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HomeMy WebLinkAboutBuilding Permit #749 - 1160 GREAT POND ROAD 4/19/2012 BUILDING PERMIT �,.� 0. NORTH q TOWN OF NORTH ANDAVER 02 APPLICATION FOR PLArate MINATION e Permit N0: eceived sq � CH Date Issue ' IMPORTANT:Applicant must complete all items on this page : .LOCATION PRQPERTY 01INER t3oa . G, /.e r Pr►rtl . MSP 2�I). PARCEL , ` EON'N D15T.R1 ' = est s rict des no Machine S1aop UAlage ;yes no �. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildin One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others:?-emp. Demolition Other Septac Flobdpla�n >: .W'e lands :Y � ��a�erslaerl�Distr ct r`� alVater'Sewer _ _ r a DESCRIPTION OF WORK TO BE PREFORMED: �e►m o Identification Pljease Tpe or Print Clearly) OWNER: Name:__(3 P,�v>'CS S� u-�� Phone: �7 7,2S-6'0� Address: �/(moo elreb� �Md Ra 4a c- q1; {CTI =dame + 5 I; P aone4 Address ,.1 ' .. Supru�sor s Construction Licensey �< Gate .; 3' F n , i s Homme Ir aprovirr ont Udensej `� :rt. _ Epp 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: $ FEE: $ � � 2� ' Check No.: ZJ Receipt No.: 0- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 'oe9Si natureof A ent/Owner _ Si nature of contractor :. ._ 9 g .__ r T_._. 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 Per Application Li 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 Pian ❑ 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:Building Permit Revised 2008_ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature ' - I ,. COMMENTS HEALTH Reviewed on Signature COMMENTS Zgning 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 DPW Town Engineer: Signature: I' Located 384 Osgood Street F'RE`DEPARTM :NT Temp Dumps#er on z�#e-yes TeX . WE Locatedat 124'Main•Strut 5 x ire Dparfirraeni:s�gr�ature/idate M tisvZ 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 NOTES and DATA— For department use) -❑ Notified for pickup - Date Doc.Building Permit Revised 2010 Location! No. 7�19am Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Che6 25207 Building Inspector ` AORTFI 0" ® 'dover- f 0 No. 1til _ o y dover, Mass., qb ISO, LAKE t. Y COCHICHEWICK ORA TED PP¢` BOARD OF HEALTH PEIRMIT T D Food/Kitchen Septic System BUILDING INSPECTOR DO V ! THIS CERTIFIES THAT............................................................................ ........................................................ Foundation ...... .... has permission to erect......................................... buildings on .....11.0.Q...... Rough QbChimney to be occupied as.... ..... ......10............T1 _!=9M'b .......... .................................................................................... provided that the person accepting this permit sharespect conform tothe 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 . 36.� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO S Rough /... Service .. .. ..INSPECTOR.... BUILDING 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 (Mall To Be Done FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Y - Street No. SEE REVERSE SIDE smoke Det. North Andover MIMAP April 19, 2012 lord W t G Yk ' try All � a r y � a t 1 t' M Interstates Interstate Major Roads Horizontal Datum:MA Staleplane Coordinate System,Datum NA083, Roads Meters Data Sources:The data for this map was produced by Merrimack pOR7M Valley Planning Commission(MVPC)using data provided by the Town of r Easements Qf •��p 'a� North Andover.Additional data provided by the Executive Office of 0 MVPC Boundary ? e r�•e QQ Environmental Affairs/MassGIS.The information depicted on this map is L:Parcels F 9 for planning purposes only.It may not be adequate for legal boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING # ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY # t .; i OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT # o� • • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ./y, '0a•,r�o�f."�g THIS INFORMATION ,SSwCHus�� 1"=309ft •�° ' \l:r••:rrliI.INCI - Oc �r:rrirn�'nt til 1'ulrlir `:rlt t� [3crarrl trf t�rrilclirr'� (l�",ul:rtitrn� ,tilt( `t:rncl:rr c . Construction Supervisor License License: CS 60219 MARK TRAINA 33 HANIFORD RD STONEHAM, MA 02180 Expiration: 4/27/2013 ( ��nuni..���t�c•r- Tin: 13389 r The Commonwealth of Massachusetts Departntent of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 wiv;v niass.gov/dia Workers' Compensation Insurance Affidavit: 13uilders/Cont-actoi-s/Electricians/Pluinbei-s Applicant Information Please Print Legibly Nanle (Business/Organisation/individual): 4Qc Kf K Address:_�p 61040 City/State/Zip: t J(Y1 C k eS4K #7 Phone #:_719/- 7a?9— Y0 c) c Are you an employer? Check the appropriate box: Type of project(required): 1.Y I am a employer witliCQ O O 4. ❑ I am a general contractor and I 6. E] New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. + ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.EJ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.[X Other�`i'7� �eh '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 subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: io U �7 �t C. r4an�' h Policy#or Self-ins.Lic.#: !/+t/ L' V.? Expiration Date: /( h� Job Site Address: cf nG( City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 7Fl` 7,� 9- YD O-o Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other r Contact Person: Phone#: A�� ® CERTIFICATE DATE(MIdIDD/YYYY) OF LIABILITY INSURANCE 10�4�2011 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. It SUBROGATION IS WAIVED, the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate docs not confer rights to the certificate holder in lieu of such ondorsoment(s). PROOUCEF, CONTACT NAME: Michael Bonacorso Bonacorso Insurance Agency, Inc. PHONE —`---– -- - ---- - m (781)273-3200 A/C.No: (781)273-05Gp 83 Cambridge Street E-MAIL P.O. Box 1502 ADDRESS:mike@bonacorsoins.com INSURERS AFFORDING COVERAGE Burlington MA 01803 INSURERARepublic Franklin Ins Co.INSURED INSURERb.Trayelers Cas & Sur Of Illini0~ Peterson Party Center, Inc. INSURERCUtica National Insurance CO a 139 Swanton Street INSURERD:Travelers Casualty and Suret INSURER E Winchester MA 01890INSURER F ------- ---- - - COVERAGES CERTIFICATE NUMBER:2011 MASTER IREVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLOGY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR i.,AY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUC�-i POLICIES.LIMITS SHOVVN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICA D U R POLICY NUMBER MM DD�Y POLICY EXP LIMITS LIABILITY EACH OCCURRENCE s 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMA E TO RENTED ---- PREMISES Ea occurrence) S 50,000 A CLAIMS-MADE ❑X OCCUR X X PP4361629 10/9/2011 10/9/2012 ME D EXP(Any one person) S 10,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,00C 000 — ----------... ._.. - AGGREGATELIMITAPPLIESPER' I iPROOUCTS-CO,�P/OP..C� S 2,OC'C,OOv PRO- -- ---- ------- POLICY, .._ _. X rOLICI' El LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 5 11000-peg B ANY AUTO BODILY INJURY(Per Person) I S ALL OWNED SCHEDULED X X BODILY INJURY(Per S AUTOS X AUTOS A-92968836-11-SEL 10/9/2011 10/9/2012 ---- X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE AUTOS Per ace dent S _ Uninsured motorist Blsplit limit S 1,000,000 X UMBRELLA LIAR OCCUR X X EXCESS UAB EACH OCCURRENCE 5 10,000,000 C CLAIMS-MADE AGGREGATE S 10,000,000 DED RETENTIONS L4361631 0/9/2011 0/9/2012 S D WORKERS COMPENSATION X X WC STATU- DTH- ANO EMPLOYERS'LIABILITY Y/N _ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? aN/A E.L.EACH ACCIDEN 5 500,000 (Mandatory In NH) WC 4361630 10/9/2011 10/9/2012 If E.L.DISEASE-EA EMPLOYES 500,000 yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TPC?^_'_''. 'PROVIS�O!!P. AUTHORIZED REPRESENTATIVE Michael J. Bonacorso ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 nninncim Th.A((1Rh name anrf Innn aro ronicfnrn,f markc of Arnpn IMPORTANT DOCUMENT Certificate of Flame 1ssistance ISSUED BY Date of Shipment 05/10/11 rAi�an Registration Number NCHOW, INDUSTRIES INC. Tent Identification F 140.1 x4,, 14957721 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable)and were supplied to: PETERSON PARTY CENTER INC 139 SWANTON ST WINCHESTER, MA 01890 ST�� CAL�Fo�� Q F. N q 9 � P ARE M 4 F RETP Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701-04, ULC 109. Serial # 8024000(l) Description of item certified: FIESTA EXPANADABLE TOP 20WX20 SNYDER WHITE VINYL Flame Retardant Process Used Will Not Be Removed By Washing. And Is Effective For The Life Of The Fabric SNYDER MFG NEW PHILADELPHIA,OH Name of Applicator of Flame Resistant Finish Signed: HC��� AN OR INDUSTRIES INC