HomeMy WebLinkAboutBuilding Permit #516-2016 - 41 CHERISE CIRCLE 10/28/2015Permit No#: IJ
-'pq
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
� NORTy\
o ,6• C
Date Issued: 10117,0116 -�qch
IMPORTANT: Applicant must complete all items on this pave
PROPERTY OWNER
MAP $ LO I PARCEL: U 10
Print 100 Year Structure yes o
ZONING DISTRICT: Historic District yes - no
Machine Shop Village yes � no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
K-1ne family
❑ Addition
❑wo or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
[ Septic ❑Well
_
❑Floodplain , p Wetlands
F-1 `Watershed District
p Water/Sewer
y -
DESCRIPTION OF WORK TO BE PERFORMED: �
/ 1 f `T'AkTALL�-nam c -f V� l t., sr AA"jiv;A�f w--x)n ,, ck..�r:t4-r1.,,1� Ql /An -5 Tk4v
�g d SQPu f
identification - Pleace Tvne or Print Clearly
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: $�_�- tm FEE: $ 2--Z� —
Check No.: Receipt No.: 2q e�l�
NOTE: Persons contracting with unregistered�c%ontrgctors do not have access the guaranty,�unnd
e
.v_.. .., ;Check # . - � i� 1 [�.-
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Sody 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
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
a
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer:
Located 384 Usgood Street
� ' x ~-ate.:..
,Fa D_EPARTt, MENETTerrip'Dumpsterontsite;
ILo�`cateci at 12 Main S ree
��LpkLt Dep m ns gn to ure/ to
$COMME OR&
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For dwartment use
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pen -nit Revised 2014
I0 -o
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
69fing, iding, 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
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
TOTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: 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: Building Permit Revised 2014
< = 'a
0 c _
Or N =< Mu
m � iA
5CD
a m
N• z o - N.
C) cn
'O o to � C• T
C O_o �C m
CD W chi' `D y p
N =. CD 2
O Q D
US CD
O o
y c3 N Q r.
' o n
CD z W rt� CD
C
t/1 '
CD o Z o co�:LICE
CL F rm (M �Nrt
o 'b cmnCD o N
-�
14
CL
z CD
-po � .
O �-
Z� N -0�,
CD CD 0
CD `c o Xm ��< S
CL Cl) CD
C
`< sv �' - —� Z CD `` P.
ch
CD
O N CD
CD
CL = c z;;r- 4:3.�p
�. cn
v "
o C
��
C _
_
Z a,
F =
CD
�` o
z* �
O G) ' n
-�CDzSU
CD
O
0 0 rtCD --I
O
CL -
0
s
V
co
N
Ln
3
o
m
(DO
mv
r+
T
m
D
z
5.:;o
H
H
n
=
<
n
o
S
m
m
�
n
D
cZi�
m
O
z
j
o
3
v
C
W
w
m
O
�
a
3
3
p
0
0
3m
C
p
Z
.D
m
7D
m
n
N
3
0
Q
n
3
W
p
OT
m
s
V
W N �
O O D n 0
O w R•o 5. �
ao°off
CD w y w
o
w .y n �.
CD �-rte,,, N y
p-� R
oEAoCD
�.
x Q
CD
C A
w O
W cho
O n
I
rr
CD CD
y
"h
O N w A ►yl
o-oZw0
Et
O
rL CL
CLCD
CD'CD
Q1 !A CA
0 wp CD
n
CD 4 y
CD H
o 0
CO vii CnD
yon CD
O fD G.
O
CD
r•r
CD
baa
� rn
O�0
�o
CD
►, a CDD
N
o CD
y O O
o°n
CCDCD
CDCD n
° y
n
N CSD y
c
rv'y
Vi
w
O Q'
CD
O 0) C/1
" a ::� y
E
co
o. CCD
o
w
0 D�
O
O
CD CD
ST
ego
O O D n 0
O w R•o 5. �
ao°off
CD w y w
o
w .y n �.
CD �-rte,,, N y
p-� R
oEAoCD
�.
x Q
CD
C A
w O
W cho
O n
I
rr
CD CD
y
"h
O N w A ►yl
o-oZw0
Et
O
rL CL
CLCD
CD'CD
Q1 !A CA
0 wp CD
n
CD 4 y
CD H
o 0
CO vii CnD
yon CD
O fD G.
O
CD
r•r
CD
x M m 1 goo
f ON0 0 ` A
f.
fD
cl
Ul
tJ
� � V1 (rq ►ten �, � �+•� N
IP
o 0 a c A C o
W
CD
x• off•
si
� a. o co
CD M
eD 0A n
CCD •~P �' CD C �•
� O � O � d � N o• ///�� �
CD
nfD
00
2 O
C (D C k oo 10
C7
v, Cy C 6 a' A
C/1 1
CD n I 7. A Q1, V
CCD
y N
.d
� C o
n c,
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
kVJ I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: /61?Q Ove y1d A) —&Lk' 41�
Phone #:
Are you an employer? Check the appropriate box:
1 t ` I am a emplo er with . 4
l '
4. ❑ I am a general contractor and I
employee (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. ❑ 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 per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
coma. insurance required.]
/010D 066 U1
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 i sJ�q Gl �) IN
13. Other 'DU o e7S
*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.
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:
Policy # or Self -ins. Lic. #: yjm3 P 7 Dy Expiration Date:
Job Site Address: r fl j5�� 0112 ct E- City/State/Zip:�IT"boyez MA 019Vy
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 c under the pains an�enalties of perjury that the information provided above is true and correct
Phone #: (� J ^ �J 3 " Nip (f� CL��
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Er/19
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 #•
OP ID: JG
CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DO/Y00/00/1sYYYI
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: If 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 statement on this certificate does not Confer rights to the
certificate holder In Ileu of such endorsement(s).
PRODUCER 975-975-1300
9e revs & Hall Insur.A93oC.lnc
305 North Mdin SL 978-976-7596
Andover MA 01810
Edward h;mlrez
T"
NAME:
PHONE :
Wow��mN0 /Q�
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170 _
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 121604
Type: DBA
Expiration: 5/2412016 Tr# 250393
QUINN'S CONSTRUCTION
THOMAS QUINN
868 MAMMOTH RD.
DRACUT, MA 01826 =
Update Address and return card. Mark reason for change.
Address 0 Renewal ❑ Employment 0 Lost Card
SCA 1 0 2OLLM1
�>� �RftlWltOfttCCQCIlt•O�%,�il[ZCIl[G:CC�1'
Office of Consumer Affairs & Business Regulation License or registration valid for indivfdul use only
Lon:
E IMPROVEMENT CONTRAC�'OR before the expiration date. If found return to.-
121604 Type;Office of Consumer Affai s and Business Regulation
5!2412016 DBA
10 Park Plaza - Suite 5170
Boston, MA 02116
QUINN'S CONSTRUCTION.!
THOMAS QUINN - z
868 MAMMO-Il-I RD-
DRACUT, MA 01826 Undersecretary Not valid withou signature
t Massachusetts - Department of Public Safety
Board of Building Regulations and
Standards
Construction Supen•iwor
License: CS -039732'
�=
THOMAS J QUINA' �•
�.
': - .
868 MAMMOTH -RD
DRACUT MA 01'826 _
Expiration- .
. commissioner
03/25/2016 =•
VINYL SIDING
INSTALLER
ASTM :� 4 756 1
VWrA�SidbW Insdu to
Quinn, Thomas Expires: 4/1/2017
868 Mammoth Rd ID#:17412
Dracut, MA 01826 Certified Since: 2014
Unresdided-gip OfEUY BW group Amh
ct • .Ims -ihm 35-000 mlic int (919-1m?) aE
mdOSId a'7a _
FeAluMtoposst'- a cturaof9Mf�r�USffU&
M. &-_-Btafts u gars sac tenacti iieQr
for Iii 1 A fian>W,- immAiessZOVI PS