HomeMy WebLinkAboutBuilding Permit #676 - 121 COLGATE DRIVE 6/8/2008 BUILDING PERMIT o* p10RT►/,61ti
TOWN OF NORTH ANDOVER ter."`'''- h' '° °p
APPLICATION FOR PLAN EXAMINATION
Permit NO: CG Date Received �'
gOcx. c I
��SSACHU`���
Date Issued: G
IMPORTANT:Applicant must complete all items on this page
LOCATION Idl C. 0l (- Y^t
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PROPERTY OWNER T It
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Print
MAP NO:)PARCEL: ZONING DISTRICT: Historic District yes nou
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resi Non- Residential
Ne ilding Onefamily
Addition wo or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
We11 Floodplain Wetlands Watershed District
Water/Sewe
DESCRIPTIONOF�WORK TO BE PREFORMED: ,
maid n 16
Identi cation.,Plgga_s�e��,Type or Print Clearly) r
OWNER: Name: Phone:
Phone:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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: $ L-�� 'I, S FEE: $ S ��
Check No.: ( '�-L � Receipt No.: �a I
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner V41r -
Signature of contractor
Location Ca /() ��
No. Date a
TOWN OF NORTH ANDOVER
3? .. OAL
' Certificate of Occupancy $
i e� . ..r... +• •
sACMUst�� Building/Frame Permit Fee $ � rr
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
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 ' ? Z> Signature
r
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
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/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 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
a
Uy
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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 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 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 2.2008
NORTH
Town of : Andover
0
o A K E dover, Mass.,
COCMICME W ICK
ADRATE D
`s BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
lb BUILDING INSPECTOR
THIS CERTIFIES THAT....... ......... �.......... .. .. .1.4h.................. ...... .............. .....................................
Foundation
...... buildings 1 ....................... Rough
has permission to erect.. ..1..... gs on ... . .1...........................
to be occupied as...... ......... .... d..........�1................A.6#.& .......... .�.� ..�.................. Chimney
Ch'
provided that the person ccepting this permit shall In every respect conform to the terms 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
S
00" PERMIT EXPIRES IN NTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU O T TS Rough
........................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place o'n the Premises — Do Not Remove Final
No Lathing or D' 7 Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Printing Property Page 1 of 1
Print
Owners OUELLETTE, JASON
Owner2 PAMELA L OUELLETTE
Address 121 COLGATE DRIVE
Map/Lot 074.0-0017-0000.0
Lot Size 20038 sq. ft.
Fiscal Year 2007
Land Use Code 101
Last Sale Date 8/24/2001 12:00:00 AM
Book/Page
Total Valuation $410000
Building Type SL
Year Built 1961
Finished Area 1961 sq. ft.
Assessor Map NorthAndoverAssessorMap74_26x36.pdf
http://maps.mvpc.org/NorthAndovermimap/Identify.aspx?datatab=PareelBasic&id=074.0-0... 6/2/2009
Town of North Andover Page 1 of 1
QBasZoning 2005 Aerials Watershed Zone Utilities SizeO❑� Selection Legend
e Map Location Markup
Q I Q Help Scale 1"= 21 ft Select - Parcels
(show all)
074B-00 14 OwnerAddress Lot Size
074A-0009 OUELLETTE,JASON 121 COLGATE DRIVE 20038
0746-0009
0740-0010
074 ON n
7 1 selected To Mailing Labels To Spreadsheet
r 0746-0017
C Property
Print
Ownerl OUELLETTE,JASON
Owner2 PAMELA L OUELLETTE
Address 121 COLGATE DRIVE
um"211 Map/Lot 074.0-0017-0000.0
S8 V404M Lot Size 20038 sq.ft.
0743016 Fiscal Year 2007
Land Use 101
TL Code
Last Sale 8/24/2001 12:00:00 AM
Get Pictometry Image- Go v2.5[beta 27 AppGeo Save Map as Image
http://maps.mvpc.org/NorthAndovermimapNiewer.aspx 6/2/2009
The Commaerwealth of Massachusetts
kf ,I Department of Industria!Accidents
Office of Investigations .
600 Nrashingion Street
Boston, MA 02111
WWW n2QSs.90VI&
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A P licant Information
Please Print Le-ibl
Nanle(Business/organization/individual):
Address: e(� .�� ( ,
City/state/Zip: N(�rah (A OV .lam Phone#: .
Are you an employer?Cheek.the appropriate box:
I.❑ I am a employer with 4. Type of Prelim(requites:
❑ I am a general contractor and I
employees(full and/or part-time).* have Dred the sub-contractors 6• ❑New construction
2.❑ I am.a.sole proprietor or partner- listed on the attached sheet._ 7• ❑Remodeling
ship and have no employees These sub-contractors have
workingfar me in any capacity. g Q Demolition
act workers' comp.insurance.
[No workers comp.insurance 5. 9• [�Building addition
p ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3 1 am a homeowner doing all work right of exemption per MGL 11. Plumbin
myself. ❑ g repairs or additions
[No workers'comp, C. 1S2, §1(4),and we have no 12.E]Roof
insurance required.]t em to ees repairs
P Y [No workers'
comp. insurance required.] 13.❑.Other
•Any applicant that checks boy'#I mutt also fill out the section below showing their workers'compensation Policy in t homeowners who submit this aff'i'davit indicating they ars doing an work end then hire outside contractors must submit a new affidavit indication such
;Contractors that check this box rnusrattach-d an additioaat shee showing.the name of the sub-commotors and their workers'cern,".Policy irfnrmstion.
!air an employer that is proving workers'compensation insurance for my employees: Below is thep lco '
informado2 cy and jod site .
Insurance Company Name: '
Policy#or Self-ins.Lie.#:
Expiration Bate:
Job Site Address:
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 p to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a S'L'OP WORK ORDER and a fine
UP
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 her under the pains and penalties o e '
rP r!ury that the information provided above is true and correct
SrMAJA
Date:
rof
—3 s
se only. Do not write in this area,to be coarpleted by s ity or town 0 IciaL
wn: Permit/License#
uthority(circle one):
f Health 2.Building Department 3.City/Town Cierk 4. Electrical Inspector 5. Plumbing la4peetorerson• Phone#:
Information a end Instructions
Massachusetts General Laws chapter 152 requires all emp 3 oyms to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, -
express or implied,oral or writton."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the'foregoing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other iegal entity,employing employees.'however the
owner of a dwelling house having not more thin three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work m such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"everystate or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or ft construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insumnee'coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the pmformariee of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation•affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s),address(cs)Band phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'co�rnpensation insurance. if an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Deparhnent of Industrial
Accidents for confirmation of insurance coverage.. Also'be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not`the Department of
industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
oompensation policy,pieasccail the Department at the numberlisted below, Self-insured companies should enter their
self insurance'lieense number on the•appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which vvilI be used as a reference number. In addition,an applicant
that must submit multiple pennit/licerm applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of'the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your caoperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of ndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0:2111
TeL#617-727-4900 ax t 406 or 1-8.77-MASSAFE
Fax#617-727-7749r
Revised 5-26-QS wwwman.gov/dia
f NORTo# TOWN OF NORTH ANDOVER
61
• _ :• oM OFFICE OF
BUILDING DEPARTMENT
" ' * 1600 Osgood Street Building 20, Suite 2-36
North Andover Massachusetts 01845
Ss�cwustt
Gerald A Brown Telephone(978)699-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please mint
1
DATE:
JOB LOCATION: (,41
Number treat Addressp
HOMEOWNER_ RYYIQ,(Gt
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
No r4i 6(.Yi d w&r I�Gi 01 15
City Town Stats Zip Code
The current exemption for"homeowners"was extended to include Owner-occupied dwellings t0 two units or less
and to allow such homeowners to engage an mdmdmd for hue who does not possess a license,pmvided that the
owner acts as supervisor). State Building (Code mon 108.3.5.1)
DEFINITION OF HOMEOWNER
Persons)who owns a parcel of Ind on which he/she resides or intends to reside,on which there is,or is intended
to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned"homeownce assumes reR=srbility for c0mlrli2nces with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that helshe understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
ements.
HOMEOWNERS SIGNATURE
n
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Foam Homeowners Emnop im
ROARD OF 1PPEAL S 688 x)5+1 CON SER V.VF1ON'689-9530 IiE.11 T1i 689-9510 �
PLANNING bug-1535
R
May 20 09 06:33p Dave Dufresne 603-642-9906 p.1
4 Family Pools North
D �( 45 Route 125,Kingston,NH 03848
Tel:(603)642-9909 Fax:(603)642-9906
Name e'vv /' f01/1 Date
Address /02/ d. ct 'g Pr, City . 4.0.''ky—e-r State Zip CJ! V5
Phone: Upofe 778—_s/Work Cell Add'1#5r7 lf, Lr-jC)i7 7
We propose to furnish one(1):
1. Pool Package of the Type: 0 Bronze, ❑Silver, C Gold,Xiatinum, C Custom
2. Pool Type: C Vantage, 0 Family Ties, 0 Crestwood, Other �r��� heef
3. For a sum of $ _�, / ,
THIS PRICE INCLUDES: See Attachment A for Details
INSTALLATIONS: Payment for installation is payable to install crew at time of install. Initials
1. rNSTALLATION of above noted pool kit: and Base. 0 Pool Base S
• Level around to withino.5 ft of existing rade. • Block under pool verticals.
• Pool/filter/pump Set-u •
2. ESTIMATED HOURS of MACHINE TIME AT S75 PER HOUR= S
THIS PRICE DOES NOT INCLUDE:
1. Electrician to BOND&GROUND POOL(Family Pools can arrange for Electrician. Payment due at time of work.)
2. Any machine time in excess of that estimated above.(To be billed at the same rate as above).
3. Removal or dumping of any materials disturbed for the purpose of pool installation including,but not limited to,soils,stone,
rock,sod,shrubs,trees,or stumps.
4. Repair to any lawns,shrubs,sprinkler systems,or driveways as a result of equipment access to swimming pool area.
5. Trucked in Water.
CUSTOMER IS RESPONSIBLE FOR: �� Initials
I. Obtaining building and electrical permits or to assume the costs of necessary permits.
2. Supplying access for all trucks and equipment.
3. Electricforpump.
4. Water to fill pool.
NOTES:
OPTIONS TOTALS
Deck Ladder -$ Basic Pool Price $ : ex,
Filter Upgrade $ Options $
Liner U rade $ 7-7tt -ke A! gov-.0e.
• Liner Receiver($6.50 x $ Subtotal $ 12j
Winter Cover ( $ Sales Tax %
Heater ( } $ Total $ 7,Q
OTHER $ Less Down payment $ 00, ab
Sub-Total $ Balance of Contract $-3 f
KIT ONLY PAYMENTS: 50%Deposit w/Order 50%Upon Delivery
W/INSTALLATION: 35% Deposit w/Order 35%Upon Start of Installation 30%@ Completion
The buyer hereby agrees to pay in full the total amount of this transaction upon Start-up/Delivery of the contracted pool. Changes
from the above contract are subject to charges where applicable. You.the Buyer,may cancel this transaction at any time prior to
midnight of the third business day after the date of this transaction. CREDIT CARD payments are not accepted for Installation
amounts.
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