HomeMy WebLinkAboutBuilding Permit #557-14 - 22 BUCKLIN ROAD 1/24/2014 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0:
Date Received
Date Issued: i Lf
IMPORTANT:Applicant must complete all items on this page
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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
ARepair, replacement ) ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
� � '= �rFloodplaiii 1,Wetlantls �,b'' �',I E,1'6 shed District
❑ Septic t,❑Well
st � r.'}�- ,'�n•%r�t`c'+rf ' '�` '� }��
(]lWate(�SeW2f� Baa r* A Viz. ` t: zr � 3a°a"a �to rra� i
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly) 9i ' .02DYT t �(
OWNER: Name. 4- Al-Ac-to-L6
Phone: o/I
Address: ,t�i�r fC,L� �► iy�� 1 -� 111 i� n�
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C®NTR;4CTQR� NameoiJ (� ,�� � c
_ ! Phone 1 /
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icense
mHomerlprovementell.
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: $ _FEE: $ 3
�.
Check No.: "� Receipt No.:
NOTE. Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owhor Siginature of contractor
-- _ n r,r_.__ .A►-:.. A F-1 r'^r+;+;nrl Dln+ Plan F1 Rtamnp-d Plans ❑
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Location
y
No. G"'__ l� 1
Date
' TOWN OF NORTH ANDOVER i
• �� ED 1
Certificate of Occupancy _
r
Building/Frame Permit Fee $1 J
Foundation Permit Fee _
Other Permit Fee $
TOTAL
j
Check# �
2 7 2 Ed
Building Inspector
Plans Submitted ❑ Plans Waived"❑ Certified Plot Plan ❑ Stamped Plans ❑
.-TI'PE OF:SEWERAGEDiSP:OSAL"
Public Sewer ❑ Tanning/MassageBodyArt ❑. . ..Swing Pools ❑
Well ❑ . Tobacco.Sales ❑
Food Packaging/Sales ❑
Private(septic tank, etc... ❑- permanent
Dum s
ter o
p n Site ❑
t
THE '
FOLLOWING WING SECTIONS FOR-OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
>. DATE REJECTED: DATEA_PPR.OVED
PLANNING & DEVELOPMENT ❑ (�
COMMENTS
.CONSERVATION Reviewed on Si nature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
i
i
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes ..
Planning Board Decision: Comments
Conservation Decision:
Comments
F
s Water & Sewer ConnectionlSi nature& Date
Driveway Permit
DPW Tovyi2 Engineer: Signature:
FIRE C3'EPARTIellrei�T Temp Dumpster on site e5 Located 384 Osgood Street
Located-at 124 Main Street no
Fire Departinerit signatuire/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
E:::EQ::l :Notffied for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The fohowing 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
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o Floor Plan Or Proposed Interior Work
o 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
Li Certified Surveyed Plot Plan
o Workers Comp Affidavit
Li 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 A
o Mass check Energy Compliance Report (If Applicable)
)
o 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
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable) -
o Copy of Contract
❑ Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the api),al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Buhding Permit Revised 2012
� NORTI.I �
Town of E •.,,, ndover
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h v ver, Mass
cocH1cHew�cK y1.
S tl
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT1441016C "r.0.�.......... BUILDING INSPECTOR
................. ....... ..... .....................................................
has permission to erect .......................... buildings on ....... ...... .�.............. Foundation
"accept�in
Rough
to be occupied as ........ ....'fi...r ./�,v ...... ........................................ Chimney
provided that the persos permit shall in every respec onform 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 CONSTRUCTI ST S Rough
Service
.............. .. .. ...................................................... Final
BUILDING INSPECTOR
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.
SEE REVERSE SIDE
/Z -1 If
Office of Consumer f-ffi-s aad.business Rea iat;on
f 10 Park Plaza- Suite 5170
Boston,3viass4,c�usetts 0211:6
H ►vnprozTenaent;ConaCtoY Registration-
QUINN'S COMSTRUC T ION
THOMASQUINN-1. -
868 MAMMOTH RQ.
Q
RACUT. MIA 08_6 -
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DOS-CAA u SWM-W044101216 -
Consumer
ns Z=r Affa;.r.:ct./1/r r egs/legulat/rr..;clf: License or registration valid for individal use only
Office of Consumer Affairs&Business R lation I� Y
ME IMPROVEMENT CONTRACTOR _ before the expiration date. if found return to:
eg�straEion: 121604 Type:
DBA Office of Consumer Affairs and Business Regulation
V
10 Park Plaza-Suite 51 0
' piration: 5/24/2014. -
Boston,MA 02116
QUINMS CONSTRUCTION
THOMAS QUINN ¢ "
868 MAMMOTH RD.
DRACUT;MA-01826 —a
Undersecretary Not valid without signature
�:�urueaee�:al�a%Gl�arsu�erselE
O&3cc oa"Consumer (fairs $usiness Rea tlQfion License of regisa ation-valid for indheidul use ouiy
IMPROVEMENT CONTRtAC i OR before the expirs:ioz date. f#*oimd reatrnto:
L i egisimflon- 121604 Type: Office of Consumer 41-41and Business Regulation
3' .:piraon, 512412014. DBA 10 Park P1am-Suite 51 70
Boston.111A 021-i6
QUINMS CONSTRUCTION
THOMAS QUINN
868 MAi UVIOTH RD.
DRAW T,MA-07820
Underseerctarnr
Not.valid Mont signature
~ Gswach�rsAt W_ epertmenf'of Pubiic-Safev,;
Board cf Building Reguiatons �€3ri�StE�i��t S� i�rtYSSiE�CC2t�-311 _'��Ot i 1S use a OUP which
Cunktru(:tj n contain?less`i,,.n 35_400 cub3C 3eeet(991m )Of
L.Icense:CS-039732 7 en-closed space. _
THOMAS J QUM
869 h1AIV1Y CF1H RD
1DRACUT MA: 01826•
Fai[ui a to possess acur
-
,ant edition of he Massachusetts.
sta�Buiiding Code is cause for revocaeion of this license.
unfit :ssi r?ec
03/2512014ForDP5Ucensinginformatianrai� �avna.iviass.GovfOPS
The Commonwealth of Massachusetts F` Print Form J.
Department of Industrial Accidents
Office of Investigations
' I Congress Street, Suite 100
Boston, MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information1�^ Please Print LeEibly
Name(Business/Organization/Individual): &/ S /W %ac
Address: —1-,H po%fto
City/State/Zip- �bA .1 NJ� 6)9a Phone #: a -,r7 /off ('tc�
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I yp p , ( 9 red).
1.[�, I am a employer with CO ❑ g 6. ❑New construction
employees ul� nd/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance.:
9. [] Building addition
required.] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.a Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: `� i�.S2Lht
Policy#or Self-ins.Lic.#:—q- Expiration Date: /
Job Site Address: Jo� AucjLQ0 kwab City/State/Zip: V_a2Tff mx� x� lgft
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 up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and en hies gefdug that the information provided above is true and correct
Si nature: �f � – Date / a
Phone#:
Oficial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
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LL _ _ _ _ n 1 n <!„ . '. .r: Employer ID #
Z " a Tom Quinn=' UINN' COT�- TRUCTIC�l�' 27-1639714
W o z o (617) 939-1353 aa m= a ? o (978) 265-2390 868 Mammoth Roaracut, MA 01826 L /
Vz 0 y ? tom@a quinnsconstructiomcom www.quinnsconstPtcction.co»t �U�` Page 1 of 3
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J a a o 0 oa$ag�� � 5 f,/ ��'1 Job Location
m J o= an d o W a a� Mailing Address(if Different From Above)
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2 W o F ? Salesperson(s): 0 Pf7 r/ Contractor Registration#: CS-039732 Ex.Date:
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Q "p z p�W F" e REQUIRED PERMITS
(.3W o W V o H The following building permits are required. It is the obligation of the contractor to secure such permits
VW c ,_ ,.
Z X d as the homeowner's agent: List any and all necessM construction-related permits. -
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— 00 = a from the Guaranty Fund provisions of MGL c. 142A.
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z �- d - o Is an EXPRESS WARRANTY being provided by the contractor? NO YES
V0 it o " « °i **All terms of the warranty must be attached to the contract**
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° — NOTE: All home improvement contractors and subcontractors shall be registered and any inquires about a contractor or
i= Q z Z 0 s jp'�
O � w subcontractor relating to a registration should be directed to:
a a Y = 4"
o 0-.0 Director,Home Improvement Contractor Registration
Q z w W w a. m o LEz o One Ashburton Place,Room 1301
o 61�go _
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