owner Simature.of contractor
.. . .. n r1--__ A n I_:..__i n /'+-":C:-A 171-4. 171...,, I—I DInnc F�
Building Department
The fol.-3wing 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
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.¢ted with the building application
Doo: Doc.Bui?ding Permit Revised 2012
.y
Plans Submitted ❑ PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑
-TY-PE OF°.SEWERAC3E.DiSP-OSAL
Public Sewer ❑ Tanning/MassageBodyArt ❑_ . ..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
DATE REJECTED: DATEAPPROVED
PLANNING & DEVELOPMENT- ❑ ❑
COMMENTS
-CONSERVATION , S
Reviewed on � Si nature
r
COMMENTS
HEALTH Reviewed on Signature
i
COMMENTS
I �
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
I
Conservation Decision: Comments
Water& Sewer Connecti®n/Signature& Date Driveway Permit
DPW Toiv 2 Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT =Temp DumpSter on site yes no
Located-bt 124 Mair,Street
Fire Ddpartmerit sigriature/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 q pp requires approval of
Electrical Inspector Yes No
DANCER ZONE LITERATURE: Yes No
MGLChapter166.Section 21A-F and G min.$100-$1000.fine
NOTES and DATA— (For department use
I
® Notified for pickup - Date
E
Doc.Building Permit Revised 2010
ocation
!o 720 "f" 76-7- Date G
753
. - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
f
Building/Frame Permit Fee
Foundation Permit Fee $ ' ,
Other Permit Fee $ y
TOTAL $
Check#
y
8 6 0 3 'f
uilding Inspector
r 1 F NORTH -
s c . . _ver
,
0
No. =t y 2 Z61S
h ver, Mass
coc»�c»ew�c« �'�•
�d RATED
S U
BOARD OF HEALTH
Food/Kitchen
PER T Septic System
THIS CERTIFIES THAT .......... . . .......� ! 6. BUILDING INSPECTOR
. .............................. ..
Foundation
has permission to erect .......................... buildings'on ...wab.....ref............. !. . �.....
Rough
to be occupied as .� ..... ....4 461b .Tjr. ....ft . 44. ..4........� �`I�S Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the a plication Final
on file in 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 CONSTRUCTION ST T Rough
Service
................................................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
6
4/1/2015 Graduation Weekend Terd.GIF
Al
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40 A4 T
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Silk
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t>ttpsJ/mail.google.com/ /scs/mail-static!s/k=gmaii.mairLen.2Ho6--gWYWU.O/m=m_i,t,it/am=PiMa4f7vUGMM2SXPIL3T/ fXVLs7vP6 94EkOwsgP-b T
ORDERNFIRMATI 16 -2
CO ON 25 3 Pg: l
_ EVENT DESC: GRADUATION/PRIZE DAY
EVENT T 2:00 M
DIME: SUNDAY DATE: 05/24/2015
EVENT
18 Clinton Drive,Hollis,NH 03049 DELIVERY: TUE 05/1.9/2015 OR WEDNESDAY AM
603-882-1234 or 603-881-8833 fax PICKUP: TUE 05/26/2015 OR LATER
1-888-RENTENT SALES PERSON:MG PO#:
www.intents.com email: sales@intents.com ORDER DATE: 12/15/2014
TERMS: NET 10 DAYS
ERICA CALLAHAN (978)725-6258 BILL ST CYR (978)265-4485
B BROOKSSCHOOL S BROOKSSCHOOL
1 1160 GREAT POND ROAD H 1160 GREAT POND ROAD
L ACCOUNTS PAYABLE I NORTH ANDOVER MA 01845
L NORTH ANDOVER MA 01845 P
TEL: (978)725-6300
TEL2: FAX:(978)725-6215
QTY ITEM DESCRIPTION PRICE TOTAL
1 100'X 120'WHITE TWIN POLE TENT 9,600.00 9,600.00
1 9'X 60'WHITE MARQUEE WALKWAY 700.00 700.00
60 FEET OF SOLID SIDEWALLS 1.10 66.00
220 FEET OF WINDOW SIDEWALLS 1.20 264.00
10 FEET OF RAIN GUTTER FOR TENT 2.00 20.00
440 FEET OF WHITE STRING LIGHTS 1.00 440.00
6 HALOGEN RING LIGHT W/6-75 WATT BULBS-6"-BIG 200.00 1,200.00
BROOKS SCHOOL IS RESPONSIBLE FOR POWER DISTRIBUTION
1 24'X 30'PARQUET DANCE FLOOR 1,440.00 1,440.00
BROOKS STAFF SETS UP&BREAKS DOWN CHAIRS
1460 WHITE"FAN BACK"FOLDING CHAIRS 1.60 2,336.00
SPECIAL INSTRUCTIONS: SUB TOTAL: 16,066.00
GRADUATION DATE MAY 24 @ 2 PM/ PRIZE DAY IS MAY 25 @ 10:15 AM
REHEARSAL MAY 21 @ 10:30 AM CUSTOMER SETS UP CHAIRS SALES TAX: 0.00
ERICA'S CELL IS 978-376-9304 DELIVERY: 80.00
54000 DEPOSIT PD 12/31/14 0.00
TOTAL: 16,146.00
DEPOSIT PAID: 4000.00
BALANCE DUE: 12146.00
Customer Acceptance Signature
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Page: 1
(Clerttfttate of 11ame Roiaatlre ,
l Date Manufactured AZTEC TENTS Invoice Number: 0202537-IN
2665 COLUMBIA ST Customer P.O.:
1/8/2014 TORRANCE,CA 90503
(800)228-3687 Customer Number: CHR030
This is to certify that the materials described below have been flame 1rptardant veneer —Trade name
treated(or are inherently flame retardant). , 1 \ BnNln Mesh ras FVZ
222.04
/ �\ ..
' `.
CaliforniaComb. tam-lex 12,14,16,18oz F-419.01
\ = Coated Fabrics Clear Vinyl l6ga/20ga F-570.02
Christian Party Rentals DAF Clear Vinyl l6ga/20ga F-593.01 t.
' DAF DAF
F-593.07-
18 Clinton Drive :
�� �> Exclusively Expo PolySateen Liner F-434.01
Hollis NH 03049Y Fe ari Precont ain[502 F-444.01
' � k� Ferrari Precontralnt 702 F-444,08
Phllllps Textiles Phil-Tex Liner F-500.01 `\
PVC Tech. Deco Cloth/Velon F-504.01
Snyder Weatherspan F-140,01
Tri Vantage Fresist Sunbrella F-368.05
Certification is hereby made that the articles described below hereof are made
Tri Vantage PatIp SDD F-121.02
from a flame-retardant fabric or material registered and approved by the Tri Vantage Big Top F-121.10
California State Fire Marshal for such\s use.The fabric has been tested and TO Vantage Vanguard Weblon F-069.01 Tri Vantage Weblon/Coastline F-069.01
passes NFPA 701 Large Scale.See chart to right for trade name of Verseidag Duraskin 81673,81515 1 F-530.01
flame-resistant fabric or material used and additionally referenced on the label of
the fabric panel.
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
David Bradley General Manager- Manufacturing
Name of Applicator or Production Superintendent Title of Applicator or Production Superintendent
ITEM CODE ITEM DESCRIPTION UNIT ORDERED PRODUCED
Z318T100E040B/O #100x40 2pc Series 2000 EACH 1 1
TP UW
#Old Style to match
previous orders#
Includes Jumper Ropes
Only
Blockout White
(Tie Downs Not Included w/
Top)
Z39900430 5/8"Polydac CP Jumper 45' EACH 2 2
Z318Z0018OB/O *100x20 End S2000 TPLA EACH 1 1
UW
w/New Plates Includes
Jumper Ropes Only
Blockout White
(Tie Downs Not Included w/
Top)
Z318Z0019OB/O *100x20 End S2000 TPGR EACH 1 1
UW
w/New Plates Includes
Jumper Ropes Only
Blockout White
(Tie Downs Not Included w/
Top) /
Continued
a P O T TDOCUMENT
sCertfflea o e silstapee 5
5 e uc�R ISSUED BY Date of Shipment 5
5 REGISTRATION � ,, c ® 5/30/2007 5
0 NUMBER y INDUSTRIES INC.
5 SJ
5 rA' P��i EVANSVILLE, INDIANA 47725 Tent Identification L5
5 F140.1 � EMr MANUFACTURERS OF THE FINISHED 04488917
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
5 (or are Inherently noninflammable) and were supplied to: 5
S5 269800 5
CHRISTIAN DELIVERY& CHAIR SER
5 1CLINTONDRDBA 8 CHRISTIANPARTY RENTAL 5
5 HOLLIS NH 30496576 S
5 5
S 5
5 5
O 5 5
5 Certification is hereby made that: S
SThe articles described on this Certificate have been treated with a flame-retardant approved 5
5 chemical and that the application of said chemical was done in conformance with California S
S Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
5 Serial # 8085010C(5)
5 Description of item certified: 45
5 5 FIESTA MARQUEE MIDDLE 9X10 5
SNYDER WHT VL#1023970A 5
5 Flame Retardant Process Used Will Not Be Removed B 5
Y
S5 Washing And Is Effective For The Life Of The FabricSNYVEK 5
j NEW UH Signed:
5 Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5
� rJ��Pc1rJ�r�J�rJ��.Pr.1�r.�JrJ�rJr.PcJ��PrJ�rJ��.Pr��PrJ�rJ��Pr�rlr.Pr�r�cPrJ�rJ�rJ�r�r�rJ�r��Pr��PrJ�rJ�rJ�cPr�rJ��P�PcJr�r�rJ�rJ�rJ�rJ�rJ�rJ�cJ�r.PrJ�cPrJ�r�rJ�rJ�rJ�r�rJ�rJ�rJ��PrJ��PrJ��P �
The Commonwealth of Massachusetts
Department of IndustrialAccidents
a 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass gov/dia
gee
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Awflicaut information Please Print Leeibiv
Name(Business/Organization/Individual):Christian Delivery&Chair Service, Inc. DBA Christian Party Rental
Address:18 Clinton Drive
City/State/Lip:Hollis, New Hampshire 033049 Phone#:603-883-5326
Are you an employer?Check the appropriate box: Type of project(required):
1.a✓ I am a employer with 40 employees(full and/or part-time)." 7. 0 New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. [:]Remodeling
any capacity.[No workers'comp.insurance required.]
3.a I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. El Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition
ensure ihai aii coniraciurs eiiher have workers'compensation insurdnce or are sole 1 110 Electi ical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$ p
14.nOther TENTS
I6.[]W e we a euipuiuilun aild 16 Ulllucls nuvr exciuscd invit aig14 u1 cxvmpi1U11 pr1 IVIGL u.
152,§1(4),and we have no employees.[No workers'comp.insurance required.] I I
'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.
tContractors 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 Com---- a^a New Hampshire Motor Transit Association
Policy#or Self-ins.Lic.#: P000/749NH/M''TA22J01"5 Rod
Expiration Date:01-01-2016
Job Site Address: _I110 D Gre !"0/[/� KGZ ' City/State/Zip: ' Odd
Attach a copy of the workers'compensation policy deciaration page(showing the poiicy 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 DIA for insurance
coverage verification.
Ido hereby certify under to pai n enalties of perjury that the information provided above is ue and correct
Signature: Date: c 3/
Phone 4:603-883'53/--6-
Oficial use only. Do not write in this area,to be completed by city or town official
Llty or Town: ICCQl1UL11;C�1�e ih
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
II Contact Person: Phone#: II
NHIHTA
NEW HAMPSHIRE MOTOR TRANSPORT ASSOCIATION
P.O.Box 3898
Concord,NH 03302-3898
(603)224-7337
CERTIFICATE OF INSURANCE
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.
This is to certify that: Christian Delivery&Chair Service Inc. DBA Certificate#: 1
Christian Party Rental
18 Clinton Drive
Hollis, IVH 03049
Is,at the issue date of this certificate,insured by the Company,under the policy(ies)listed below. The insurance afforded by the listed policy(ies)is
subject to all their terms,exclusions and conditions and is not altered by any requirement,term or condition or other document with respect to which this
certificate may be issued.
COVERAGE AFFORDED UNDER INC LAW OF THE FOLLOVONG STAT E. NH
TYPE OF POLICY EXP DATE POLICY NUMBER LIMIT OF LIABILITY
Continuous`
Extended
Policy Term
Workers'Compensation 09/01/2015-01/01/2016 P000749NHMTA2015 Bodily Injury By Accident $1,000,000
Bodily Injury by Disease Policy Limit $1,000,000
Bodily Injury by Disease Each Person $1,000,000
ADDITIONAL COMMENTS:
'If the certificate expiration date is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration date.
NOTICE OF CANCELLATION: (Not annlicable unless a numher of days is AntAred helow_) Before the stated expiration date;the comnanv will not
cancel or reduce the insurance afforded under the above policies until at least 30 days. Notice of such cancellation has been mailed to:
NH MOTOR TRANSPORT ASSOCIATION SELF-INSURANCE GROUP TRUST
a:__ n_i:....... o nom_:-
11111wu011 ucnve y a V.n011 ocivi%8 111%-
I
11%- I -
dba Christian Party Rental
18 Clinton Street
Hollis, NH 03049
�- -� U
Authorized Representative
Concord,NH 603-224-7337 02/06/2015
Office Phone Number Date Issued
Sep-25 14 06:16p Mike LeBlanc 978 534 7983 P.
Massachusetts -Department of?1b:;c Safety
Soard of Building Regulations and Mand:,as
License: CS-067484
MICHAEL P LEBWC
611 PIERCE ST = s
LEOMINSTER MIA 014S3,.
Commissioner 06/22120/6