HomeMy WebLinkAboutBuilding Permit #659-2017 - 1661 GREAT POND ROAD 5/1/2018 �ORTy
BUILDING PERMIT
a � �{ TOWN OF NORTH ANDOVER
APPLICATION FORLAMINATION ., T
Permit No#: -5 ' l ate Received
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Date Issued:
IMPORTANT:Applicant must complete all items on this page
ELOCATION}
PROPERuTY OWNER`' - -C �--
F Pnnt; �1DDYear Structure ye ' I nor
SPA ELS L- -� ZONING 01 TS R]CT+�r �x Historicy®rstfl tC$ ryes
mss": r' -l'x i..F.i --a..-,.... � -
Machin
e Shop=Village yes, Ano
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building A One family
Z Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic Oy1%Vell ❑ Floodplairi' D Wetlands Watershed Distract
• ...- .r` r -y�r" ..,;i� �,
❑..Water/Sewer.,.
DESCRIPTION OF WORK TO DE PERFORMED:
Waal FvikmEA z e C ST'S )R'
Identification- Please Type or Print Clearly'
OWNER: Name: . TK-,1- (.Lr� Phone:q28-85'Z-g61Z ,
Address: L4 �� h S Sup 2Q) �jd r �vjmt A4 0 )9(Y
T�,wvv4s .A
Contractor Name ,7�. -111.A A j A Phone: G17�- 5Z,- Z
v ^ ;_W ,.. gi'�z+"s� pi �,✓+•a'. .., y rasesSr-"'"'7,. - y �s; Ir....m•- i-'�^w^ +�-`#"*
R , �S_.rte 'e
. �4 'ta.ct: „`r 'FS =.` * s.+ r ` r #
-c�
Soo .- License S }, . _,, .r tEx 'Date
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S s' ?z
Home;ImprovemeL'icense _���,. , Exp Date
h,t;
ARCHITECT/ENGINEER — Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
�- .Total Project COSI: $ ISOc7. FEE: $ 90-'0-0
Check No.: 2 �31� Receipt No,: GIs r
NOTE: Persons contracting witli unregistere contractors do not have:access to the guaranty
S_ignature_of_Agent/O- Signature of contractor'
Plans Sub.i'nitted p Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
J
T-OF F 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
PLANNING & DEVELOPMENT Reviewed On .
�J&l Signature_ 0
.COMMENTSl
— �1 n5�► 1 �� ��--ill �le�� `,►� .a ��`1
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on I Zd Si natur
h
COMMENTS r
Zoning Board of Appeals: Variance, Petition No: 2616-001 Zoning Decision/receipt submitted yes
Planning Board Decision: �2"/(3 Comments
Conservation Decision: 7 126113 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 I
6, 12
,�
Number of Stories: -W 'k 04Total square feet of floor area, based on Exterior dimensions. Ppb
Total land area, sq. ft.: y2 ZO.S� I(A*�
to
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)
2 wa TRjfl G d
❑ Notified for pickup Call Email
ate Time Contact Name
Doe.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
I'
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/Cross Section/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
40TE: 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
4
Doe:Building Permit Revised 2014
Location 1 G" r e A PUN n
No. S `I - G 17 Date I �` t�-O '}— k,
• • TOWN OF NORTH ANDOVER
., Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# X33
l/ Building Inspector
NORTH
own o ndover No. 01
6 h , ver, Mass,
cocNicHew�cw ��'
V BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ...... L. ....... �.....1s.......................................................................... BUILDING INSPECTOR
..... ....
OF #^ , . Foundation
has permission to erect .......................... buildings on ........�1................� T N....................�................
... Rough
0 ♦IAMff� i �. t S 1� 1 It�
tobe occupied as ........ .4... ...... .................................. ............................ ................. 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 CONSTAiQQ1I T Rough
Service
.. ...... ......... . ...... ........... Final
BUILDI NSPEC R
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.
Plans Submitted N Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ❑ Swimmin 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
i
QNMOSignature—
.
PLANNING & DEVELOPMENT Reviewed On
I
CONSERVATION Reviewed on Si nature
COMMENTS (�
HEALTH Reviewed on I Zd Si natur
4��/
COMMENTS ur�Ci ( a�Q f 5eW21'
Zoning Board of Appeals:Variance, Petition No: 2oi6-odI Zoning Decision/receipt submitted yes
1
Planning Board Decision: '/(3 Comments
Conservation Decision: �26A-s 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 signatureldate
COMMENTS
-)imension
Number of Stories: IaONOM Total square feet of floor area, based on Exterior dimensions. Plus'
�
Total land area, sq. ft.: Zo aS� _ -.. GY!
tv 5
ELECTRICAL: Movement of Meter location, mast or service drop.requires approval of
Electrical Inspector Yes No
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (f=or department use)
2 wa- TRA 4
❑ Notified for pickup Call Email
ate Time Contact Name
Doc.Building Permit Revised 2014 _. .
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200'TWBUTARY A31 f13•) PROPOSED CONTOUR ..
\ i —•.i•B2—••_ EDGE Or WETLANDS °1e DATE:Mar<h241,2013 Rev
1 '\ LroDe Or WATER "-AJL SCALE T"v 20'
PLAN
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■(121.0) PROPOSED SPOT GRADE D 1
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y.• \'' , 42,720 S.F. coya �'-1 I
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\ TO GRADE NBTTe mv¢ LOCUS PLAN
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INV.iJIdO '\.p •�.- �,\ \ A23 d` REA'S POND
A WDµEOI PROPOSED ( \ •�tT� �Ak
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DA AP ROV \ 4 \ \4 '�'• ' }Y ,a '�A22 +!� i
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I HEREBY CERTIFY THAT THE PROPERTY LINES $ \ e•pvc „
SHOWN ON THIS PLAN ARE THE LINES OF EXISTING L•36' tvt •, cww.vtaa /
ONNERSHPS,AND THE LINES OF THE STREETS AND u, ^\•; s•O.o6Be B' /
WAYS SHOWN ARE THOSE OF PUBLIC OR PRIVATE L .JN v.-t B.e -
STP.EEI OR WAYS ALREADY ESTABUSHED,AND PIN(SEI) -.-. .curd NrOxutt mN• 1mT0 PN(SET) - �•
THAT NO NEW LINES FOR OOSTING OWNERSHIP OR A,a ay.-Ma v.-1mB t
FOR NEW WAYS ARE SHOWN,AND THAT THIS PLAN ua Pa°n° /°vim✓ —� — "' -
CONFORMS TO THE RULES AND REGULATIONS OF — • b;7 M.
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THE REGISTERS OF DEEDS OF MASSACHUSETTS.
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REO.PROF.LANG SURVEE ° °Y5 ay.11i.et a NY-n2.ea•
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R-T ZONING DISTRICT • .._.— POND
- RAZ' j 0 �• _ ''tr•�� •r y '
'EDGE OF.`NETT, i\ nr"v:xi"iaysT
.._— CERTIFICATION PLAN ���t+OF
1661 GREAT POND ROAD \andover PD RNORTH ANDOVER, MASS. OnSUltantS OCIODWIN
\ Prepared for in C. ��,48133
T
r TKZ, LLC • aivaos
1 East River Place
SCALE:1"=40' DATE:6-13-16 Methuen, Mass.
o tGG► GG\C- T Sas •
6 I HEREBY CERTIFY THAT THE LOCATION OF 711E STRUCTURE SHOWN ON THIS PLAN WAS DETERMINED BY A FIELD
SURVEY, CONFORMS TO THE SMACK REQUIREMENTS OF THE NORTH ANDOVER ZONING BYLAW AND IS NOT
LOCATED IN A FLOOD HAZARD AREA. /t/ ✓
pRoPREG. PROF. LAND SURVEYOR
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a 42,720 S.F.
yo R�1030.01
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NOTICE NOTICE
TO TO
� / r
EMPLOYEES9 r4 EMPLOY
EES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you
notice that I(we)have provided payment to our injured employees under the above mentioned
chapter by insuring with:
Associated Employers Insurance Company
NAME OF INSURANCE COMPANY
P_O. Box 4070 Burlington, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
WCC-500-5006517-2016A 10/01/2016- 10/01/2017
POLICY NUMBER EFFECTIVE DATES
1060 Osgood Street
M P Roberts Insurance Agency North Andover, MA 01845 (978)683-8073
NAME OF INSURANCE AGENT ADDRESS PHONE
TKZ LLC 4 High Street#201 North Andover, MA 01845
EMPLOYER ADDRESS
08/04/2016
DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYED.
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® DATE(fATUD0/YVYYi
aco�e� CERTIFICATE OF LIABILITY INSURANCE
6/21/16:
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(es)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER ACT
NAME- Sandi Munroe
M.P. Roberts Insurance Agency PHONE FAX
1060 Osgood Street EA!a 11 Exit- (978) 683-8073 No: (978) 683-3147
ADDRESS: Sandi@mprobertsinsurance.com
North Andover, MA 01845 ,Nsur>r 5 AFFORDING COVERAGE.__ ,-_- --NAIGA
1NSUR62A:ESsex insurance Co
I'MURED INSURER B:Associated,Employers Insurance
TKZ, LLC -
INSURER C
c/o TOM ZAHORUIKO --------- - - -. _
INSURER D: '.
78 GREAT POND ROAD INSURER E:
NORTH ANDOVER, MA 01845 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TI E TERMS.
EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOVW MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRi ADD�SUBA� i POIIGY EFF i POUCl EXP ,'. <
LTRI TYPEOFINSURANCE !1 t POUCY NUYDER MlOO/YYri A:!!lD6YTYY F UNITS
I
A l GENERAL LIABILITY ; i 30X4936 ! 7/13/15i 7/13/16;EACH OCCURRENCE -s ,1,000,000
DA Ah'�GE rO RENTEi) -
X!CCrrnERCInL GE>GRAl.1bTBam I 'PREtdISES CEO occure•Ir•i
...
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CLAIMS MADE ' X)OCCUR i t MED FXP(Aware nasal, -S
5,000
PFRsoN:us ADV INJURY s 1,000,000.
j i,LIENLIIAL ACCAFGATE
CEN'LAGGREGATE L68TAPPLIES PER ;PRORUCfS•(7 nPit e^AGG S
I PRa LOC I ----—-— ;E .
X.POLIcr
AUTOMOBILE LIABILITY ``I I:ONUR+I:U SIn[a t Lu.11)
ANVAUTO j 110D0.YINJORY(Par(nrtnn) '_
ALLOWDEU SCIIEUULED
AUTOS AUTOS 1I
s BODILYINJYIPoI,cc,.,til S
i UR
r NDN-11iAT1FD
HIRFDAUTOS _AUTOS i :(Per acudenl} 15
UMBRELLA LUIS OCCUR - ` ! EACH OCCUF+)2LNCE ;£
`EXCESS LIARI
CLARdS 19AD°; .RE GATE
DED RET ENTIUNa
VJORKERSCQI7PENSATION ! + iWCC5005006517-2014A 10/1115; i0J1/16 _'o)/CTviwirs' _ iii------
YIN '
g AND EMPLOYERS LIABILITY 1
ANY PROPRIETOIUPAR7NERA:XECUT1ArL I F.1.F.ACHACCIDE.Tf 5 1rDDD,000 '
OFFI(TFU&kIER EXCUDEDI NIA) -
-([aarWtory in NH) 1 'EI-DISI SL-E1 FIJPLOYrF:S 1,000,000 j
L)L)S K1PFIONtOF O t 1
'UESLCRIP RUN O'r DPL-RATION^u ts•Fi.t• EL.DISEASE-POUCYInAR S 1,000,000 1
i
DESCRIPTIONOFOPERATIONSl LOCATIONSrVE10CLES(Ana^JI ACORD 101,Additional Rem*s Schedule,ifm a spore isrequrrd) - I
1
I(
i
i
CERTIFICATE HOLDER CANCELLATION
t
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OEUVERED IN 1
TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. i
BUILDING DEPT {
1600 OSGOOD STREET AU)H0 D EPRESENTA
NORTH ANDOVER, MA 01845
I
1988-2010 ACORD CORPORATION. All rights reserved.'
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mali:
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License; CS-055417
Construction Supervisor
THOMAS D ZAHORUIKO
4 HIGH STREET SUITE 201
NORTH ANDOVER MA 01845
Expiration;
Commissioner 0410512018