HomeMy WebLinkAboutBuilding Permit #900-11 - 53 MAYFLOWER DRIVE 6/27/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: (9oo — !�
Date Issued: &/y7///
Date Received
TANT: Applicant must complete all items on this
"Ilt
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
11 Addition
El Two or more family
11 Industrial
❑ Alteration
No. of units:
El Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DhZSUK1Y I WIN UP W UY4,& i U Dr,
(Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name Phone:
Address
Supervisor's Construction License:
Exp. Date:
}
Home Improvement License:
ARCHITECT/ENGINEER,
Exp. Date:
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: $ G'
f
Check No.: y� �% Receipt No.:�
NOTE: Persons contr acting wi u� is red contractors do not have access to the guaranty fund
Signature of Agent/Owne� ignature g 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 Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE .DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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
NV I is ana UA I A — (for department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
_� _ 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
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
a Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition or Decks
o Building Permit Application
Li Certified Surveyed Plot Plan
a Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
a 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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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: Doc.Building Permit Revised 2008mi
Location -�5j- (,z
No. 0 Date /Z 7
TOWN OF NORTH ANDOVER
0 -
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 'V rl "/ 7
40-
2 4 62,
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ACORDM CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY)
06/06/2011
PRODUCER 978. 887.4900 FAX 978. 887.2404
Edward F. Sennott Insurance Agency, Inc.
16 South Main Street
P. 0. Box 457
Topsfield, MA 01983
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED ]&] Heating & Air Conditioning, Inc.
17 Arlington Street
Dracut, MA 01826
INSURER A: Great American
INSURER B:
INSURER C:
INSURER D:
INSURER E:
r-nvCDA r_Gc
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
DD'
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DDIYYYY
POLICY EXPIRATION
DATE MMIDDIYYIY
LIMITS
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE y
GENERAL LIABILITY
PAC6418906-04
06/01/2011
06/01/2012
EACH OCCURRENCE $ 1,000,00
DAMAGE TO R
PREMISES Ea occurrence $ 300,00
COMMERCIAL GENERAL LIABILITY
MED EXP (Any one person) $ 10,00
CLAIMS MADE FKOCCUR
PERSONAL & ADV INJURY $ 1,000,00
A
X
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,001
PRO- PRO LOC
AUTOMOBILE
LIABILITY
ANY AUTO
CAP6418957-02
06/01/2011
06/01/2012
COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
BODILY INJURY $
(Per person)
A
X
X
YX
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY
(Per accident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS / UMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR FICLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY IN
ANY PROPRIETOR/PARTNER/EXECUTIVEY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
WC6418907-04
06/02/2011
06/02/2012
X TORY LIMITS ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYE $ 1,000,000
E.L. DISEASE - POLICY LIMIT 1 $ 1,000,00
If yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
f`CGTICIreTC 44nl 111=0 CANCELLATION
ACORD 25 (2009101) V 'latsa-[UUU AL;UKU 6UKrUKA l IUIV. Au ngnts reservea-
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE y
Evidence of Insurance
Peter Sennott LA
ACORD 25 (2009101) V 'latsa-[UUU AL;UKU 6UKrUKA l IUIV. Au ngnts reservea-
The ACORD name and logo are registered marks of ACORD
a
Commonwealth of Massachusetts
Sheet Metal Permit
Date:
Estimated Job Cost:'14 Q
-501
Plans Submitted: YES NO
Business License # 196
Business Information:
Name: J&J Heating & Air Conditioning,
Inc.
Street: 17 Arlington St.
City/Town: Dracut, HA 01826
Telephone: 978-454-8197
Permit #
Permit Fee: $
Plans Reviewed: YES NO
Applicant License # 15(W
Property Owner / Job Location Information:
Name: V t i en e_T n c
Street: 53 /� 4 t/ F1 Wt r D r,
City/Town: Alo ✓ VA Ai d oy e v HA
Telephone: q7 � - & t 3 3/ 3
Photo I.D. required / Copy of Photo I.D. attached: YES NO
Staff Initial
J-1 / M -1 -unrestricted license
J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less
Residential: 1-2 family '" Multi -family Condo / Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. ✓ over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: Renovation:
HVAC ✓ Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney / Vents Air Balancing
Provide detailed description of work to be done: