HomeMy WebLinkAboutBuilding Permit #773 - 43 CANDLESTICK ROAD 6/2/2010Permit NO: '
Date Iss
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
4
Date Received ; S o!6 a
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic ,R''1Nelf ' °
Floodplain : 6tiands
:Watershed District
Water/Sewer
Ur-OLKir i 1UN Ur VVUKK I U t3E PKEFURMED:
Identification Please Type or Print Clearly)
OWNER: Name: E-, I J0 I (C- Phone: 916- wb Ao'6
Address:_ 6�4�,\L—s �L 2
CONTRACTOR YNaine.. n 1... r Y K . , _ w "Phnna
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: $ 15, C�� e5s % FEE: $ 6& ----
Check No.: J Receipt No.:
NOTE: Persons co tracti wit re s �d contractors do not have access to the guaranty fund
Signature of Agent/Owner SIg nature 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
COMMENTS
CONSERVATION Reviewed on ]ao Si nature `11
COMMENTS - 1J �av\� `� �w I crC OL
HEALTH Reviewed on z< /..cSi nature
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:
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 department use) ,
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
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
❑ 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: Building Permit Revised 2008
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Stream Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A Brown
Inspectpr of Buildings
HOME -OWNER LICENSE EXEMPTION
Please print
DATE:
JOB LOCATION/
nmbes , Street Address
HOMEOWNER
Telephone X978) 688-9545
Fax (978) 688-9542
�3/r33�-�fp
1-�•••� Home incus Work Phone
PRESENT MAILING ADDRESS awlPiz
City Town state Zip Code
The current exemption for "homeowner--" was to Mdudc owncr-oc .died dwellmigs to two units or less
and to allow such homeawners to engage an individual for hire who does not possess a ligase, mmided that the
owner acts as supervisor). State Building (Code teCtion 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.Khomeowncr" assumes responsibility for cOIWH ngs with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that be/she understands the Town of North Andover Building Deparbmert
minnmrrm inPection procedureg and requirements and that he/she comply with said procedures and
HOMEOWNERS SIGNATURE /
1
APPROVAL OF BUILDING OFFICIAL
Rmind 10.1005
Fmm Homeoumm Ema ption
BOARD OF APPEALS 6g8-9541 C()NSERV r10\ 688-953 HEALTH 5xg_9;40
PL.L\NING 696-9535
The Commonwealth of Massachusetts
1 Department of industrial Accidents
Offcce of
4or 4 Investigations
600 Mashing ton Street
�c Boston, MA 02111
www_h ass.gov/dia ,
Workers' Compensation 1witrance MMidavit: guilders/Contractors/Eiectriciatts/Piumbers
Applicant Information
Please Print LMbl
Neale (Business or�geniration4ndividoal); /llj �'J�j•L_
Addmss: / �n �� <S 74 (C
City/State/Zip: Z,+41z5!L 41- �21,PPhone A.-
.Are you an employer? Check the appropriate boz:
I. ❑ I am a employer with 4. ❑ I am a general contractor and I Type of prel� (required):
employees (fu(1 and/or part-time).* have hired the sub -contactors b ❑New construction
2. ❑ I am .a.sole proprietor or partner- listed on the attached sheet 3 7. ❑ Remodeling
ship and have no employees These sub-contaactors have
working for me at act workers' comp. insurance, 8_ Q Demolition
9.
[No workers' comp. insurance 5. ❑ We are a corporation and its ❑ Building addition
required.] officers have exercised their 1Q.❑ Electrical repairs or additions
3 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself [No•workim' comp. r:, 152, § 1(4), and we have no
. insurance. uired. t 12.❑ Roof repairs
mq ] .employees. [No workers'
comp. insurance require&] I3.❑.0ther
;AnyHomeowner¢ who submit this a
applicant twist checks bob }� t must also fill out the section below showing their workers' 6Dmpensetioo policy information.
4Cortaacmrs that check this box
1 ffidavit indjMing they ars doing an work and than hie outside contractors must submit a
new Affidavit indicating such
must chrQ additional sheer showing the now of the sub-
corttraetors and (hair workers' wrap. paucy inform aon.
I am an envkyer that is proviafing:workcrs' compensadori irisurance or
information. f mY employees: Below is tlseFolic!' aria'yob site
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/Statelzip.
Attach a copy of the workers' compensation policy declaration page. (showing the policy cumber and expiration date).
Failure to se=re coverage as required under Section 25A of MGL c. 152 cart lead to the imposition of criminal
fine up to $1,500,00 and/or one-year imprisonment,penes penalties of a
of up to $250.00 a day against the violator. Be advisedthata opylof than statement may be foe fbrm of a rwarded to the Office of
a fine
Investigations of the DIA for insurance coverage verification.
I do hereby cerfi un er thhee� penalties of perjury that the information provided above is true and coarct
C s
STPrrattd'C:
Date
Phone
ficial use only. Do not write in this are¢, m be completed by citj, or town officio[
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of health L Building Department 3. CkY/Town Cierk 4. Electrical Inspector S. Plumbing Inspector
15
6.
Contact Person:
Phone #.
Information a nd Instructions Y
Massachusetts General Laws chapter 152 requires all emp 3 oyers 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, assodiatian, corporation or other legal entity, or any two or more
of the'fbmping engaged in a joint entetprise, and includir-tg the legal representatives of a deceased employer, or the
receiver or t mstee of an individual, partnership, association or other legal entity, employing employees. However the
owner- of a dwelling house having not more than th= spas-tinerrts and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maimtrnanee, construction or repair work m 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 stege Ourlocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or iiia 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 t3he commonwealth nor any of its political subdivisions shall
enter into any contract far the performance of public work until -acceptable evidence of compliance with the insurmcm
requirements of this chapter have bean presented to the cordracting authority,"
Applicants
Please fill out the workers' compansation• affidavit compie✓tely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), addrns(es) mind phone manber(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members orpartnets, are not rmluiredlto carry workers' ccs-rnpensation insurance. Ifan LLC or LLP does have
empioyees, 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 retur ed to the city or town that the .application for the permit or license is being requested, nottthe Department of
Industrial Accidents. Should you have any questions rep= -ding the law or if you are required to obtain a workers'
compensation policy, please -call the Department at the numberlisted below. Self-insured companies should enter their
self-insurancelieense number on tine*appropfiate 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 appliaurt.
Please be sure to fill in the permit/license number which %%-i]I be used as a reference number. In addition, an applicant
that must submit multiple permitAiewme applications in any given year, need only submit one affidavit indicting 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 be= officially stamped or marked by the city or fawn may be provided to the
applicant as proof that a valid affidavit is on file for f kare permits or licenses. A new affidavit must be filled out each
year. When 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 Investiptions would thea to thank you in advance for your cooperation and should you have any questions,
please do not hesitate tao give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department ofindusttW Aacideats
Office of Investi aiions
600 Washington Street
Boston, MA 02111
TeL # 617-7274900 Ext 406 or 1-977-MASSAFE
Fax # 617-727-7741
Revised 5-26-115 wwwmass_gov/dia
ES, Gt90nPlf.A-rTl7" IS 0 O
A I,�, A.r1'TY 0 f T4c '5w"U"oe-4 VTotlkL
t,YSTEM. ST Is ,A ZLCOLO OF T49 Lar.*rb►J
AW E L.9 varn0J PF -rW k W.1 n t Nes tiYSTbN
"HF0Wrr.k Ty.
1. c�GN
Pu HP I '
C1 �k- o
LOT2v I
i
t
AS Rt`I LT PLAN
A'
OfDIS.pGSEMAL SYST8;U.MURFA�CE
LOCATED IN
A PREPARED FOR
DATE: ".
a a
SCALE: I '
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 O TEL (617) 475-3533, 373.5721
usf1Fwm-�1a UOT
4'WtH, =T is A CEcoeo OP 149 I %0rrW
AW e1.6VAmrW PF T,49 &—yTIWA *Y*n-
cOHfounoTV.
12-4IYs 500
Vier F%lst.a
III (
1-765;
P°"'to
P
Lgouo Dee
Ler V
51
(4t,l zoo)
i,
117E �l
AS BUILT PLAN
OF
gtjBSURFAM DIS SYSTEM
LOCATED IN
I.1o�rt.1 a.�DevEe , Me,X • �4'�i /�v�� K'►GG CZOA�
ISS PREPARED FOR
�DkaBe1ZID EGI?s.PEI.S �/ /fir, _
DATE:
TL �-
MALE: 1 11 g,j �w
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS
66 PARR STREET • ANDOVER, MAssAGHUSETTS 01610 6 TEL (617) 475.203. W3.5"I
F NORTH TOWN OF NORTH ANDOVER
R
ooma OFFICE OF
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: 05-/2 a/ 7 `Z'
JOB LOCATION: 4 35 wls4.� /Z"D
Number Street Address Map/Lot
HOMEOWNER (� 4� 970- Fog -I&P
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 1'3 S'hc 1L /2,1-0
City Town State Zip, rode
Y
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 co ly with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
O
�
'V
.�i
u
C/!
C/)
U
G
cd
o
uo
v
U
w
a
o
E-4�
W
so
C
a
W
w
U)
5
a
O
rh
o
c4
izo
w
z
P-4
w
C-/)
u
aoG
ce
nw
Liu
o CIM
z
2
9
co
O
co
O
C.7
Z
co
CL
O y
D O
O Om
CO3 p0,0
CD.�
CO.) O O
.P m m
CD C3 CD
C ~ 4.0
= O �
O
CD O cm OL
eCv o Q
_
C Q
CO2
cc
O C
Q
.COD
C CD
0 CL
V CO)
c C
c
CO2
LLI
cl
Y/
LLI
U)
W
W
19
W
co
c�
o
CD c
CD
O H
C
CO
J
�c'fl
a�
to m
o
=
Q L
Ea
�CD
\p
o
= C
0
o c.
N
�► c��
CD
C
0CD
� cm
c
. m c
O
L
CO)
h
CDC:
O
H
C
J
�
-
CO
O
zip
t
C
�CCU
O
L
m
N m
t Z
Cc*
Of
c O Q
d p =
'm
m
Giy O
V -� Z
L
O
d
cm
H
O
=
Lm
mL r 3
O
N
~
y m o
m
COD
YJ
p
eo t m
D
O.
V
O
C. v
C*
�0H=
O
Z
eyo
=
*. CL
�
2
9
co
O
co
O
C.7
Z
co
CL
O y
D O
O Om
CO3 p0,0
CD.�
CO.) O O
.P m m
CD C3 CD
C ~ 4.0
= O �
O
CD O cm OL
eCv o Q
_
C Q
CO2
cc
O C
Q
.COD
C CD
0 CL
V CO)
c C
c
CO2
LLI
cl
Y/
LLI
U)
W
W
19
W
co
Information an- d 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 inthe 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 o$ 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 be cause 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 c--anstr-uct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coimpUance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
eater into any contract for the. performance of public work im-til 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), addresses) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) wish 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 sxwe to sign and date the affidavit. The affidavit should
be rctarned to the city or tow,'Ti that the auulicatMon for the pe-MM'tQZ license t5 being requested, not f.he Departv:ent. of
Industrial Accidents. Should you have any Questions regardir—w g the raw or ;f you are r�. �iiired 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 pemut/lic-we number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/liceme 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 burn leaves etc.) said person is NOT required to complete this affidavit-
The
ffidavitThe 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
allThe Department's address, telephone and.fammumber.
The Commonwealth of Massachusetts.
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021.11.
Tel. # 617-72.7-4900 ext 406 or 1-977-MASSAFE
Revised 5-26-05 ray: # 617-72.7- 7 749
iA'ww-mass.. gov/dia
The Commonwealth of Afassachusetts
Department of industrial Accidents
Office of rnvestigations
600 Washington Street
BOSto/z, M4 02111
Workers' Compensation Insurance A vit Buiide s/Contrac
:mllcant Information tors/Electricians/Plumbers
Name (Business/Organization/Inaividual):
Address:�- � C'A-r-n�E s4-, c Ic-
01
:R?�
City/State/Zip: ►M�c�tl�(� d A . Olf 4 S
Phone #:
1 Are you an employer? Check the appropriate boa:
L ❑ I am a employer with 4. ❑ I am a general contractor and I
2. ❑employees (full and/or part-time) * have hired the sub -contractors
I am a sole proprietor or partner_ listed on the attached sheet I
ship and have no employees These sub—contractors have
working for mem any capacity.
[No workers' comp. insurance 5. ❑
wired.]
a homeowner doing all work
Myself [No workers' comp.
insurance required.] t
workers' comp. insurance.
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. ima.',
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
ce reautred.] I 13 ❑ Other
""*mt' tfi.
: -ny .scan_ that checks box 4l muss! alst+ iii cu! fhe seca� b=dor. s
Homeowners who submit this affidavit indicating the;, are do.-- n •w ^vuor' nd :ate u o outs commmon Macy Wfe. Ga on
'Contractors that check this box must attached an additional sheet showing the �� hire outside contractors asr. submit a new affidavit indicating such.
r
name of the sub -contractors and their wcrrkPrc'
�.� employer that is providing workers' compensatio
infoo rmation. n iRSzerance for my employees. Below is the policy,and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy deciarafion ace (showing page ( wing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL 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
Investigations of the DIA for insurance coverage verification be forwarded to the Office of
I do hereby certify era the ai d penalties o era u �
Siggnature:
[!� � fP J rJ ihrtt the information provided above is true and correct
—Date:- 0� 20 ? v7 v
Phone #: nl7k—
[Ofi,ase only. Do not write in this are¢, to be completed by city or town offcial
own:Permit/Licenseuthority (circle one):
f Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. P}umbinR bInspector
erson:
Phone #: