HomeMy WebLinkAboutBuilding Permit #Exception - 21 FULLER MEADOW ROAD 12/3/2014Permit No#:
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
I IMPORTANT: Applicant must complete all items on this page I
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
[I Addition
0 Two or more family
0 Industrial
0 Alteration
No. of units:
11 Commercial
[I Repair, replacement
0 Assessory Bldg
11 Others:
0 Demolition
[I Other
0 Septic []Well
[I Floodplain 11 Wetlands
0 Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Aritimcc-
I Contractor Name: Phone:
Address:
Supervisor's Construction License:
Home Improvement License:
Exp. Date:
p. Date:
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE S . CHEDULE.BULDING PERMIT.'$12.00 PER $1000.00 OF THE TOTAL ESUMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: = ` ' Receipt No.: , , -
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
8ig'na,tu-re of Ag e--n-t-/-O-wn-er-- Signature of contractor
Location �?- I , I thi
No. G -1 �—I<
Check #17-04
0.
Date
TOWN OF NORTH ANDOVER -4
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
Or
Plans Submitted El Plans Waived Certified Plot Plan El Stamped Plans
TypF OF SEWERAGE DISPOSAL
Public Sewer El
Tanning/Massage/Body Art
Swinuning Pools
Well El
Tobacco Sales
Food Packaging/Sales 11
Private (septic tank, etc. 11
Pernianent Dumpster on Site F1
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Sianature
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 Con nection/sig nature & Date Driveway Permit
DPW Town Engineer: Signature:
I FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street - ,
Fire Department signature/date
COMMENTS
Located 384 USgOOd btreet
no
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 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For department use)
L1 Notified for pickup Call Email
Date Time Contact Name
- - - - - - - - - . . .. . .... ...................
Doc.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.
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
u Building Permit Application
Lj Certified Surveyed Plot Plan
• Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
Lj Copy Of Contract
Lj Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Mass check Energy Compliance Report (If Applicable)
Ei 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)
u Building Permit Application
Ei Certified Proposed Plot Plan
• Photo of H.I.C. And C.S.L. Licenses
• Workers Comp Affidavit
Lj 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
Doe: Building Permit Revised 2014
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Department ofindusmfdAeridents
Offlee of lnve'�qgadons
600 W
ashington Street
Boston, MA 02111
wwmassgovIdla
Workers' Compensation Insurance Affidavit Builders/Co . ntraktors/Electridans/Plumbers
ApylicantlaforMatio&___ -glesse PAA �Les&N
v Name
,Address: k \,k
". City/State/Zip: ( �,03-Uoo—�Oc5
Q �A '33 QOne
Aie you in empidyer? Check ther appropriate box;
I.. C3 I am a tmployer;�ith
4. CJ I am a general r�ojltracta� and I
C113P10YCC3 (M MWOr PMT -time).*
bave hiied. the mib-coutt"actors
2.'Cl 1 mn a s61c proprietor or pumer-
listed ofi the attached sheet'
sbfp and have no employees
These sub.CMMCM Uve
-working for me in any capadity.
'(No
workers, cotm. insurance.
S. C1 We are a corporation and its
workers' comp. U=ance,
required.l..
officers have exercised their.
3. F1 I am a tomeowner doing all wo'rk
right of exemotion per NMGL.
myself [No workers' comp.'
c. 152, 1 1�4), and we have no
insurance required.]
eMloyces. [No woTkers'
cornp. ins�rance requited.]
Type9f project (req*ed):
6. 0 i4ew coi�tructiou
7, [3 RimmdeUng
n peimoution
9. C]. Building addition
10-0 ElectLical repairs or additions
I IQ gl�uftg repairs or additi6ns
12,C] Roof repairs
13)Q 014tj WQW) b LA ('rl
Any ipplicnatthat checks box A must also 191 outthe section below showing tbatrwoftml policy infinmtlon:
Homeommas who submit Oda affidavit indi=ting they are."& all wo'& sritd ten him outside aamftrs must subn* a now afildavit indicating such.
tc- OnUuton that check this lxm must attsehad.An addid=4 shest showfiii is naft of the sub-contmotors and their *�*arsf .
map. policy womutioil.
I am an employer thal is providing w4rkarsl c6nspemaden insurancefior my 9mp10ee&r.BWow-1s thepollcy andjpb site
Information.
insurance Company
0 U4
�Poficy # or. Self -ins. Lic, M.
Expiration Date: 0
Job.Sitc Addriss: 2 _P 1-d '—City/Stateizip..
Attach a to" of the workers' com*sxdon policy declaration page (showing the policy n"suber and expiration date).
Failure to semfe coverage as required =der 8ection 15A of biGL c..152 can lead to the imposition of crimin4penalties of a
6ne up to S1,500.00 and/or one-year imprisoumeu� as well as ci4 penalties i1i the fbmof a STOP W' ORK ORDER and irme
of up to -S250.00 a day against the� vialwor. Be advised that a copy of this statem6t =y be fbrWarded.to
the Of 6cc of
Investigations'of the DIA for insufance cdv�rage verification.
I do hereby ceMp under thepaim and penafi* ipfpedury that the Information provided abevc Is true, and coo
vSimatur
Official use ettly. Do'not write In this area, to be completed by cilty or town offleiaL
Clt.Y!Dr Town: PermittUcense-#
IssHfug Authartty (�ircle one):
L.Board of Health. 2. Building-Depurtment 3. Cityrrowu Clark 4. EleMical Inspector S. plu�tbin% Inspector
*6. Other
Contact Person: P -hone
UMMIMIzorunij r1nr-r ime i— we-- e — si
7 Summer Street
CHELMSFORD, MA01824
www.cheimsfordfireplace.com
TEL (978) 256-6328
FAX (978) 250-9474 %OAM PHONE
EMAIL cheimfire@aol.com
SHII
TO
9LSTOME��IL
M 0*
OM -44MAM
'Z
r VWD FOR
30 rJAYS 21130
cw-_- � �- j 7D;�
No Refunds on Special Orders. No refunds after 30 days.
Payment due upon time of order.
All dimensions given by customer are not the responsibility of C -F C.
p�rmit fees and addi�ioq�l P
�Pe e�xtra.'
Fireplace Width: �fir Depth-��YRear Width: Rear Height:
,�.Height:
Customer Signature:
-7
0'V
72-�
3yfl
rlDJATE (MM/DDNYYY)
ACQRAD CERTIFICATE OF LIABILITY INSURANCE /12/2014
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. 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). CONT CTiesse Germain
PRODUCER NAMP
PHONE XC, No)* (603) 641-9849
Foy Insurance Group - Manchester (AIC A No r-ki). (603) 641-8111
E -M 'L
1889 Elm St ADDRESS: NAIC #
Manchester NH 03104 INSURER A 'Merchants Mutual Insurance 3329
INSURED INSURER B:
STEPHEN BRISSETTE INSURERC:
291 WEST ERIE STREET INSURER D:
IMANCHESTER NH 03102-5058 1 INSURER F : I i
COVERAGES CERTIFICATE NUMBER:CL1411738388 REVISION NUMBER:
THIS IS 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 THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
JAD,,DLI LDC LIMITS
'LNTS,R TYPE OF INSURANCE POLICY NUMBER (MMIDDIYYYYI (MMI M �ACH OCCURRENCE $ 1,000,000
GENERAL LIABILITY DAMAUE T5 REN I tL) 500,000
PREMISES (Ea occurrence $ -
X COMMERCIAL GENERAL LIABILITY 7/11/2014 7/11/2015 'MED EXP (Any one person) $ 15,000
A CLAIMS -MADE I—XI OCCUR oP9097148
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OP AGG $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: $
_X1 POLICY F � iPFRCO� 7 LOC COMBINED)SINGLE LIMIT $
AUTOMOBILE LIABILITY (Ea acciden 1,000,000
BODILY INJURY (Per person) $
A ANY AUTO 10/21/2014 1.0/21/2015 BODILY INJURY (Per accident) $
ALL OWNED SCHEDULED :API040224
AUTOS AUTOS PROPER-ZDAMAGE $
NON -OWNED (Per ..1, 1
X HIRED AUTOS AUTOS $ 5,000
X Comp $250 MX Coll $500 Medical Expense
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE AGGREGATE $ —
DFD RETENTION$ X I TWC,9TATU' OTH-
CRY LIIU
A WORKERS COMPENSATION Tj
AND EMPLOYERS' LIABILITY Y/N E.L. EACH ACCIDENT $ 5
ANY PROPRIETOR/PARTNER/EXECUTIVE A State NH 00 000
N NIA 10/4/2014 10/4/2015 L I S Loy $
OFFICER/MEMBER EXCL WCAI033879 E.L. DISEASE - EA EMPLOYE $ 500 000
(Mandatory in NH) 00 000
E.L. DISEASE - POLICY LIMIT $ 500 000
If �'Ss6R'1psT1'0N uO'F"O'PERATIONS b.l..
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If 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 THE POLICY PROVISIONS.
Bill Kissel
21 Fuller Meadow Road AUTHORIZED REPRESENTATIVE
N. Andover, MA
ACORD 25 (2010/05)
INS025 (,)oions) ni
Lisa� Bisson/MMACY
@ 1988-2010 ACORD CORPORATION. All rights reserved.
Tho Ar.OPr) n=ma nnril Innf% mra ranieforarl mnrke ^f Arnpn
0
TURN YOUR OLD, DRAFTY FIREPLACE INTO AN ENERGY EFFICIENT SHOWPIECE.
DIMENSIONS
Minimum Fireplace Opening
291/4"W x 23%"H x 181/2"D x 25"W (rear)
27"W x 211/2"H x 171/z"D x 221/2"W (rear)
141/2 " D when installing with 3 " projection kit
Actual Size
311/2"W x 26'/16"H x 25%"D
301/2'W x 221/4"H x 171/4"D
Glass Viewing Area
330 sq. in.
272 sq. in.
Flue Size
6"
6"
Firebox Capacity
Up to 40 lbs.
Up to 30 lbs.
Log Size
Up to 22
Up to 22"
HEATING CAPACITY
Burn Time Up to 12 hours Up to 10 hours
Approx. Heating Area' Up to 2,000 sq. ft. Up to 1,500 sq. ft.
Maximum Heat OUtpUt2 55,000 BTU/hour 40,000 BTU/hour
Heat Distribution 150 cfm twin cylindrical blowers included 150 cfm twin cylindrical blowers included
TECHNICAL SPECIFICATIONS
Efficiency 75% 75%
Emission (Grams/Hr.) 3.6 grams/hour 3.0 grams/hour
CLEARANCES
to Side Trim (max. projection 1112
223/4" (from center of insert)
21 " (from center of insert)
to Side Trim (projection > 1112
Northfield cast iron in Classic Black
Mead cast iron traditional in Classic Black or Majolica Brown
Surrounds
311/4
2 61/2
to Side Wall
Exeter steel in Classic Black
Caprice cast iron profile in Classic Black
to Mantel (12 " projection)
43
47'/2" (flush mount), 441/2" (with 3" projection kit)
to Top Trim (max. projection 11/2
41
471/2" (flush mount), 361/2" (with 3" projection kit)
Base Risers
extend 8" on either side (441/4" total)
extend 8" on either side (461/2" total)
Floor Protection (11/2 " min. thickness)
extend 18 " f rom f ront of insert4
extend 18" from front of insert (25" total)'
with optional 3 " projection kit - 16" from front of insert
ACCESSORIES
'These values are based on operation in building -code conforming homes under typical winter climate conditions. If your home is of nonstandard construction (e.g. unusually well insulated, not insulated, built
underground, etc.) or if you live in a more severe or more temperate climate, these figures may not apply. Since so many variables affect performance, consult your Vermont Castings authorized dealer to
determine realistic expectations for your home.
2These values can also vary depending on how the unit is operated, and the type and moisture
content of the fuel used. These values are based on maximum fuel consumption obtained under
laboratory conditions and on average efficiencies.
'In the US, if the insert is elevated 21h" or more, no thermal or ember protection is
necessary beyond 16'.
fln the US, if the insert is elevated 2112" or more, no thermal or ember protection is
necessary beyond 16".
WkN�QN
CASTIN S
THE ART OF WARMING YOUR HOME
Made In
the USA
Warning: Hot glass will cause
149 Cleveland Drive burns. Do not touch glass
Paris, Kentucky 40361 L us until cooled- Never allow
UL c@ M E M 8 IF R
vermontcastings.com I L) LISTED children to touch glass.
To avoid personal injury or property damage, the product described by this brochure must be installed, operated and maintained in strict compliance with the instructions packaged with the product and a[I
applicable building or fire codes. Contact local building or fire officials about restrictions and installation inspection requirements- All photographs and drawings in this brochure are for illustrative purposes
only and are not intended for, nor should they be used as a substitute for the instructions packaged with the unit. Appearance and specifications of the product are subject to change without notice.
02014 Vermont Castings Group
VC 1314 v1
Georgian cast iron square in Classic Black or Majolica Brown
Northfield cast iron in Classic Black
Mead cast iron traditional in Classic Black or Majolica Brown
Surrounds
Exeter steel in Classic Black
Caprice cast iron profile in Classic Black
Steel surround in 2 sizes
Projection Kit
M3PKCB 3 " projection kit in Classic Black
Base Risers
Trim kit base riser in 3 sizes, Classic Black
'These values are based on operation in building -code conforming homes under typical winter climate conditions. If your home is of nonstandard construction (e.g. unusually well insulated, not insulated, built
underground, etc.) or if you live in a more severe or more temperate climate, these figures may not apply. Since so many variables affect performance, consult your Vermont Castings authorized dealer to
determine realistic expectations for your home.
2These values can also vary depending on how the unit is operated, and the type and moisture
content of the fuel used. These values are based on maximum fuel consumption obtained under
laboratory conditions and on average efficiencies.
'In the US, if the insert is elevated 21h" or more, no thermal or ember protection is
necessary beyond 16'.
fln the US, if the insert is elevated 2112" or more, no thermal or ember protection is
necessary beyond 16".
WkN�QN
CASTIN S
THE ART OF WARMING YOUR HOME
Made In
the USA
Warning: Hot glass will cause
149 Cleveland Drive burns. Do not touch glass
Paris, Kentucky 40361 L us until cooled- Never allow
UL c@ M E M 8 IF R
vermontcastings.com I L) LISTED children to touch glass.
To avoid personal injury or property damage, the product described by this brochure must be installed, operated and maintained in strict compliance with the instructions packaged with the product and a[I
applicable building or fire codes. Contact local building or fire officials about restrictions and installation inspection requirements- All photographs and drawings in this brochure are for illustrative purposes
only and are not intended for, nor should they be used as a substitute for the instructions packaged with the unit. Appearance and specifications of the product are subject to change without notice.
02014 Vermont Castings Group
VC 1314 v1