HomeMy WebLinkAboutBuilding Permit #563 - 150 PINE RIDGE ROAD 4/2/2008 c '� "'&P000 Z Z
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BUILDING PERMIT o�tt�ED .bgti
3? 't''•- h•i6 OL
TOWN OF NORTH ANDOVER c
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received pDRATED•�'cy
9SSACHU`-+��
Date Issued: 2
IMPORTANT: Applicant must complete all items on this page
LOCATION G(t C(. tJ'
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PROPERTY OWNER '3-0 W' -k Dl`
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MAP NO: 210 PARCEL:-6�5 ZONING DISTRICT. Historic District yes 2101
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building a famil
Addition_ Two or more family Industrial
(AlteratioQ No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District.
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Ty a or Print Clearly)
OWNER: Name: -t- ClolL1,q ti �+A-� Phone: (t78 -bA-r,-S.yy 0
Address:
CONTRACTOR Name: -lrlt_� � &o a/ZaA Phone: 276-q '7-05-?-b
Address: 2 ty IT Y A. l /nay!. f Cwt wt1Sf
Supervisor's Construction License: Exp. Date:. 5 kL 08
Home Improvement License: l \ a `� Exp. Date: . t -
ARCHITECT/ENGINEER Phone:
Address. Reg. No.
FEE SCHEDULE.BULD/NG PER /T:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 000 FEE: $ 7 Z r
Check No.: 532 e--- Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the gilara and
Signature of Agent/Owner Signature of contrac r
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 AffidavitIL
❑ 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)
o 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
I
i
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
SEWE( :)RAGE DISPOSAL
:Pu7blicewer 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
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
COMMENTS
t
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Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
li
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature &Date Driveway Permit
Located at 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)
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❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
• f
Location
No. Date
NORTH TOWN OF NORTH ANDOVER
Of •.So
' Certificate of Occupancy $
s�cMus Building/Frame Permit Fee $ 7z-
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ '
a
Check # ��'� 9
21038 1w�,
ilding Inspector
xAORTH
Town of Andover
AWL
NoX 'w
G 3
LAK oL' dover, Mass.,
I� C0CH1CKEWICK y
ORATED PPS` �C.1
`s BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
ccam�-- BUILDING INSPECTOR
THIS CERTIFIES THAT.........�.�.f'�...� . a�
SO.:........ ..:......... '. ... ...
• • • Foundation
has permission to erect........................................ buildings on ../........... 1..............�1........... ................... Rough
to be occupied as � !:1�1... e�,r - !.�'•' ... r�' . �f':... :......�1 `� J/f?' Chimney
... ............... .... ... ... .c5�...........�......
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, 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 TARTS Rough
t.......... .................. Service
BUM-DING INSPECTOR-4
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 BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
✓fie Pan�rnauuP,cr,� o�,./�aoaaclauaelza
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:- 111089
Expiration: 1/25/2008 Tr# 124541
Type: Partnership
QUINLAN&RAND BUILDERS ,
TIMOTHY QUINLAN . 7
34 TRINITY CT gam `
N ANDOVER,MA 01845 Administrator
T Poa� /Gl�o��le�o
rril- BOARD OF BUILDING REGULATIONS
r License: CONSTRUCTION SUPERVISOR
Number.-GQ. 055283
fi A Birthdate 05/16/1960
Expires':05/16/2008 Tr.no: 25589
Restricted, 00 f ,
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JEFFREY D RAND
205 GOLDEN HILL AVE f` G
HAVERHILL, MA 01830- " ZAZ
Commissioner
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: 15-0 P(I-r` j2oak PO, is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c115S150A,.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
l OA.
The debris will be disposed of in:
C3 - �ZL� �(z o1-61K`—Z w.ti
(Location of Facility)
Sign re of Permit Applicant
y1 Z 6 10,
Date
The Commonwealth of Massachusetts
Department oflndustrW Accidents
Office of Investigations
600 Wiishington Street
.Boston, MA 02111
www.mass.gov/dna
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers
A Brant Information
Please Print Le 'bI
Name (Business/Organization/Individual):_ �y i h1(-1�'h�
13v�c.�C2S _
Address: . Z ov fr-IrC ,
City/State/Zip.._ Phone.#: .7e -t(S 7. —p(�_Zv .
o
Are you an employer? Check the appropriate box:
1.❑ I am a employer with ' 4. ❑ I am a general contractor and IFi&Rmwdeling
ject(required):.,
employees (fiill and/or part-time).* have hired the sub-contractors construction
2.�I am a'sole proprietor or partner- listed on the attached sheet
ship and have no employees These sub-contractors have
working forme in as c aci to ees lition
Y ap �P Y and have w '�'• orkers[No workers' co , co .ins 'inct►ranCe $ ' •auranc ddimP mp e. ing fion
required.] 5. [� We are a corporation and its ical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their
myself. right 11.❑Plumbing repairs or additions
Y [No workers' co ri t of exemption per MGL
insurance required.]t c. 152, §1(4), and we have no 12.❑Roof repairs
employees. [No workers' 13.[] Other
comp,insurance required:]
`Any applicant that checks box
#1 must also fill out the section below showing
their workers'
t Ars ameoa:zewho subnsit this affidavit indicating they compensation policy information.
are doing all work and thea hire outside contra ton must submit a new affidavit indicating such.
'COM--torr,that check this box must attached an additional sheet showing the name of the sub-contrectoss and state whether or not those entitie
employees. if the sub-contractors.have employees,they must provide their work=,comp:policy number, s nava
I am an employer that is providing workers'compensation insu
information. rance for my employees Below is the policy.and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
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.
15
fine up to$1,500.00 and/or one-year � 2 can lead to the imposition of crimtnal penalizes-of a
y 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 covers a verification.
Ido hereby cern under e p ' pe 'es of perjury that the informaimn provided above is true and correct
Si atuie:
p Date: 2 .D v
Phone#.: ( 7
OfficiaL.use only. Do not-write in this area, to be completed by cuy or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town C
Other, lerk 4.Electrical Inspector 5.Plumbing Inspector
6.
Contact person:
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every p=rson in the service of another under any contract of hire,
express or implied,oral or written." r
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 including the legal representatives of a deceased employer,or the
receiver or trustee-of an'individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartazents and who resides therein, or the.occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on 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"every state or local licensing agency shall withhold the is or'
renewal of a license or permit to,opera'tem business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=npliance with the insurance coverage required." '
Additionally,MGL chapter 1,52, §25CO) states'"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for.the performance 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 coripletely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s), address(es) and 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'.compensation insurance. If.an LLC or LLP does have
employees., a policy is required. Be advised that this affidavit maybe submitted to the Department 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,orif you.are required to obtain a workers'
compensation policy,please call'the Department at the number listed below. Self-insured companies should.enter their
self-insurance license 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 sureto fill in the p=nit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitlhcense applications is 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.Where 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 burn leaves etc.) said person is 1-40T required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation 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 Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4300 ext 4-W or 1-877 1\4ASSAFE
Fax # f 17-727-7749
Revised 11-X22-06 _
ww w-mass-gov/dia
Quinlan & Rand.
IBUHLDERS
34 Trinity Court
North Andover,MA 01845
Phone 508-682-1570 • 508-521-4196
Prop 0 S a l Page No. of Pages
PROPOSAL SUBMITTE`D'TO� PHONE DATE f
STREET JOB NAME
CITY, STATE AND ZIP CODE r JOB LOCATION
Ai_06\1N. OL(3 Lj 15 S AIN►(t_
ARCHITECT DATE OF PLANS JOB PHONE
We hereby propose to furnish materials and labor necessary for the completion of:
V UJ 60-W(ti.G JV STa(Z A-C* )i Pill 61V O
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-- `SINSrq:c__ . tuct"(1112AL 01yTL_C,:jt -t liZL(j_cx64c. OTig—li
Atmel, —VA CC\ M U 9 -A-S AAJ�
WE PROPOSE hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
OtAC v L4ti-� y r>C— ,OV1
dollars ($ ` U )
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a substantial
workmanlike manner according to specification submitted,per standard practices. Any altera- Authorized
tion or deviation from above specifications involving extra costs will be executed only upon Signature
written orders,and will become an extra charge over and above the estimate. All agreements Note: This proposal may
contingent upon strikes,accidents,or delays beyond our control. Owner to carry fire,tornado withdrawn by us if not a epted within days.
and other necessary insurance. All subcontractors are covered by personal liability insurance.
ACCEPTANCE OF PROPOSAL The above prices, specifications and condi-
tions are satisfactory and are hereby accepted. You are authorized to do the work
as specified. Payment will be made as outline above. Signature
Date of Acceptance: Signature