HomeMy WebLinkAboutBuilding Permit #676-11 - 315 TURNPIKE STREET 4/7/2011BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
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
Demolition
Other
T�►�%T
_
Septic well
Floodplain VNelands
atershed District
Nater/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
On is li' e w a I ,ei sfA i I a z `XS<D" T-er1t 41� 1�L1 rasS
T I (a 621 nd f Lie Meri-mnAd �o! _Ae e, S oAl b 01 7�/ L' `d � 1•{1lA�'I I�e�, .
Vie" "01 rerwe ve, ®e,
4 1 rail
Identification Please Type or Print Clearly)
OWNER: Name: Phone: '77S -FSI -52Z)7
Address: &,40dver IYO 4/8
CONTRACTOR Name: 1^15+;Ai�q PAIZ" Ri ANrAL. Phone: 6Q A
Address: ItM �'!-V6 e Is , �- 43689
ANOW
Supervisor's Constructiont License: Exp. , Date:
Home Improvement License: ry Exp..Date:
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: $ *2 �
Check No.: 171 �2 0 ri Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
atre of contracor ofAent/Owner. SignSge gY
U
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
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED
CONSERVATION
COMMENTS
DATE APPROVED
DATE APPROVED
DATE REJECTED DATE APPROVED
HEALTH
COMMENTS
4
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
I
Dimension
Number of Stories:
Total land area, sq. ft.:
H
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA —
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
nt use
No
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
o 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/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
❑ 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
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Locationv6——f 6//,,,v//4 " `
No. Date 7
r
NaRT� TOWN OF NORTH ANDOVER
OL
s
' Certificate of Occupancy $
Building/Frame Permit Fee $
JACHUSE
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
P�-
2
Building Inspector
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ETiF1CATE 4F LIABILITY INSURANCE
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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: It 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 statereent on this certificate does not confer rights to the
certificate holder In lieu of such endorsemelri(s .
PRODUCERACrSeth
Tebbetts Insurance Agency
4 Main Street
Hollis NH 03049
Tebbetts
PHONE(603)455-3333 Ne (603)791-4651
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ADDRESS: Seth@tebbettsins.con
PRODUCER
mh 0000159
AWORDINGCOVERAGE NAICS
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Christian Delivery & Chair Service
18 Clinton Drive
Hollis NR 03049
RmwamA.Citizenz Insurance Company of 31534
n1sul:etB.Hanover Insurance Company 22292
INSURmc.CHARTIS
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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.
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/1/2010
/1/2011
EACH OCCURRENCE $ 1,000,000
PRE SEs Ea S 100,000
MED EXP yoneperson) S 5,000
PERSONAL& ADV INJURY S 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIESPER:
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BODILYINJURY(Perpemn) $
BODILY INJURY (Per acMent) $
PROPERTY DAMAGE
(PeraaSdant) i
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DESCRIPTION OF OPERAMONS I LOCATIONS I VEHNCLLS (Attach ACORD 101. AddNkxW PAme f Sctrdt ft **we spnse Is I1pfl 00
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE MALL BE DEUVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AU 11HORIZEa REPRESENTATIVE
Seth Tebbetts/SAT �•� rs.-s
25 (2009109) ®1988-2009 ACORD CORPORATION. All riahts reserved
I"IbWAa R0D-4M 1 Be ^% urcu ,tame ane 1090 are regMef9a UMMS of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
IF Boston, Mass. 02111
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
PHA
Name (Business/Organization/Individual) : t. ri ST//ah I VCr /-C%JQ/l^ �rV,L"2, Ty/G jl^/�7j,41'l / AeT -� )i&A l
Address:
City/State/Zip: Qli� ATI c.lq Phone#: —006'
— 532Jo
Are you an employer? Check the appropriate box:
1. dram an employer with 2-0
4. ❑ I am a general contractor and I
employees (full and/or part time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance. $
required]
5.0 We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption perm MGL
insurance required] t
c. 152, § ] (4), and we have no
employees. [no workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contactors that check this box must attach 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.
.lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. n //__ I
Insurance Company Name: (, /,l rIS
Policy # or Self -ins. Lic. #: 9 7 G►S 3 Expiration Date:
Job Site Address: 3/.S U,na 1, Sf rc�.� City/State/Zip: IV,9,- M /idOt/er, I%�
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Date: //-/7
X
Print Name: z e l 6:0 [ l / 4t Phone #: '��3 ✓ 3Z
Official use only Do not write in this area to be completed by city or town official
City or Town:
Permittlicense #:
Issuing Authority (circle one):
I.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person:
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treated (or are inherently flame retardant).
CHRISTIAN PARTY RENTALS
' 18 CLINTON DRIVE
Hollis, NH 03049
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Certification is hereby made that the articles described below hereof are made
from a flame-retardant fabric or material registered and approved by the
California State Fire Marshal for such use. The fabric has been tested and
passes NFPA 701 Large Scale. See chart to right for trade name of
flame -resistant fabric or material used and additionally referenced on the label
of the fabric panel.
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UW with DoubleValance
Bruin
Mardi Gras
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Clear Vinyl 16ga / 20ga
F-593.01
DAF
DAF
F-593.02
Date Manufactured
AZTEC TENTS
F-434.01
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F-444.01
2665 COLUMBIA ST
INV NUMBER: 0184331
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03/04/2011
TORRANCE, CA 90503
P.O. NUMBER:
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(800)228-3687
CUSTOMER NO: CHR030
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This is to certify that the materials described below have been flame retardant
Tri Vantage
treated (or are inherently flame retardant).
CHRISTIAN PARTY RENTALS
' 18 CLINTON DRIVE
Hollis, NH 03049
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Certification is hereby made that the articles described below hereof are made
from a flame-retardant fabric or material registered and approved by the
California State Fire Marshal for such use. The fabric has been tested and
passes NFPA 701 Large Scale. See chart to right for trade name of
flame -resistant fabric or material used and additionally referenced on the label
of the fabric panel.
en or
Trlicle Mme
UW with DoubleValance
Bruin
Mardi Gras
F-
13vin
Mesh
7222.04
Caliromle Comb.
LBm-Tex 12, 14, 16, 18oz
F-419.01
Coated Fabrics
Clear Vinyl 16ga / 209a
F-570.02
DAF
Clear Vinyl 16ga / 20ga
F-593.01
DAF
DAF
F-593.02
Exclusively Expo
Polysateen Liner
F-434.01
Ferrari
Pmcontraint 502
F-444.01
Ferrari
Precontraint 702
_ F-444.08_
Phillips Textiles
Phil -Tex Liner
F-500.01
PVC Tech,
Deco Cloth / Velon
F-504.01
Snyder
Weathempan
F-140.01
Tri Vantage
Freslst Sunbrella
7368.05
Tri Vantage
Patio 500
7121.02
Tri VantageBig
Top
F-121.10
TO Vantage
Vanguard Weblon
F-069.01
Tri Vantage
Weblon / Coastline
F-069.01
Verseidag
Duraskin 81673, 81515
F-530.01
THE FLAME RETARDANT PROCESS USED WILL NOT BE REMOVED BY WASHING
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ITEMS MANUFACTURED TYPE PRODUCED
2000 ipc Series 1500 Top UW S 3
20x40 ipc Series 1500 Top UW S 1
15x15 ipc Qwik Style Tops UW S 2
20x20 ipc Festival Top UW S 2
w/ Ratchet Tensioners & Flag
with Double Valance
2000 ipc Qwik Style Top Only
S 2
UW with DoubleValance
k #.
David Bradley
General Manager- Manufacturing
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Name of Applicator or Production Superintendent
Title of Applicator or Production Superintendent.
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2000 ipc Series 1500 Top UW S 3
20x40 ipc Series 1500 Top UW S 1
15x15 ipc Qwik Style Tops UW S 2
20x20 ipc Festival Top UW S 2
w/ Ratchet Tensioners & Flag
with Double Valance
2000 ipc Qwik Style Top Only
S 2
UW with DoubleValance
20x40 ipc Festival Top UW
S 4
w/ Ratchet Tensioners & Flag
with Double Valance
20x4Ox8 Festival Frame Only
S 2
(2Peak)
40x40 2pc Jumbotrac Top UW
S 1
40x20 Mid Jumbotrac Top UW
S 1