HomeMy WebLinkAboutBuilding Permit #941-14 - 22 PRINCETON STREET 6/25/2014TOWN OF NORTH ANDOVER
�APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued: . L 1 12-5-11
Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION
. ..... Print
PROPERTY OWN
Prinr - I - - 100 Year Old Structure yes no
MAP NO: R57 PARCEL:-/'—/ ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT,
PROPOSED USE
Residential
Non- Residential
New Building
0 One family
,X,Addition
D Two or more family
El Industrial
11 Alteration
No. of units:
[I Commercial
11 Repair, replacement
11 Assessory Bldg
El Others:
0 Demolition
El Other
El Septic El Well
El Floodplain El Wetlands
0 Watershed District
11 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
/c- Ll el— 6-e 71- C2�X__
OWNER: Name:
Address:
Please Type or Print Clearly)
0
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: —Exp. Date:
ARCH ITECT/ENGI NEER Phone:
Address:
Reg. No.
.- 36 0 -S-20-3
FEE SCHEDULE: BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ 35 -DD FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with u7nr Ostered contractors do not have access to the guarantyfund
'Vy
nature,
t _9 f g tq Lq Q ��Kn. Sicinature of co0tractor
Plans Submitted LE PIMs Waived El Certified Plot Plan El Stamped Plans
-Plans Waiv d -1L - .7.-Gertified Plot Plan Stamped F1
Plans -Subm'tted e
Plans
-TY,P?E-O,Y-.gEWERAGE-J)ISPO,SAL'.�
Public Sewer
Tanning/Massage/Body Art
SwmmiDg Pools
Well
Tobacco Sales
Food Pack�ging/Sales 11
Rrivate,,(,septic tank, ttc,_
aneut pumps
Perm ter oia� Site
.3HE-FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE.APPROVED
�PLANNING & DEVELOPMEN 7T
COMMENTS
CONSERVATION Reviewedon—. .(waoq� Signature--
fV
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comme
Conservation Decision: Comments
Water & Sewer Con nectionisignatu re &.Date Driveway Permit
DPW Towa-2 Engineer: Signature:
LOGalea jo/4 usgooa jtree
FIRE -DIEPARTME-NT Temp Dumpster on site yes no
Located- at 124, Ma in Street
..-Fire DbpdftMel,'-It.si_qhatu-i�7e/date�-"T
A.
COM-MENTS
--Dimension-.
Number of Stories
.Total land -area, . sq. ft..-.
Total square feet of floor area, based on Exterior dimensions._
-ELECTRICAL: Moverrient.6f Meter location,* niast-or service drop requires approval of
.Electrical Inspector Yes No
DANGERZONE LITERATURE: -Yes No
MGL-.Ch'aPter166. Section 21 A -xF and G min.$100--$1000 fine
Nu i t5 ana UA I A — wor aepartment use
El Notified for pickup - Date
Doc.Building Pennit Revised 2010
Building Department
:—The fol�,'nwino 18:'Mist of thtre�uired,forms to be.-filled*out.for�the.appr.opCiate. permit to be obtained.
Roofir.g, Siding, Interior Rehabilitation Permits
Ll B7 uilding Permit Application
o VY-orkers Comp Affidavit
Ei Photo Copy Of K.I.C. And/Or-C.S:L Licenses
Li Copy of Contract
D Floor Plan Or Proposed Interior Work
Li Engineering Affidavits for Engineered products
NOTE: All dumpster. permits require sign off from Fire -Department prior to issuance of Bldg Permit
Addition Or Decks
ci Building Permit Application
Lj Certified Surveyed Plot Plan
Li Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
Li 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
Li Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cast�s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apo,�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.Building Permit Revised 2012
Location ;41 x--�-v 'r-,
No.94 i — v- Date
I
Check #
2.,1- i 11 /'@�
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $#&
Foundation Permit Fee $
Other Permit Fee $—
TOTAL $ 4
Building Inspector
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Rail Line Wetlands Zoning
Bu:inei 1 OiZrict
Interstates r' Exempt Lands In Bu ine� 2 Di ric Horiwntal Datum MA Stateplane Coordinate System, Datum NAD83,
— I
— SR C3 Busine� s 3 Dist6ct Meters Data Sources: The data for this map was produ�oed by Merrimack
IN Busine a 4 District 14ORTN Valley Planning Commission (MVPC) using data pmvided by the Town of
Roads = Genera Business District 11,6. , North Andover. Additional data provided by the Executive Office of
Ci Easements C3 Planne, I Commercial De, 6. Environmental Affaim/MassGIS. The information depicted on this map is
E3 MVPC Boundary r. Corrido Development D!isjt
0 Corrido Development Drst 0 for planning purposes only. It may not be adequate for legal boundary
0 Corrido Development D , definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
0 Municipal Boundary ist MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
Zoning Overlay �ndus ri il 1 District THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY
E3 Adult Entertainment nd sid il 2 Distinct OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT
0 D ntown Overlay District 0 :nd.us 6 :� 3 4 0 AS LIME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
District
i wt d S District S
H � oric District 93 n
E3 Water Protection Reside, c. 1 Dtstrl. THIS INFORMATION
R idei cc
0 Parcels as 2 District CHU
M.R—ide cc 3 Disfin I
13 Hydrographic Features it 4 D!str! c�
n
C: I D�::ri
— Streams 1" 91 ft --(�—d: c c
de ce 6 District
I .%,-f2let sidential District
SUBJECr PROPERTY
MAP 85, PARCEL 14
ROBERT B. & RITA E.
CUNNINGHAM
CAMDEN STREET
NORTH ANDOVER, MA 0 1845
ZONING DISTRICr R4
FRANK S. GILESp,
PLAN OF LAND
LOCATION
CAMDEN STREET
NORTH ANDOVER, MA
PREPARED FOR
ROBERT B. & RITA E.
CUNNINGHAM
------------
PRINCETON
S 26013'9" E 150.00' - -" - \ /
MAP 85
PARCEL 23
12 00 S.F.
ii
25'
251
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P 85
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N 26013'9" W 150.00'
CANMEN
C:\CLI]ENTS\CtTNNINGHAMBOB\PLOTPLAN.DRG
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MAP 85
PARCEL22
14'
rn
o
�6
10'
7.2'
The Commonwealth of Massach useiffs
DepartnintofliidustriqlAceld�rits
Office of Invesfigations
6#0 Washington Street
Boston., HA 02111
www.massgovIdla
Workers' Compensation Insurance Affidavit: Builders/Contr.actorsMectri , clans)PUku*ber , a
AMIleant hfumation PloasePrintLealb
Name (BusinesslorganizationftdMdual): kOh-, tf C P M h I /J Q
Address: 2-2- PrlinCeJ'M LlIett
city/stat (,/I veK 0 1 a 9E Phona: 9-7 0 .5 -7.0 2
Are you an employer? Check the appropriate box:
Type of project (required):
i. F1 I am a employer with -
4. [11 am a general contractor a -ad 1
6. 0 New construction
employees (hH and/or part-time).*
2.01 am a sole proprietor or partner-
have hire d the sub -contractors
listed on the attached sheet. I
7. 0 Remodeling
ship anTlavano-employees
Uieso sub -contractors have
8. El Demolition
worMug for me, in any capacity.
workers' comp. insurance.
9. ElBuilding addition
[No workars, comp. Jnsurauce
5.E] We are acorpora�on audits
10.[] Electricalrepairs or addMons
required.]
3.M I am a homeowner OQlng all work
officers have oxercised.their
right of exemption p or MOL
11.[1 Plumbingrepairs or additions
myself EEO workers' bomp.
c. 152, §1(4), and we have no
12.Q Roofrepairs
insura-acarequireq.)
0 oye6s. [No workers,
MP1 -
13.[] Other
.
comp. msurancerequired.]
Mny applicant that checks box& must also fill out the sertionbel6wshowingtlaeirWoricers'compensationpolioymtormation.
T-I-lomeowners who subinitihisaffldavitindicaffigtheykedgingaUworg and then hire outside contractors must submit anew affidaVitindicatifig such.
TContractorsthatcheckthis box must attached mialddiflonal sheet dhowlagtho name of the sub-contraGtors andfheir -workers' comp.polloyWormation.
.1 am an emy . foyer that isproviding workers'compellsadon insuraneeformy employees. Below is thepolley andfoh site
information.
Insurance Company Name%
Policy 4 or 8 elf -ins. UG. 9:
I-) -_ L-Lypap-Ld - , 6,1 I -L
lob Site Address,, 4- 4412HI14E� - �/ I I%, V_, I _Pity/state/zip.
Attach a copy of the workers'comp 'ationpolley declaration page (showingthe policy number and ex
ens pixation date).
Failure to secure coverage.asre 4 dunder Section 25A ofMGL o. 152 can lead to the imposition oferiminal penalties of a
- TWO.
fine up to $1,500.00 and/ox one. -Year imprisomnent, as well -as civil penalties itt the form of a STOP. WORY, ORDER and a fine
of -up to $250.00 a day againstflia violator. De advised that a copy of this statement may be forwarded to the Office -of.
Investigations of the DU for ibsuranco coverage verification.
I do herely cera
fy, u1i fizq,,6a1qd andpenaldes ofperjurp Mal the informationprovided above is true and correct.
_qiannfnrA.- Date- /,-//s--// �,,
Mone
Ofjt-ciaj use oply. Do not write in 61s area, to be completed by cl� or town official
City or Town: Permit/License#
Issuing Authority (cjxcle dne):
I.BoardofHeaffh2. Building Department 3.0tylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
CootactPerson; Phone M
Information and Instructio-'
ns
Massachusetts General Laws chapter 152 revires all employers to provide workers, compensation for
the
,ir e
Pursuant ry Mployees.
to this statutD, an erV10Ye0is defined as "...eve person M the service of another under any coiifract of hire,.
express orimplied, oral orwritten.11
An employeils defined as "an individual, partnership., association
I co.,poration or other legal entity, or any two or more
Of the, f6i4ing engaged in ajolut enterprise., and including the legal representatives of a*ceased employmor the
Xe6eiv6r or. ft*d 8 tee'of an individual-, Partnership, as�ociatiou or other legal entity, employing emPloyeas. )646verth6
owner of a dwelling house having notmore than three
apartme
,uts and who resides thereiq, or tho occupant ofthe
dwelling house of another who employs persons to do maintenance, construction or repair workon su6h dwelling house
or on the grounds or -building appurteliant thereto shall not b Deal's G of such employment b a deemed to b a an employer.�l
MGL chapter 152, §25C(6) also states that "every state or lo'cal lie-ensmig agency shall withhold the issuance or
renewal of a license or p ermit to op erate a business or to construct buffdIngs in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required.11
Additionally, M(iL claapter 152, §25C(7) states 'Weither the commonwealth nor any Of its political sub (ivLions shall
enter into MY Contract for the. p orformance ofpublic work until '
acceptable evidence of coinpji�nce with the insurance
requirements of this chapterhavo beenpresentedto, the cQutracting aathc_rity�
plicants
Pleas,G,fill out the workers, compensalfou affidavit completely, by checking t1lo b0xD
s that apply to your situation and , if
ji6c0jsarY� B-OPPlYsub-contaltor(s)name(s), address(es) andphonanumber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability PartaDrshipg (LLP) with no employees other than the
MeMbOrs Or P�rtuers, are notrequiredto carry workers' compensation insurance. If anLLC orLLP does have
0Mployeqs,apol1qy:1sreqWred. Do advised ffiatthl� affidavit maybe submitted to the Department of judustdal
Accidents for confirmation of insurance cover
age. Also be sure to sign and date the affidavit. The affidavit should
be leturnedto the city or town that thb applicatim for the pannit or Ecenso is being reqaeA0q, not the Department of
Industrial Accidents. Shouldyou have any questions regarding tho law or if you are required to ob'taia a *orkers'
Componsationpolicy, please call the Department at the number listed below. Self-insured companies should enter their
self-insuranco license number on the appropriate line. . . I
City or Town Officials
Please be sure thatthe, affidavit is complete andprintedlegibly. The, Department has provided a space attha bottom
of the affidavit foryou to fill out in the event the office of Invostigations has to contact you regarding the applicant.
Pleas , a be -sure to M intho pennit/licensonumbrr wldchwill be used as a reference number. f
thatm'astsubmitmultiPlapermit/licenso applications in any given ' u addition, an applicant
year, need only subnlit ona affidavit indicating cutr6ut
p olipy information (if necessW) and under "Yoh Site Address; the applicant should write "all locations in
town)22 A: �O' or
PY ohho affidavit that has been officially stamped or marked by the city or town maybe provided to the
applicant as proof that avalid affidavit -Is' onfile'forRiturapermits orlicenses. Anew affidavit Mn' st be faleLd out each
year. Wharea home owner or citizen is obtaining a license oibermit not related to any business or commercial venture
a dog license or�ermit to butu leaves etc.) said Person is NOT required to complete this affidavit,
The OfflGa of Investigations would like to thank you in advance for your cooperation and shouldyou have any qu
please do not hesitite to give us a call. esR)TI,
Mae Department's address, telephone, aind fax number:
Thf4, CQ M.- Monwealth orma =9 O'hweiftq
ofte Qf 1JAVOStIgA ama
6 0 Wasbingtoll stxe, a
)308ton, M..A 02111
TO, # 617-7217-4900 at 406 Qx I -S77,
�M
Revised 5-26-05
To" iVORTEC ANDovFR
OPFICE OF
09 -BUffiDINGDEPARTMENT
it +Zak
XorthAndovor, Massachuse
ttg 01 S45
Gerald A. Brown Te-leThone (97�) 688-9545
lusPoctor ofBulldings
-F�'x (978) 689-9.542
HDIMMMER119ENSE MI&TION
)3MDING PFRMT JCATION
P1 r se pn
lea
J013 LOCATiON, Z9
Number StreetAddress M
M ot
IMMOWNER
C*
Name. home Phone C-1
Work Phone
PRPSENT MAILiNG ADDRES S_
ZZHP Code
The current oxempHon for,�homeowners,, was extended to fiticlUde owjap
,r-ocp
clipied dwall
10 allOWSUb-h hDiMoViffier-S to engage a -
r, i2,(jividual.f�r hire -Who LT' -Ds to two units -Or I ass and
acts as supervisor). State ]30, ding does Mt Possess a license, provided that the. owner
(Code Socjon
DEFINITION OF HOMEOWNER
Pe-TsOn(s) Who _qwns aparcel of land on which he/she resiaes or intezds to reside, On which there i Olisinfendedto
bb, a one or two famlY structures. A person who constructs more thatone
considered a homeowner. home in a two-yearperi6d shall not be
The Undersigned "h0medwner" assumes respDrtsibifItY f0rcOmpliances with the State Building Co
AP-Plicable codes., by-laws, mles andregulations. do and other
The Undersigned "'homeownep cQrti
,fies that halshe, &dorgtands the Town of Xorth AudovorBuilding Dep
M'a"nurn insPOctiOn Procedures and re ' artra eat
requirements, quIrOments and that he/she will comp
,1,Y with,said pro cedures and
Pxoued�res and
HOMEOVvr,\MRS SIGNATMIc
APPROVAL OF BUMI)ING OFFICIAL
RevlsOd 7.2009
'Form Rorne-ovmers ExemptiDn
130ARD OF APPEAM 688-9541
CONSERVA'RON 698-9530 HEALTH 698-954o
PL-KNNING 689-953i