HomeMy WebLinkAboutBuilding Permit #751 - 1160 GREAT POND ROAD 4/2/2015 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
MPORTANT:Applicant must complete
all items on this page
L®'ATI.ON' 1011YI��� -
Print
y �PR0PEfRtx' OWNER'
1
p 100 Year 0 d Stru yes. no
� cture� `r
9 -
MAP,NQ 3 ,PARCELI�� y- ZQNINGtDfS1TRIGT _ _ iHistonc District yes anon
__- — -
MachirieShop Village _ yes
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 _
'Septic ❑W611^ �'Floodplair D Wetlantls = ' `Watershed District;
S�Wewer_
DESCRIPTION OF WORK TO BE PERFORMED:
Yl or Q 60 Mr we 4® X5-
p,
rmyd will be, ph �2,711
Identification Please Type or Print Clearly)
OWNER: Name: roa�� ��h eDl Phone: g7�-J_73-83 7g'
Address:
_ � ��
CONTRACTOR Name:(_;.i1 /! }'? l"Q'"�' `' -
- ! Plione 3 8g3 5 3.2
Address: - Il n_ � �'aU�
t 1 �3
=l-�- -
- - Mihoel A [.e-blan
isor's:Construction`Licensed s_ p Exp Date:�0 Z _ _
;x
Supery
Home Inn r0Yemerif License:- � . -__ _. Exp ?Date:-�
�e - _ ._�
M i -6l a 6o Phone: (003- 03V - 76760
Address: A� Ive 1 /V/�OAPL? 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: $_�1 300 " Q FEE:
_ $ �;
Check No.: Receipt No.: ���
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature,of contractor. ,
_- _ ... ri .-.. •n. a n nl-.& P' i-- F-1 C4--- ^rl Dinnc F�
Building Department
The foh,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
❑ 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 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 submAted with the building application
Doc: Doc.Bui?ding Permit Revised 2012
Plans Submitted ❑ Plans-Waived-0 Certified Plot Plan ❑ Stamped Plans ❑
.•TYPE OF°.SEWERAGEDISPDSAL
Public Sewer ❑ Swimmin Pools 0'
Tanning/MassageBodyArt ❑. - . g j
Well ❑ ❑
Tobacco.Sales Food Packaging/Sales 'El
`
Private(septic tank, etc... ❑__ Permanent Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED: DATEAPPR_OVED
PLANNING & DEVELOPMENT- ❑ ❑
COMMENTS
CONSERVATION Reviewed on 2 Sic nature /�v Q4
COMMENTS
WEALTH Reviewed on Signature
COMMENTS
• Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
z -
Planning Board Decision: Comments
Conservation Decision: Comments
Water &Sewer Connection/Signature & Date Driveway Permit
DPW Tow;-, Engineer: Signature:
Located 384 Osgood Street
FIRE OEPART�ili NT =T:emp Dempster on site yes no
Located-at 124 Main Street
Fire'®epartinerit signature/date`
COMMENTS
--Dim-ension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, roast or service drop requires approval of
Electrical Inspector Yes No
ANDER ZONE LITERATURE: Yes No
MGL Chapter.166.Section 21A-F and G min.$100-$1000.fine
NOTES and DATA— (For de artrnent use
I3 Notified for pickup - Date
Doc.Building Permit Revised 2010
ocation '
Jr
io. Date L
. • TOWN OF NORTH ANDOVER
m ..
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#R
8 6 0 " wilding Inspector
r 1NORTH - 40
ic ve" -
0
: :
NO.
h ver, Mass, i Z
COC KICKlWKK �oi
A00ATE0 HPa��S
S U
BOARD OF HEALTH
PERMIT T _LD Food/Kitchen
Septic System
THIS CERTIFIES THAT 6«Z1 �. ....:s D ............. BUILDING INSPECTOR
Foundation
has permission to erect buildings on ��`''`�'�.10
p .. ...... ...... ............. ....................................
�� Rough
tobe occupied as ..... a..y.S. �......................................'I .............................................................. Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application 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 CONSTRUCTIO RTS 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.
4/1/2015 Prom Terd Locabon.GIF
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https:!/mail.google.com//scs/mail-static fjs/k=gmaii.main.en.2Hofr-9WYWU.O/m=m_i,t,ittam=PiMa4f7v_UGMM2SXPIL377 fXVLs7vP6 94EkOwsgP-b T-... 1/1
ORDER CONFIRMATION 25369-3 Pg: 1
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EVENT DESC: PROM-40X50F
EVENT AiTiEVENT DIARY: SUNDAY DATE: 04/26/2015
18 Clinton Drive,Hollis,NH 03049 DELIVERY: FRI 04/24/2015 OR EARLIER
603-882-1234 or 603-881-8833 fax PICKUP: MON 04/27/2015
1-888-RENTENT SALES PERSON:MG PO#:
www.intents.com email: sales@intents.com ORDER DATE: 02/12/2015
TERMS: NET 10 DAYS
MATT GRANT (978)273-8378 MATT GRANT (978)273-8378
B BROOKS SCHOOL S ON TOP OFF ROOF
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 40'X 50'WHITE FRAME TENT(KT) 1,300.00 1,300.00
180 FEET OF CATHEDRAL WINDOW SIDEWALLS 1.20 216.00
2 VALUE TENT DOUBLE DOORS 6 FOOT WIDE- 350.00 700.00
18 WHITE VINYL COVERS FOR CEMENT BARRELS 7.50 135.00
18 WEIGHTED BARRELS TO SECURE TENT 12.00 216.00
180 FEET OF WHITE MARKET LIGHTS(7 WATT ROUND BULBS) 1.25 225.00
2 HANGING WHITE CHANDELIER(4 GLOBE) 80.00 160.00
BROOKS IS RESPONSIBLE FOR POWER DISTRIBUTION
1 18'X 40'DANCE FLOOR 1,440.00 1,440.00
1 170,000 BTU TENT HEATER(PROPANE NOT INCLUDED) 15/20 AMP CIR 275.00 275.00
2 100 POUND TANK OF PROPANE-2 TANKS PER HEATER 110.00 220.00
2 EMERGENCY LIGHTS WITH LIGHTED EXIT SIGN COMBO 60.00 120.00
2 FIRE EXTINGUISHERS 15.00 30.00
1 TENT PERMIT-ESTIMATED 200.00 200.00
AN ADDITIONAL HEATER PERMIT MAY BE NEEDED!
FURNITURE MAY BE ADDED
SPECIAL INSTRUCTIONS: SUB TOTAL: 5,237.00
STUDENT CONTACT: HARPER DREW
SALES TAX: 0.00
DELIVERY: 115.00
0.00
TOTAL: 5,352.00
Customer Acceptance Signature
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SIM
Certificate of jflame Req;f5tanre }
1 T REGISTERED ISSUED BY: Date treated or
00���! APPLICATION manufactured
AZTEC TENTS
CONCERN N0. •.=
490 ALASKA AVENUE
CAL COMB r- TORRANCE,CA 90503619. 1 D4IZOO6
O 0 (310)328-5060
REt�
This is to certify that the materials described below hereof have been flame retardant treated(or are inher-
ently nonflammable).
FOR CHRISTIAN PARTY RENTALS ADDRESS 18 CLINTON DRIVE -
CITY HOLLIS STATE NH, 03049
Certification is hereby made that: (check "a"or "b") c
(a) The articles described below this certificate have been treated with a flame retardant chemical approved
❑ and registered by the State Fire Marshal and that the application of said chemical was done in confor-
mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal
Name of chemical used............................................Chem.Reg.No.........................
Meathod of application
(b) The articles described below hereof are made from a flame-resistant fabric or material registered and
'` ❑ approved by the State Fire Marshal for such use; Fabric has been tested and passes NFPA701-96.
Trade name of flame-resistant fabric or material used..LaminatedFabrle .Reg.No. ......h MR!
The Flame Retardant Process Used .WILL NOT Be Removed by Washing
(will or will not)
•• *
David Bradley Chuck Miller- President
Name ofApplicator or Production Superintendent }�,,���� Title
ffil
ka ... �... w ps tea• s a a
CUSTOMER ORDER NO. R160265
ITEMS MANUFACTURED:
1-40'x40'(2 PC)JUMBOTRAC TOP ONLY CLEAR-WITH WHITE TRIM
1-40'x10'JUMBOTRAC MIDDLE TOP ONLY CLEAR WITH WHITE TRIM
2-405x20'JUMBOTRAC MIDDLE TOP ONLY CLEAR-WITH WHITE TRIM
1-30'x30'(2 PC.)JUMBOTRAC TOP ONLY-ULTRA WHITE
1-305x20'JUMBOTRAC MIDDLE TOP ONLY-ULTRA WHITE
The Commonwealth of Massachusetts
Department of IndustfialAccidents
d 1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation,Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Apuiicant information Piease Print Leeibiy
Name(Business/Organization/Individual):Christian Delivery&Chair Service, Inc. DBA Christian Party Rental
Address:18 Clinton Drive
City/State/Zip:Hollis, New Hampshire 03049 Phone#:6u3-60.5-5sz6
Are you an employer?Check the appropriate box: Type of project(required):
1. ✓❑I am a employer with 40 employees(full and/or part-time).* 7. ❑New construction
2.U 1 am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. Remodeling
9. Demolition
3.[:]l am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑
10[]Building addition
4.[]l am a homeowner and wilt be hiring contractors to conduct all work on my property. I will
ensure inat aii wntraeiors either have workers'compunsu6un insurance or are soie I i.i^J ]CCU iva]r6pana yr auutuvila
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ repairs
re airs
These sub-contractors have employees and have workers'comp,insurance.=
14,nOther TENTS
U.�W C WC a euipuluilull w1U 16 u luvl$IIaVC CXCl CINci 01011 light Ul CXCuipbull Pet IVIG,C.
152,§1(4),and we have no employees.[No workers'comp.insurance required.] 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.
Insur-ance Cotnp-ny u�,„P New Hampshire Motor Transit Association
Policy#or Self-ins.Lic.#: P000749NH/M-TA22015 Expiration Date:01-01-2016
Job Site Address; _I !D D_ l eae Poli ,� Qd • City/State/Zip: 4 P ,��� �—
Attach a copy of the workers'compensation poiicy declaration 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 pais n enaldes of perjury that the information provid
edvnd correct
Si nature: Date:
Phone#:603-80-3-5 46
Oficial use only. Do not write in this area,to be completed by city or town official,
Ciiy or T own: rerillat/i,iceuSr i+
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Ciiy/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
I� Contact Person: Phone#: li
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NEW HAMP5NIRE 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, INH 030449
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 VZ LAW OF THE FOLLvVONG STATE: 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 tern,you will be notified N coverage is terminated or reduced before the certificate expiration date.
NOTICE OF CANCELLATION (Not annlicable unless a numher of days is entered below_) 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
\iir 111stiai 1 Dcii'er y cox%I Iaii JCI ViUC II 1
dba Christian Party Rental
18 Clinton Street
Hollis,NH 03049
Authorized Representative
Concord,NH 603-224-7337 02/06/2015
Office Phone Number Date Issued
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Sep 25 14 06:16p Mike LeBlanc 978 534 7983 P.1
Massachusetts -Department of Pub:t-c Safety
Board of BuRding Regulations and Standmrcls
47, 1 1,14!
License: CS-067484 M.
MICHAEL P LEBJANC
611 PIERCE ST
LEOMINSTER MA 01455,
E x Pi'm 10
Commissioner 0612212016