HomeMy WebLinkAboutBuilding Permit #590 - 29 PEMBROOK ROAD 4/2/2010 RTF��10
BUILDING PERMIT 011 14O o ,6'qa
TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATION
Permit NO: ® Date Received3 p"AA7ED 01,
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Date Issued: Z' U
IMPORTANT:Applicant must complete all items on this page
i.0_CATION �' '
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PROPERTY 0WNER-'* -
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MAP 210 �` PARCEL ZONING DISTRICT Historic District ye o
h Machine-Shop Village.- ye o
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
k Septic Well' EloodplainWetlands . - Watershed.D strict
Water/-Sewer
DESCRIPTION OF WORK-T-O BE PREFORMED:ORMED:
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Identification lea T e or Print Clearly) ^ ?o9
OWNER: Name: / Phone: J
Address:
If
_V
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CQNTRACTOR dame: Phone.
Address:
4 -
Supervisor's Construotion License Exp Date
R
Home 1rn row
3
p vement°License: Exp °Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 0 �yy FEE: $ s
Check No.: S Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
I gnature of Agent/Owner' =x ' Signature of'contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
E COMMENTS
CONSERVATION Reviewed on-3)9,51/0 Si nature
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COMMENTS cz7 Va — 6 w
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 Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
-,FIRE DEPAARTNIEiVT =Teriip C?umster on site yes no . _. .
Lbcated°at1241Main Street
Fire:De0ar#mer�t signature%datem .
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_ v ,
"CQMMENTS -' "
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
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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)
11
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❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
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Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
f
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
. f
❑ 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
r ❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
I' 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 G.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
i
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
Doc:Building Permit Revised 2008
Locatior,?
No. Date
NORTH TOWN OF NORTH ANDOVER
F 9
Certificate of Occupancy $
• i „ � 1
�'+s'•^° t<�' Building/Frame Permit Fee $
�cMus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22697 -
`---�'Buitding Inspector
F NORTH TOWN OF NORTH ANDOVER
OFFICE OF
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BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover,Massachusetts 01845
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE.EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: I� I o
JOB LOCATION:
NumberL Stree Address p� Map/Lot
HOMEOWNER (J��1I�1G ��� ��/� ( -7f-g7�j_369�
Name Home Phone Work Phone
PRESENT MAILING ADDRESSc261 &,m bay j L-
l 11 O
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
—00.A- 0641 Anntn,_�
.APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
A
The Commonwealth of Massachusetts
Department of Tradustrial Accidents
Office ofInvestigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ibl
Name (Business/Organizabon/,Individual): , ov,h6l
-------------
Address: haW
City/State/Zip: "Iff _ Phone#: ' )T_g2/p
Are you an employer?Check the appropriate box:
Type of project(required):-
LO I am a employer with . 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors ti' New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet, t ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
[No workers' comp. insurance 5. 9 ❑Building addition
p ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL .1 1.❑Plumbing repairs or additions
myself. [No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
COMP.insurance required.] 13.[1 Other
applicant that checks bo #i must also fill out the section below shoe>•:ng their workers'commas—on cy
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information:
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
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. 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 nd the pains and penalties of perjury that the information provided above is true and correct
Si afore: ���`
Date.: `7
Phone#:
Official use only. Do not write in this area, to be completed by city or town officiaC
City or Town: Permit/L.icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6. Other
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 person in the service of another under any contract of hire,
express or implied,oral or written."
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 apartments 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 15.2, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)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 completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es) and phone number(s)along with their certificate(s)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 may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
bee returned to the city or town that the application for the permit or license is being requested,not the Deparamrent of
Industrial Accidents. Should you have any questions regarding the law or if 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 sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in 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 bum leaves etc.)said person is NOT 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax 617-727-7749
www.mass..govddia
2) GROUND PREPARATION
The preparation of the ground is the most Pool Dimension & Wall Length
important step in the installation of the pool.
POOL SIZE Diameter Wall Len th Top Sheet
a) Mark off your pool area by driving mm. ft in. mm. ft in. Q'ty
stakes. Have a helper hold a tape 12 3,611 11 10 2/8 11,346 37 2 5/8 10
measure or a string and mark off the 15 4,572 15 0 14,363 47 1 4/8 10
pool perimeter using flour or chalk. -5,486 18 0 17,236 56 6 5/8 12
Remove sod inside the pool area to a 6,401 21 0 20,109 65 11 5/8 14
distance of 1 feet beyond dimensions - 7,315 24 0 22,981 75 4 6/8 16
shown in the plot layout around entire 7 8,230 27 0 25,854 84 9 7/8 18
perimeter of pool. 30 9,144 30 0 28,727 94 3 20
33 10,058 33 0 31,599 103 81/8 22
b) Remove all grass from within the
entire pool area. It is not enough to just
cut the grass. The sod must be
removed.
c) Two or three inches of sand is the best for your liner. Using sand eliminates the necessity to level inside of frame
area except where exceptionally high or low areas exist.
These areas should either be dug or filled in. This does not mean the perimeter or frame area. That area must be
firm and level by digging only.
d) Do not fill low spots in the area where pool wall will rest. as setting may cause your pool to
become out of level. Making sure pool bottom is flat.This is a must.
e) If your site is.not on firm soil, use 2" patio blocks for the base of the wall Care should be
taken to center a patio block under each bottom plate. The top of the patio blocks should be
flush with the prepared ground surface.
a
3) ASSEMBLING BOTTOM NAIL
STEP 1: Before proceeding to the next step, place a large amount to
Before proceeding, remove the steel wall from carton and stand on a 3'x3' sifted earth in the middle of the circle. (see chart for the
board inside pool area as shown at right. Put the liner, (leaving it in the amount on the first page.)
carton) inside pool area.
Sifted earth should not contain any pebbles.
STEP 2: Place a patio block under each lower joint around curved
Insert the bottom rails around the entire perimeter using lower joints on the area.
flush with the prepared ground surface.
I
3) ASSEMBLING BOTTOM (RAIL
STE
STEP 1: Before proceeding to the next step, place a large amount to
Before proceeding, remove the steel wall from carton and stand on a TxT sifted earth in the middle of the circle. (see chart for the
board inside pool area as shown at right. Put the liner, (leaving it in the amount on the first page.)
carton) inside pool area.
Sifted earth should not contain any pebbles.
STEP 2: Place a patio block under each lower joint around curved
Insert the bottom rails around the entire perimeter using lower joints on the area.
circular portion of the pool.
Leave one section open that will be nearest to where you will locate your
filter.
1/4in
Step .
i-a''(':}"�:'�.*✓,.�{ice''^
Build a
J,.1 ;o:+ 7.
ground
gently
>�
IMPOF
The ea
p Top of patio block even with mound
ground surface. liner OL
damag
preven
Insurance Adjustment Service, Inc.
139 Billerica Road, Unit Al
Chelmsford, MA 01824
(978) 256-3334 Fax (978) 256-3354
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139, SECTION 3B
Date: April 3, 2010
TO: Board of Health/Building Inspector
City Hall
North Andover, MA. 01845
ECEIVE®
RE: Insured: Cindy Catalano
PR. - 0110
Property Address: 29 Pembroke Rd
N Andover MA 01845 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Date of Loss: 3/15/2010
Policy Number: BBYSVC
Type of Loss: water
File or Claim Number: 62011
Claim has been made involving loss, damage or destruction of the above captioned property,which may either
Exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6,to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate,please direct it to the attention of the
writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file
number.
Thank you for your cooperation.
Very Truly yours,
Sean Hayden
Adjuster
Ext: 124