HomeMy WebLinkAboutBuilding Permit #1060-15 - 34 RALEIGH TAVERN LANE 6/16/2015 LF BUILDING PERMIT NORTH
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TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
Date Received
Permit No#: s R�reu
9 SACHUS
Date Issued:
PORTANT: Applicant must complete all items on this page
LOCATION 3 L "S���'� c✓�y�� �"^
Pr
PROPERTY OWNER e` er
Print 100 Year Structure yes no
MAP /� 7 PARCEL:J/6tf- ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
or more family [I industrial
❑Addition ❑Two y �
❑ Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg >< Oth rs:
❑ Other j
❑ Demolition -- -- ---- -- - -
El Septic ❑Well El Floodplain
El Wetlands ❑ Watershe District
0 Water/Sewer
DESCRIPTION F WORK TO BE PERFORMED:
Identification- se Typfi or Print Clearly
OWNER: Nam e�� - < � � Phone: Q j—�q Z���
Address:
[A—ddress:
ctor Name: Phone:
visor's Construction License: Exp. Date:
Improvement License: 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: $ �,�y FEE: $
Check No.' Oq Receipt No.:
NOTE: Pe ns contractinm with unregistered contractors do not have access to the guaranty fund
J
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Dody 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 e U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on �o Signature
COMMENTS
HEALTH Reviewed on ' Signature
M1
COMMENTS
_SLA,,' tn I
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
t'Planning Board Decision: Comments
Conservation Decision: Comments
Wafter& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPAR�TMENT Temp0DLim pster.gwite eyes .
tfocatedfat 124iMamtStteet ` ' I
Fire+D_"epartment�sgnature/da#e _
COMMLNTS
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)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit 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
OTE: 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/Cross Section/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
OTE: 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
;a 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Location / �j
No.A&( Date Y
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $Y
Building/Frame Permit Fee $ ��O-�
Foundation Permit Fee
Other Permit Fee $
TOTAL $ :
t Check#�3
r
-� `• Building Inspector
NORTH i
Town o �.. E _ over
No. ;;s,*..-
T y
o ti T
soh , ver, Mass,
QQ COCHICHE Wt CH
x,95 RATED r'P�,`'(5 4
U BOARD OF HEALTH
Food/Kitchen
PER IT T Septic System
.�. 1 .
THIS CERTIFIES THAT ........ .... BUILDING INSPECTOR
'
has permission to erect Foundation........ buildings on .
�. Rough
to be occupied as .......�.
.®................................................................................................ Chimney
provided that the person accepting this permit shall in every respect conform 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
200 UNLESS CONSTRUCTION A 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.
OFFICE OF
TOWN OFNORTH ANDOVER
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tWNT
1600 DBkood StrectBi ff ft2a'f•Sitito243 6
.j1 tCGVCYI.neR
7 pORa7xn F4��(�SSNoithAndover,-Massaehusetta Of 845
Geralcl A.Brown TO-1 phone(979)688954-5
lnspeefarol$riildings -Fax (978)689-9542
�.• • Q ilEaWNE LICENSE PXM&LION • .
PLICATION
pleaseprint .
DATE:
PB�,C+CTTIO
dumber treetAd ess Map/Zot .
Elmo. Home phone WozkPhone .
dip Cod-
TA current exemption for'Homeowners"Was extended to i.GJnci5 owner oectipied dive7lings to f4vo units or less 2nd
to allow such ho_meo muffs to engage lire-Who does-not
possess a licG31se,provided that the ow=nctsassupervisor). S,ateBu?lding (Codeuect?on
Person(s)Who awns aparcel ot'land on which 1te(she resides or intends to reside,ou which there is,ox is iufended to
be,a one or two i'arrxily structures. Apersonwho constructs more t7iat one home in aha earperiod shall not be
considered abomeowner,
The lmdersigmed°`I7cmoUwner°'assumesresponsibilztyfo_rcOmpliances twA the State 13uitding Co de and offier
Applicable codes,by-law;rules andTagnlations.
The mdersigned"homeowner"cert fies that he/she understands tfie Town ot•Nbrth AudoverBui&g D eliatfinemt
mini r nuJm in2pection.procedures and requirements and tf at helsha will complY wjth;said procedures and
requirezuents, .
Y10ACEO RS SIGNATME L
APPROVAL OF 33 MD)NG OFFICIAL ,
Revised 7.2009
Fonu liomeowners Exemption ,
xY
3 OARD OFAPPEA.T-688-93'41 •• CONSEVATION 688-9534
1'3EALTf16$8-954a PEATTNIAIG 688`9531 •
The Commonwealth of Massachusetts
Department of IndustrialAccidents
W r I Congress Street,Suite 100
d Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Please Prin
,AVhcant Information
. t Leiribly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New'construetion
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.] 9, ❑Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition
4':&e am a homeowner and will be hiring contractors to conduct all work on my property. I will
11.❑Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole ,
proprietors with no employees. 12;0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 Q Rbof repairs
These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other
6.❑We are a corporation and its.officers have exercised their right of'exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors 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:
Expiration Date:
Policy#or Self-ins.Lic.#:
Job Site Address: City/State/Zip:
ompensation policy declaration page(showing the policy number and expiration date).
Attach a copy of the workers' c
Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance
coverage verification.
Ido hereby certify under tlzepains a dpenalties ofperjury that the information provided above is true a orrect.
Date: 0
Si nature:
Phone#:
Official 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
Phone#:
Contact Person:
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 defied 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
receivefor 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 152,§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(1)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-contractors)name(s),address(es)and phone number(s)along with their certificates)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
be returned to the city or town that the application for the permit or license is being requested,not the Department 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 permit/license 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 wwwrnass.gov/dia
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GILBERT REA
4. 44 Rea St. SHEET NO. OF
NO. ANDOVER, MA 01845 CALCULATED BY DATE 9—
Phone 682-9864
CHECKED BY DATE_
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PRODUU204.1 a Inc.,Gmtm Mass.01411.
_ Lot #11 Rawleigh Tavern Rd.
A,y
Off Farnum St.
Osgood Realty Trust
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby-make application for a permit for a sewage disposal installation at
{Lot ll-awleigh Tavern Rd. . I will install this system in ac-
cordance wit��=the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 290. I will install a con-
crete septic tank of 1000 in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 200 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
That may be attached to the permit. Plot Plans must be submitted with application.
DATE 3 i L
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described. /
DATE
t
Signature of I petting Officer
Percolation Test 6 min Soil: Clay
Garbage Grinder
r u
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
3 v-]
0
1. NAME DATE 0
2. ADDRESS TEL.
3. NO. OF BEDROOMS DEN YES NO
4. GARBAGE GRINDER YES NO X,
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
i •
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE l0 3 1
NAME OF APPLICANT �&asL
LOCATION r �`
Addresof lot no.
BUILDING: Dwellin '7� Other
SYSTEM: New K.- Repair
GENERAL DESCRIPTION OF LAND
_ L=
SUBSOIL: Clay__ G vel Sand
PERCOLATION TEST minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK_ 16-&-D gallon capacity.
LEACH FIELD 2-o--Q lineal feet of drain pipe.
)I),�PA .---' QL -�- ,A-d
William J. a r scoll, Engine
Board of Heh
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