HomeMy WebLinkAboutBuilding Permit #823 - 1160 GREAT POND ROAD 5/16/2012 BUILDING PERMIT of "°eT" qti
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
p�gA7E0 I•�` (5
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Date Issued:
IMPORTANT:Applicant must complete all items on this page
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RCEL ZONING DISTRICT�-H`storic--Drstrict fires no
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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 Well Floodla�n g `' lie#lands x Watefsled D�striot r
alVated.Sewer , L
,: ,.
DESCRIPTION OF-WORK TO BE PREFORMED:
7b &6Rec�' a CoO x!cy-g) Y- P?o x,2o Te ),ec x 4 'T61,77'� 00-7
Re
4e: Identification Please Type or Print Clearly)
OWNER: _ 3pso-ok-s srliu-b/ Phone: ??'-74s- 63w
Address:—&(,o G*eq-�- 4d RG�
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C®NTRAC7' R Nerr�e:T� Srrrt
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Address }
Su eruasor's Construction L�cer�se ��-� � � w
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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: $ �®er-co FEE: $
Check No.: -)�-7'q 0 Receipt No.:--a 3 I C
NOTE: Persons contra ting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owrier SignatuMOT contractor. =-
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
o 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
Ll 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: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
I
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
COMMENTS
.HEALTH Reviewed on Signature
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
DPW Town-Engineer: Signature:-
Located 384 Osgood Street
F�RE'DEPR '1IE1�IT Ternpurnp� er orisi#e yes` Brio
Located at,1r24"Main Street
f
F»e De�alrtmetsigraurellee
777.7-
C,01UIMENTS
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) -
i
❑ Notified for pickup .- Date
Doc.Building Permit Revised 2010
Location
No. Date 1�
e ' TOWN OF NORTH ANDOVER `=
0
.,: Certificate of Occupancy $
Building/Frame Permit Fee $ ( U
k ` Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
25310 Building Inspector '
TRUCKS T 0 IE- TER HARE
W
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60"x 00
TREE ZAN
TREE
TREE `
65'FROM TREE TO
CORNER OF TENT TREE iREt I ;
TREE TREE
TREE TREE I I
BUII_DINC
DRIVEWAY HBU D N C , �
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SREETT
S I REE
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NORTH
0 Of _ Andover .
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No. F� IIIm
C, 0 , dover, Mass.,0 LAKE
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COCHICHE WICK
ORATED p' C:)
`S BOARD OF HEALTH
T T D Food/Kitchen
Septic System !
-PER I
BUILDING INSPECTOR
THIS CERTIFIES THAT.................
� S t .Ol
....�..... ............ ...... ................................................................................. Foundation
has permission to erect.............. .... buildings on .1.1.60. &`... �.......�.w.......... Rough
6.10 xj(1t0 be Occupied aS ..... ..0.................. ................ ................................................................. Cimny... h� e
provided that the person accepting this permit shall in every respect 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, Afteratiorr 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 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 oftllassacltusetts
Departntcrit of Industrial Accidents
Office ofhivesti,ations
600 lVashin'ton Street
Boston, MA 02111
rvww.mass.,,I,orldict
Workers' Compensation Insurance Affidavit: I3tuilders/Contractlies/Llcctriciatrs/I'luntbers
Applicant Information Please Print LeGibly
Name (Csusincss'OrL'a!)icluu;/Irdividual): CZt K� K
Address:__3Y2 �Rbc7f
City/State/ZiP: wI Yle h�e_SK , �� Phone #: 7c9/ 707 /— yU a
Are you an employer? Check the appropriate box: Type of project (required):
1.Y I a n a employer with O O 4. ❑ I am a general contractor and I
(i. New construction
employees (full andror part-time). have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. = t ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me ui any capacity. workers' comp. insurance. 9. ❑
rBuilding addition
\o v:orkers' comp. insurance 5. El 'We are a corporation and its
required!.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeovvner doing all work right of exemption per MGL 11.[:] Plumbing repairs or additions
myself. [Neo workers' comp. c. 152, §1(4),and vve have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' ��� / l�
13.(9 Other h
T
cotiip. insurance rcquired.j -
'Ary 2pphcan,that cheeks box=l must also til:out the Sect ior•below showing their workers'compensation policy inCo;mztion.
Homeo.vners who submit this atiidava indicatirn,trey are doing all work and then hire outside contractors must submit a ncv at`itdava indicatm.such.
'C.ont,actors that cheek this box mustattached an additional sheet showing the nave of the sub.:otractor and their worker'comp.policy inCorma6or.
I ant an eniplo}'er that is providin,; workers'coinpensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: L) ��L Q ] >�'t ►-}
Policy_o:Self-ins. Lic. (/u C y,3 cO/G 3 o Expiration Date: 10641w,
Job Site Address: ���� 6e&;P /anel pedCity,State/Zip: C�Ut✓�'�
Attach a copy of the yr orkers' 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 andior one-year imprisorunent, as well as civil penalties in the form of a STOP 1 iORK ORDER and a fine
of up to 5250.00 a day a-ainst 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.
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Sienaturc: %"Pe� p Ce
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Phone 7F/— 7.1 9— vu?rd
Official use only. Do not write in this area, to be completed by city or town offieiaL
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Citc/ToNNn Clerk a. Electrical Inspector 5. Plumbing Inspector
" Other
Contact Person: Phone r:
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CERTIFICATE DOES NOT AFFIRMATIVELY OR- NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
GELD'.';. THIS CERTIFICATE OF I�'tSUP,;;iiCE DOES NOT CONSTITUTE ACO?:Tr^^,ACT ESVJEEti THE ;SSU-1111G, INSURER(S), AUT}IORI�
PEP RESENTATIVE OR PP.OJUCER,AND THE CERTIFICATE HOLDER. c1_
I-MPORTANT: It the certificate holder is an ADDITIONAL INSURED, the policy(ies) nlust be endorsed. It SUEROGATION IS Vl.AIVED, subject to
cOle terms and conditions of the policy,certain policies may roquire an endorsenicnt. A staters^_nt Gr; this cr_r,ificat docs not c: rb_r rigiits t-, II;,-.
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CERTIFICATE MAY E= ISSUED OR P. ERTgllyt THE INSUR;NCE AFFFORDED EY THE POLICIES G=SCRIEED He HER=-IN IS SUSJECT TO ALL THE
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`CERTIFICATE HGLD-F. CANCELLATIOt" ---
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5 REGISTRATION ISSUED BY Date of Shipment 5
5 APPLICATION � OR 06/08/04
5 NUMBER rMINESRIE�INC.®
EVANSVILLE, INDIANA 47725 Tent Identification 5
5 12140.1 'M *4 MANUFACTURERS OF THE FINISHED 03850284 5
55 TENT PRODUCTS DESCRIBED HEREIN S This is to certify that the materials described have been flame-retardant treated 5
5 (or are inherently noninflammable) and were supplied to: 5
S657150 S
SPETERSON PARTY CENTER INC
5 139 SWANSON ST 5
5 5 WINCHESTER MA 01890 5
5 5
5 5
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5 Certification is hereby made that: S
5 The articles described on this Certificate have been treated with a flame-retardant approved S
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5 Serial # 8151030(3) S
5 5
5 Description of item certified: 5
L5J CENTURY MIDDLE 60WX20 SNYDER 5
WHITE VINYL WITHOUT WEB GUYS
S Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is (Effective For The Life Of T'he Fabric 5
5 SNYDER MFG NEW PHILADELPHIA,OH Signed: r '. ' I
C� SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5
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5M MANUFACTURERS OF THE FINISHED
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5 This is to certify that the materials described have been flame-retardant treated 5
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657150
S PETERSON PARTY CENTER INC 5
S139 SWANTON ST 5
5
WINCHESTER MA 1890 S
5 5
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SSerial # 5
5 8151110(2) 5
SDescription of item certified. S
55 5 CENTURY NIIDDI,G(i0WX30 SNl'DER
WHITE VINYL WI'I'I-10U1'WE13 GUYS
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5 Washing And Is Effective For The Life Of The Fabric 5
5 5 SNYDER MFG NEW PI III -IIA.OH
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Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5
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TENT PRODUCTS DESCRIBED HEREIN
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
657150 5
SPETERSON PARTY CENTER INC 5
5 139 SWANTON ST S
5 S
SWINCHESTER MA 1890 5
5 5
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5 5
5 Certification is hereby made that: 5
5 The articles described on this Certificate have been treated with a flame-retardant approved 5
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SSerial # 5
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SDescription
CENTURY MIDDLE(0\��\30 SNYDER of item certified:
5
5
WHITE VINYL Wl'F110U1�WEB GUYS
5 5
Flame Retardant Process Used Will Not Be Removed By
5
5
Washing And Is Effective For The Life Of The Fabric 5
5 - 5
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5 , r EVANSVILLE, INDIANA 47725 5
MANUFACTURERS OF THE FINISHED 03850284 5
5 F140.1 TENT PRODUCTS DESCRIBED HEREIN
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5 (or are inherently noninflammable) and were supplied to: S
5 657150 S
SPETERSON PARTY CENTER INC
5 139 SWANSON ST C5J
5
5 WINCHESTER MA 01890 S
5 5
5 5
5 5
5 5
SCertification is hereby made that: S
The articles described on this Certificate have been treated with a flame-retardant approved 5
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S Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
55
5 Serial # 8151030(3) 5
5 5
5 Description of item certified: 5
5 CENTURY MIDDLE 60WX20 SNYDER
WHITE VINYL WITHOUT WEB GUYS 5
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5
5 SNYDER MFG NEW PHILADELPHIA,OH Signed S
5 `SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5
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