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HomeMy WebLinkAboutBuilding Permit #1188-2016 - 500 CHESTNUT STREET 5/12/2016 BUILDING PERMIT TOWN OF NORTH ANDOVER o ti U g � � APPLICATION FOR PLAN EXAMINATION « i400 Permit NO: U (1 Date Received 1 V l � goRgTto nP~' Date Issued: 9SSACHUSE� IMPORTANT:Applicant must complete all items on this page qAp" `mss' .` ° IJP a ° � G`�,�` 3!*t`a^s ++d 2's.r'. t �•�" I?ROPERTY IINEI' J = � A, €� 5",',#s n , 'ms's :; ^� •tet'" "e �' :t'"' 's.4 Arlt»r.3' Y � r ,yw � L .y''�. i,W011 21 ..� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial XRepair, replacement ❑Assessory Bldg ❑ Others: ,F❑ Demolition ❑ Other We11 �` c Rei aM Floodpla►n fl Wetlands Watershed ©rstnetggg Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: �"7lL �P�{�!w� Sl ��1�-�V41(IJ 41 CONTRACTORS Name j,as. ' 4y _ ,ix •t �Address � y r � 1x.� •� �„ak.p� r$ _._.���a=.s `�• s..o* .,�o-��' ��` � s'*�,.�^ao `° ?� td ,*.*�''.. s�+e 'fit �� „� k �'�` ' c55A 7774 7 SU erU15Q at Con's,r +fionelmprovetnent �cense § -,s e} ` 1.'•:ke. `'. S.-i `, E' m"i Y ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULD/NG ERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED_COST BASED ON$125.00 PER S.F. Total Project Cost: $ U?/lI _ FEE: $ Z\ Check No.: 16 V I Z Receipt No.: �e,' Q NOTE: Persons contractin W 1 u re stere ontractors do not have acc�T the gu t1'fund nature o#�, ge uur�erdeo corJtractorr J 'w` ® OF NORTH q BUILDING PERMIT �o TOWN OF NORTH ANDOVER 0 to p APPLICATION FOR PLAN EXAMINATION`" c °HA Date Received:. _ TED Permit No#: gSSACHUs�� Date Issued: IMPORTANT• Applicant must complete all itemszQn4ls=page LOCATION Print PROPERTY OWNER Print ?D0 Year Structure yes no MAP PARCEL: ZONING DISTRICT:-Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑One family ❑Addition ❑Two or more family El Industrial El Alteration No. of units: [I Commercial El Repair, replacement ❑Assessory Bldg El Others: ❑ Demolition ❑ Other El Septic 0 Well ❑ Floodplain p Wetlands ❑ Watershed District [ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp.' Date: Home Improvement License: Exp.--Date ARCHITECT/ENGINEER Phone: a Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED CosrBRSZX�=QN$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt Nd. NOTE: Persons contracting with unregistered contractors do not have_-aceess o_the guaranty fund f }_u Signature nf�aeiitLOy��e�-:� SIS�f � Locatil)-�j�,f b No. 7c�1 Dat f • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ �o Other Permit Fee $ _ TOTAL $� r �' Check# -70 30369 Build ng Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiumning Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dwnpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i PLANNING DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS i HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision.- Comments r Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: ! FIRE DE Located 384 Osgood Street ( E.PARE M_E-NTS - Temp D`um is er on sitei es }Lo ated at T24tMain Stre QT � ` Fire ®e artment`,gnatu e%da t , C®MMENTS y �a Dimension Number of Stories: Total square feet of floor area, based' dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service dP®p,regxires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$100o fine NOTES and DATA—(For department apse) I ❑ Notified for pickup Call Email Date Time Contact Name Doe.Building Permit Revised 2014 r 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 IN 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 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 IN 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 Doc:Building Permit Revised 2014 1 r 'i - NORT�y - - _ ver O " p+ No. _ t - h ver, Mass 2filio 0 L^Vqfcoc"Icnewicw 1' �J— P 7,qS Qq TED U BOARD OF HEALTH PER , ITT Food/Kitchen LD Septic System THIS CERTIFIES THAT .......... .......��!... . .... a.- � BUILDING INSPECTOR haS ermission to erect Foundation p .......................... buildings on���.. !�5.:�► ..c�.... rf-.... Rough tobe occupied as ................ . ...Ap......' .....`.r .� .......................................................... 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 UNLESS CONSTRUCTI7RTS. Rough .............. ... . ...d. ..6iL6.......................... Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Repuired 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. a � 1Estimate # 00073 Date Mar29 201:6 u Jay Forst Roofing 500 chesnut st N Andover, Ma jdog29@msn.com Status :Pending Accepted Date Accepted By - roofing removal -install 90 degree drip metal on all perimeter edges 1.00 $9;000.00 $9,000.00 -install ice Grace shield 6\\\\\\\'up from the drip edge and along all eves.3\\\\\\1'of ice shield will also be placed in each valley -install synthetic underlayment on all surfaces not covered by ice and water shield(synthetic underlayment is stronger than standard fel undertayment) install Architect shingles GAF HD or Certainteed Landmark shingles using 6 nails per shingle for increased resistance against shingle blow offs install hip and ridge flash all pipes with pipe flashings 18\%W\"ice shield will be installed on flashings. flash metal flue pipes with steel pipe flashing install applicable ice shield and flashing against all walls install valleys using cut or weave valleys - .--. ..• -. Subtotal $9,000.00 Labor and material include dunpester include Total $9,000.00 Phone:978-569-7135 1 Page 1/2 i r, Estimate # Date7.1 Mar 29 2016 Terms & Conciif bras cf J� Forst Date: Date: Phone:978-569-7135 1 Page 212 f'Jlfl)1 QKf�t The Commonwealth of Massachusetts bepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le:ribly Name(Business/Organization/Individual): L t--C_ Address: 7�-/ � AZo 9-,o City/State/Zip: iJL,s'goyLo ow- ei M Phone#: 7;z4— 6- Are you an employer?Check thea propriate box: Type of project(required): 114 am a employer with 1, 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7_ ❑Remodeling ship and have no employees These sub-contractors have g_ L]Demolition working for me in any capacity, employees and have workers' 9 L]Building ti addition [No workers'comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL insurance required.]; c. 152,§1(4),and we have no 12.[ Roof repairs employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box1l 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. +Contractors 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: A1-f P-( 6X 6uil17•l) 5r�L/ y^,.-n/44_�- Policy#or Self-ins.Lic.#: S�W �gl� S�1 Expiration Date: It I t � /-zzl Job Site Address i�0'0 City/State/Zip: A1a n474 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the, I for insurance coverage verification. I do hereby ce nder t e pains d_pe alties of perjury that the information provided above is true and correct Si ature: Date: Phone#: 9 Z rZ Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 11/17/2015, CERTIFICATE OF LIABILITY INSURANCE u 20 zols 'MS CESdTWICATtr M 135UM A5 A 4W4rr OF&NF tOATW ONLY AND CONFERS NG WOWS UPON THE CERT;4 LATE HOLDER,THIS CERTIFICATE DOES u<)T AFFIRVIiATwELy aR Nr-GAWEL.Y AMEND,EXYEND OR AiL'TE72 THE COVER"4f.'r�AFFORDED BY THE POLICIES BELOW. THIS CERITI' ATE OF 115I5tdRANCE DOES NOT CONS'UTE A CONTRACT EE:i V. N THE ISSU NG*WRMI($), Aur-IORILED R PKESENTAT'1 E OR PRODUCER,r 001 E CF,RTIRCATE HOLDER INIPORT.Aut It}tls corRufit 5t dhtt ii an ADDMCNAL INSURM,tho polacriles).1rit5st tae vrpdo scA If SUBROGA-TIONOS INIAI.VEp,tiulakect�n the im mm and comMoi*W tha policy;cettam pofiicitt ny!rcgWm an icktamnt A stminem on this twit ficaw tdtws ridt confer dgbls to the earfifit gta tater lit lieu edsuch alndoraotnsr5M. vxrxxl Eet ° Dabbic Byer DYER raata.�:Il•ESt€fANCE rola s � ` „ aarc�e.'�rr7 9S)472-55� we a oc �I�s3)47.2.2414 i7$Routs Iart.Azz2 ��ate.. I?j r1r a�nre�crnr c c�!_5T ; __ 9%54C.rd[P.Imi A.FFC�F(,8a�f3 C91dfdilk� } ._..Pd::iCA Seaford '� 93190 irt3Utn ds Is�uFe4 , !iMMa."�R-C t STEVE DEfi 1ARDINS,LLC R Ce; ed', hlre 9°aahaway Mmrd invurarwe CumjabY6les 21 PM ATE ROAD luw; l E- TYI1lrAENDRO MA.DISTS iNgbwt RF COVEI:t.AGES CERTIFIC4TE NLIM15ER: PEVISION NddMEEFt TH4.S is TG CERTIFY THAT THL IrOMES OF INSURANCE 7 t$TED BE-Pow Hr vt SEEN IM ED TO THE WS REID NMAMA ABOVE rOri THE I'UCY PERIOD INDICATED.-rJQii THSTANDIRG ANY FiEMIREFRF_`OT,TERB OR.>r-GN[MON.OF A' Y�CONTFAr-T OF.OTHER DOCut:461JT Vwu?P.ESPECT To Vt"CH THIS :. �kTkPItXm MW BE ISSUED OR.@o AV P-MTAIN.'rHEFta„�ua'&a.P�t4;'E F�.S=Ck'�,R�s"3 BY T44E POLIMEa d.` SCROD HEREW 15 5I.1?QEGT TO a01.tt T19L'-MmiS, EXCLI➢Fis`CKS AND CONDITIMS C"r SLICH POLICIES.fik AUS SHI0Md MY HALF�&1=EN REDIJ?,FD ET PAID CLAWS. LT, _ a�..W 1 Pos r� ¢cr�crr5 £.TtETYPE t7F lil5UR.8N-^� -I-..r.. ; F�LiCI+tdLsq _.... cers:-xsrrr!t�.ecra:m+..rst-ra D? 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'MEEXPtgAT l: DATE !dOTIGE MILL BE, $tELAr,-MDY,,4 .CIC'}P rad° sX9'ttstt: A RDANOr ttFffM THE P',OLICY F'as17V45;0NS. t62SMassachusetis/saaeme AU-.An th�EfAr,%TM i.�ing?ara,�iA:C2dE L1 t 3w c9p- 00RPORATIOM,,tllrisgt�teserv�ed.. �t�3' .�Qt4I� TM ACORD name.eid logo arc miak%erediT sees sof ACORD r i i a � a I ��e ipomnnealC�o�C�aaaccc�u�4e�,� � 1�5na of lreusnm€r Aft 8s Busga�$e:��rlatittn E WN t7NlE MPF?Q1/€Ajtl tONMACiM on: TMM v to fsvith aS' - i F1' f3 d — l Raymwd MMM i6 i1 ELL ST Ducat Ike flMM26 —" 1Ti�deasee�'etarg �0' Massachusetts -Department of Public S'a.eu Board_ of Buildinu Regulations and Standards constructio. t; Raymond A Merrill- 1 16 Thissell Street - �. 5 Dracut MA 0192 Expiration Commissioner 05/29/2016 DEBRIS DISPOSAL AFFIDAVIT rJ�%_ �j Q-tI �����!T �"• � /�z1 I'LL /��v�i1. In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: Name of Waste Facility Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure,M.G.L.c.40 s.54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c.111 s.150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by.the Building Department and attached to the office copy of the building permit retained by the Building Department.If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. 780 CMR-6'h Edition Signature of Permit Applicant Date