HomeMy WebLinkAboutBuilding Permit #175-15 - 57 Lost Pond Lane Road 8/19/2014 NORTH
BUILDING PERMIT 016�tio
TOWN OF NORTH ANDOVER °
PLICATION FOR PLAN EXAMINATION * ,�
h
Z
h
Permit No#: r Date Received
SSACHUS�
Date Issued: t
IMPO TANT: Applicant must complete all items on this page
Q
LOCATION /0
rint
PROPERTY OWNER_ ' - =-- _ -
P 100 Year Structure yes nno
MAP jPARCEL _ rint ZONING DISTRICT. Historic District yes
Machine Shop Village yes _
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
El Septic n Well J 0 Floodplain ❑Wetlands El Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
?C 22 c
Identification- Please Typer Print/Clearly
OWNER: Name: t r t C�(��(w 1� ( ` .tea��,� Phone: l
Address:
Contractor Name:- _ _.__ Phone:_
Address: -
Supervisor's Construction License: _ Exp. Date: -_
Home 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: $ � ZZQ FEE: $
Check No.:�V-� Receipt No.:
NOTE: Persons contract n with unregistered contractors do not have access to the guarantyfund
Signature of . gent/OwnerA Signature of contractor
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/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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New ConstructionSin le and Two Family)
� g Y)
❑ 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 2014
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
PLANNING & DEVELOPMENT Reviewed On X /� Signature_
COMMENTSPe r p&kl_ Avly. 241'�
CONSERVATION Reviewed on �� - Si nature
D OZ6,�,
COMMENTS-1/1L
HEALTH Reviewed on V257 Si nature
-Z
COMMENTS
fl
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
d
Conservation Decision: 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
NOTES and DAT (For department use)
, -
Au-S 40
i
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Location O q Ails
No. t Date
• • lKf(
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $ s
TOTAL $
Check# ' t
�-BGiilding Inspector
r 1 NORTH -
_ . w: 10
: : - ..: sor
h ver, Mass, A + I7b Lr
COCHICH&WICII
A-�A `V
7,QS R1TE0 P. J�.(5
U BOARD OF HEALTH
Food/Kitchen
PER IT T D Septic System
•
THIS CERTIFIES THAT .......... BUILDING INSPECTOR
0 ..1
has permission to erect .......................... buildings on �.�/�. .1 ... Foundation
�. .... Rough
to be occupied as ........ ... ..2.2,........Perl:�ala........................................... ............. Chimney
provided that the person accepting this permit shall in erespect 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 MnNT ! ELECTRICAL INSPECTOR
1`
-UNLESS CONSTRU S R S Rough
Service
........ ........ ........................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fina'
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
J���� � � � ��. � } INV. OF
INV. OF
NIF
THOMAS F. WGRATH & I INV. OF
JACQUELINE McGRATH NIF INV. OF
LOUIS G. &
PAMELA E. RESETTA INV. INTC
BOTTOM
--------- 239-85 ALL E
Pi
4�1 EDGE
-11, OF SAND
BACKFILL INV. OF
LOT 5 INV. OF
D-BOX
NIF
GLEN G. & MARY H. AREA = 3.49 ACRES PT INV. OF
PRYOR
OF s P 96-12A
o
INV. OF
P
ALL E
SEPTIC 38.
TANK
TP 9��12
6 0.8
I Ick)
PT
P 96-12
---------- A
76.6' STEVE
ANGELA
QUICK-4
STANDARD MONITORING
CHAMBERS WELL
(6 ROWS OF
js�op 9 CHAMBERS)
100 L. BENCHMARK
F.
1-112" SCH CUT SPIKE SET
40 PVC 14" OAK UP 1.0'
FORCE MAIN EL.=151.72
PUMP UNIT
10 L.F. 4-
SCH 40 PVC
o 4:r1S71Ac PIPE
QA 1?A
PROPOSED
30'X 22'
PERGOLA
240' r -,
w
0
0
30.1'
SEPTIC
O)
r
EXIST.HSE
D
299' EXIST.GAR.
335'
LOT 5
3.5 ACRES
OHO
ti
(, 81' 50,
102'
PROPOSED PERGOLA ���NOF� MICHAELL
oJ.
�yG
CLIENT: HOWARD L.000PER o SERGI 1
U No.33191
LOCATION: 57 LONG PASTURE DRIVE,NORTH ANDOVER,MASS. �gNOFESS�O�oP
DATE:AUG.2014 SCALE:1"=100' SUR\l
PROFESSIONAL ENGINEERS & LAND SURVEYORS
CHRISTIANSEN & SERGI, INC.
160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830
WWW.CSI-ENGR.COM TEL.978-373-0310 FAX. 978-372-3960
DWG.NO.:00.000.L1
ne Commonwealth of t!2'assachasetts
. .�e,����ien�of.�nc��cs�rc�l.Acczclen��
• . Office of Xnvestigations
ky 600 Washington Street
Boston,MA 0. 111
ww.massgo-P1dhz '
WQr eX$9 Co)tpexwation Tumance Affidavit:lour GerigiCoxitractorsYIectrlclansl?I*b,exs
mutant Wop atjon Please.Fflnt Led
A h
airoe(BzxsiuessfOrganizationlfndzvzdual}: j41� �s.1/����/� (_��.rr
6x?
Address: �•s A✓-e .
-T
City/Statc/.11)6 AAUNW Phone 0:_ C1?8 3 '`J 6�
Are yout an employer?Check the appropriate box. Type of project(required):
�. d I am.a general contractor and I
1.Q I am a employer with______�. 6. El h7ew construction
employem(fulland(oxparttime).T havenedthesub-contractors
2.El ani.a sole proprietor or partner
listed on the attached sheaf. 7• R emadeling
ship and`havana•emplayees These sub-contractors have 8. [l Demolition
worMng for mo in any capacity. workers'comp.insurance, g, ❑Building addition
PTO W01ROrs'comp.Jnsurance 5• F]We are a corpora ion and its 101]Electricalrepairs or additions
, /egaked.] officers have exereiseatheir
3.6 41 am a homeowner cjoing all work right of exemption per MGL I I..[]Pxmnbing repairs or addi€zow
myself ENOworker s'com . c.152a§1(4)a andwehaveno I2.Q
Roofr6p
airs insuraricerequixed.a i o workers'
empto ees.[
13.[]Other,
comp.insurance required.]
Auya21311cantthaiciiecksbox#1mustalsoM61thesectionbel6wshowingtheirworkers compensationpoEcyinformation.
Homeowners who submitthis affidavit indicating6ey go doing allwork and then hire outside contractors must snbmit anew affidavit indicating suoh.
TContraetorsthat elaeekthis bo�mustattached as additional sheetshowingthauamo of the sub-con[raetors andthekworkers'comp.policyinfomlation.
f am an employer that is,providing tuo lre�s'cor�tpe�asation insurance fOMY employees Sero is the oliey ar�rij0 t'e
info�matio�t.
Insurance Company Name%
� Y
Policy#or Selz 3M.11G.#: Expiration.Date:
Tob Site Address: City/State(.ip:
.flash,a copy oft ewoxkers'compensation-poltey ilfeclaration page(showing-Me policy number and ex*affoa date).
Allure to secure coverage as xequiredunder Section 25.A.of o.152 cart lead to the imposition of of
f e up to$X,500.00 andlox one year imprisopntent,as well.as civil penalties in the form of a STOP WOPX ORDER.and a fine
of-up to$250.0 0 a day against the violator. B e advised that a copy ofthis statement may be forwarded to the Office of
investigations of the DIA.for insurance coverage VOTMOR&R.
.ado 11e�eby cep ' under meyains an penalties of era y mat tree information provided alio.e is fta antieorrect. "
Si ature• Date: 2//4/
l
I'lZone#:
Offleial use Daly. Do not write in tiais area,torte coyqued by city or town official.
City or Town: Perminiceuse#
Issuing Authority(circle one):
1.130ard of Health 2.Building(Department 3.City/'Poway Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - "
information and Instructions -
Massachwetts General Laws chapter 152 xeq#os all employers to provideworkers'compensation fox their employees.
Pursnant to this statate,m employee is defined as"...every person E the service of another under any contract of l*o,
express orimplied,oral orwritten:'
An er layei%is defined as"an individual,p.artztexship,association,corpoxatka or other legal entity,or anytwo ormor'e•
Of the Foregoing engaged in ajoint enterprise,and includingthe legalxepxesentatives ofa'deceased epee ip ex
,.or the
',
receiver ortrdstee of an.individual,partnership,association or other legal entity,employing employees, &uvea the
owner of a dweliinghousehaviugnotrnore thmtbxee apartments audwbo xesides therein,orthe occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or onthe grounds orbuilding appurtenant thereto shalinot because of such employmentbe deemed to be an employer:"
MQL chapter 152,§25C(6)also states that"every sfate or local Incensing agency shall withhold the issuance or
renewal of a license or poxmit to operate a business or to consExact buildings in the commonwealth for any
applicant who has not pro duced.acceptable evidence of compliance with,the insurance coverage required"
Additlonally,MaL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political sab(ji`sions shall
entexinto anyContract for the Performance ofpubHcworkmt acceptable evidence of compliance withtheinsurance
requirements of Oris chapterhave b eenpresented to the confracfxng authority."
,Applicants
Please fill out:the workers'compensation affidavit completely,by checking the boxes that apply to your sifaation and,If
9iacessaxy,supplysnb-contractox(s)name(s),addxess(es)andphonenumber(s)alongwiththeir cerecate(s)of
filgTrmce. LimitedLiabilityCompanies(LLC)orLimitedLiabJRtyPmrtnerships(M)vrithno employees otherthanthe,
members oxpartners,arenotrequiredto canyworkers'compensatieninsutance. If an LLC orLLP doeshave
employees,apolicyzs xeq*ed. Be advhcdthattbis affidavitmay be submittedto theDepartment of Industrial
Accidents for confirmation of insurance coverage. Also be suxe to sign,and date the afdavit. 'the afrtdavit should
be retumedfo the city or towa that the application fox thepennit or licensee is being regao ted,not the Department of
Industrial Acoidenfs. Shouldyou have any questions regarding the law or ifyou are xegaixed to obtain,a*orkers'
coaapensationpolicy,please call the Department attltanumbexlisted below. Saffinmrodcompanies sbouldenter thok
• self~insurance ltcense number on the appropriate line. - .
City or Town Officials
PleasebesnxethatthoazidavitiscompXeteaudpxiutcdle,gibly. The Department has provided aspacoatthe bottom
ox the affidavit for you to fill o-at in the event the Office of Investigations has to contact you regarding the applicant
Please be-sure to fill inthe pem1101cense number whichwill be used as a reference number, h addition,m applicant
thatrnust submitmultiple permitllicemo applications in any giveayear,need only submit one affidavit indicating current
PORGY Wormaiaon(ifnecessmy)and under"Yob Me,Address;the applicant shouldwxite"all locationsin (city or
tower)".A:copy oFthe affidavit thathas been ofciallystamped ormarkedby the city oxtownmaybepxovided to the
applicant aspxbofthatavalidorlicenses. ,A.=affxdavitmustbafiNed but each
year.'W ere a.home owner or citizen is obtaiiring a license ox permit not related to any business or commercial venture
(i.e.a dog license orpiermit to burn leaves eta.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you ia advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Departments address,telephone and fax number:
Tho Co onw-omltlt of M-aua l"Amofta
DeTaxtme,ut Qfbdu al Accidents
ofAce of11mafsgattom
600 Wa"gtQx?." e
TOL 617.7 �4900 W406 Qx 1-87 -MMS 'E _
Devised 5 z6-Q5 Fax#617-727""7 '49
TOWN OF NORTH
o oto � DovEp,
OFFICE OFlit
.
BUMI)INGDEPARTMENT
1600 Dsgood StreetBuilding 20,-Suite,2-36
7 �6 3-im US
Ius (S .North Andover,Massachusetts 01845
S�.sctt ��
Gerald A.Brown � Telephone(978)688-9545
Ykspector of Buildings
Fax (978)688-9542
,. R(DivMo)MR'I;zCENSEpXEI&rzorr '
UA1*J UN
- please Urint ', .
DATE;
roB zOC TzoN: S ® 1�
Number S_[reetA dress Map/Lot �' .
Name w
. .. Horne Phone
WorkMone
-PRESENT.MMiNG ADDRESS�
Ak -/
` Caty To,=m stAe
gip Code.
The current exemption for"•Itomeowner8"was extended to
nohide fo allow such homeo„vers to , . owner-oectiPted
engage.au.ir-lcasalduel in„s to Uvo units•oy;ess
an
dfhiwnes-notpossessalicanse,provideactsassaperyisor). 9tate3uldhE (Code Secdon dthat theoyyner
DEFINITION OFHONMOWNER
Persons)who awns apaZcel of ale on which,he/she resides or intends to reside,on which there is,or is intended to '
be,a one or twoaioiIy situ aures- A person who constructs more that o
cons' ue home' .
zde -
red ahomeowner, rn atwa yearperiod shall not be
The undersigned"Izomeowner”assumes responsibi
Applicable codesIityfor cbmplianceswith the State Buil din Code an
,by laws,rules and xegnlations, g d outer
The undersigned`°homeowner"certifies that Itelshe understands the Town o
minirnu f North
rzt inspection prooedums and re Andovo Building De'artment
requirements and that helshe will comply with,said procedures and p
requirements, •
ROMEO ' .
WNERS SIGNA.TL7RE
.APPROVAL OF BIIMD)NG OFFICIAL,
Revised 7.2009
Form Homeowners Exemption ,
'13 DAR))OF APPEALS 688-9541r T
• C07�SEtZ�4 A•TZON 688-9530 HEALTH 6$8-9540 PL.A,TINTNG 689-9535
'• o nark ago TOWN OFitT RTff ANDOVER
_ OBFICE OF _
• ' �b ,,� :'X600DsgoadStreetBuilding20 Surte236
�SSRct�us��� North Andover,Massachusetts 01845 ,
Gerald A.Brown Telephone(978)588-9545
Inspector of'&Idzngs - Eax (978)588-9542
HOMEOWNER.•YI'CENSE Exm/h m '
BTM)NG PERM T. PUCA.TION
Pleaseurint ." •
DATE:
JQB LOCATfON; $ �,� F
Number
Scree
�dresst .
Ma
. plZot �''
.T�OMEOWeIER
Name �H
me Phone
Work Phone
-PRESENT MAMNG ADDRESS [
zip Cod;
The current exemption for"homeo
to F-ED12V Sash hDMCfD -'t" ,wners"was extended to iholude owner ooctipied diyeHkgs to tWO units Ur;ass 2n_d
acts as su
eagl e an indivaaual•for lire who does aotpossess a i cense,provided that the owner
pervisor). Sfafe3uildhig (Code Section
DEFINITION OFHONIEOWNER
Persons)who awns apazcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be, i one or two fauuly structures. A person who constrnnts more that-one home in a fwa yearperio d shall not be
considered a bomeownez:
The undersigned"homeowner"assumesresponsibili foroo •
Applicable codes,by Taws,rules andzegulations. � �hznccs with Elie State auilding Code and other
The undersigned"homeowner"cerE;hes that he/she understands the Town of
gorth mnum-um inspection procedures and requirements and that helsh
requirements, e will comply wz h said procedures and epazfinenf
HOMEOWN`.LRS SIGI�I-A7`URB ,
APPROVAL OF BTff DMG OFFICIAL
Revised 7.2009
Form Homeowners Exemption
'BOARD OF APPEALS 688-954TCOI�SErRr
• �ATTON 688-9530 HEALTH 688-9540
PLANNING 689-9535
A4
5ao
Location
41
No. 3 Date
O:NORTol'1TOWN OF NORTH ANDOVER
tt.•o :• �O
3? •. • OL
A
Certificate of Occupancy $
60
s ,• �Eta
Building/Frame Permit Fee $ ^l
s►c►aus �D(/
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ Q' ,--
Check #
r
14612
Building Inspector
Location IF loi,5 � �C�tio dSIV��
No. 432 Date 107—ID w 0 o�
NORTH TOWN OF NORTH ANDOVER
F p
Certificate of Occupancy $
Building/Frame Permit Fee $
sACHUs
Foundation.Permi#Fee $
Other Permit Fee 4 $ 5_0
TOTAL $ y
3 �'gS sr F S td�
Check # ?-pie
�'
C
15 7 u Building Inspector
�p
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
g �n ,,> .,�:� �,,,1•=� ��5�11` -. .A1 �,i�?�' x. a=" `•w.`3 �s-zy. °� .�has 2 ... �s
BUILDING PERMIT NUMBER. DATE ISSUED.
SIGNATURE:
Building Commissioner/Inspector of Buildings Date z
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
/a /-�bj,4a a f Im A Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frontage 11
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
R 'red Provide R red Provided Required Provided
1.7 Water Srly M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: >.
Public 8' Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System '-1
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M
2.1 Owner of Record
S. M(14 Pell 30)h4 7rlll15-1,600 � N �
a
Name(Print) —� Address for rvnce: :—
a f- ,
Signatu Telephone
2.2 Owner of Record:
Name Print Address for Service:
z
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: /4-1 Not Applicable ❑
Licensed Construction Supervisor: I 1 L44
0
f t License Number
Address
t,Dwe iI � 5 3���
' ' ` ° Expiration Date
Telephone
3.2 Regi tered Home Improvement Con Not Applicable ❑
Vj
Company Name 17
Ad
13f
C-d Registration Number
Expiration Date /y
Si natur Telephone !�
SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) 1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Si ned affidavit Attached Yes.......11 No.......❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be UFFICIA"USE QNLX
Completed by pennit applicant
1. Building (a) Building Permit Fee 6
06 Multiplier
2 Electrical (b) Estimated Total Cost of q
Construction nl 9 17, 9
3 Plumbing Building Permit fee(a) X(b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, U31 1 �.0-" � QkQfb ,as Owner/Authorized Agent of subject property
Hereby authorize CW n,� I' c to act on
My behaJJ,in all matters relative to w rk authorized by this building pennit application. a O
1A C'P
Si natu` f Owner 0 Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief, \
Print NJV
a e
Si at o Owner/A nt Date
NO.OF STORIES ' SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS 1 sT 2ND 3
SPAN
DM ENSIONS OF SILLS
DIMENSIONS OF POSTS
DM ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OFC <,
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE tJo
FORM - U - LOT RELEASE FORM `
INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from
Boards and Departments having jurisdiction have been obtained.This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT �D rl ITtO _1'(USk PHONE
ASSESSORS MAP NUMBER LOT NUMBER .
SUBDIVISION (.() S�U/Z° CS�a��CS LOT NUMBER Cr
STREET &n IC STREET NUMBER
OFFICIAL USE ONLY
...........................................................................
OMMENDATIONS OF TOWN AGENTS
. ..�.... ................................................. 2222 ....2060.
F� 5 DATE APPROVED
NSERVATIO ADMINISTRATOR
DATE REJECTED
COMMENTSAl k
i /
DATE APPROVED 306
� (/6
TOWN PPKI&ER
DATE REJECTED
CON9 ENTS
DATE APPROVED
FOOD INSPECTOR-HEAL�THDATE REJECTED
A.-/U DATE APPROVED o� G
SEPTIC INSPECTOR-HEALTH
DATE REJECTED
CONRviENTS
PUBLIC WORKS-SEWER/WATER COTI
1
DRIVEWAY PERMIT
�v:sc� �1Vfi✓+�(.tEw� S U�r'��-czars :arvc�
APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR. DATE
f
{ TOWN OF NORTH ANDOVER, MASSACHUSETTS
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET, 01845
J.VVILLIAM HMURCIAK P.E.
DIRECTOR Telephone(978)685-0950
F
NORrh Fax(978)-688-9573
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DRIVEWAY PERMIT
DATE
LOCATION 57
BUILDER hone
OWNER phone
THE NORTH ANDOVER SUPERINTENDENT OF OPERATIONS
MUST BE NOTIFIED OF THE GRADE AND SETBACK FROM
STREET . CALL THE SUPERINTENDENT'S OFFICE BEFORE
FINISH GRADING AND SURFACING FOR APPROVAL OF
SUCH ENTRY.
FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT.
v
GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT
TOWN OF NORTH ANDOVERBUILDING DEPARTMENT
This form shall be used to assist the Building Department in their determination of exemption under section
8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the
necessary information as requested below.
Permit A plicant Property addres Map/Parcel
q J, 9 97 V/
Applicant's Phone Number Single Family Two Family
I the undersigned applicant for the above property attest that the attached building permit for which this form is completed
does comply with the EXEMPTION section 8.7.6 ofthe Growth Management Bylaw.I also understand providing this form does not
absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the building
permit.Further I understand that my interpretation ofthe exemption status is subject to review by the Building Department and is only
officially accepted when the building permit is issued.
Based on section 8.7.6 ofthe North Andover Growth Bylaw the above lot and the work as applied for on the above lot,in the building
permit application and associated attachments complies with one or more ofthe follow'
P PP mp m sections as indicated b a check mark.
g Y
This is an application for a building permit for the enlargement,restoration or reconstruction of a dwelling in existence as
ofthe effective date ofthis bylaw,provided that no additional residential unit is created.
i� The lot(s)was/were created prior to May 6,1996 and are exempt from the provisions of section 8.7 ofthe Zoning Bylaw.
This application is for dwelling units for low and or moderate income families or individuals,where all ofthe conditions
of 8.7.6 are mei and or represents dwelling units for senior residents,where occupancy ofthe units is restricted to senior citizens
through a properly executed and recorded deed restriction running with the land.For purposes ofthis section"senior"shall mean
persons over the age of 55.
This application is part of a development project which voluntarily agreed to a minimum 40%permanent reduction in
density(buildable lots)below the density permitted under zoning and feasible given the environmental conditions ofthe tract,with the
surplus land equal to at least ten buildable acres and permanently designated as open space or farmland.The land to be preserved shall
be protected from development by an Agricultural Preservation Restriction,Conservation Restriction,dedication to the Town,or other
similar mechanism approved by the planning board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent
parcel on the effective date ofthis Section 8.7 and shall receive a onetime exemption from the Planned Growth Rate and
Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel.
This application represents a lot which is ready for a building permit(all other permits from all other boards and
commissions have been received and the project is in compliance with those permits),and the Development Schedule does not
accommodate issuing a building permit in that year.One building permit will be issued per year per Development until such time as
the development schedule accommodates issuing building permits.Applicant must submit an approved FORM U with this
EXEMPTION.
PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A
DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS.
BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED
BUILDING PERMIT IS ALLOWED AN EXEMPTION AS CITED ABOVE.
FURTHER I UNDERSTAND THAT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE
CHECKING OFF OF A ABOVE EXEMPTION WHICH DOES NOT COMPLY,WHETHER DONE TO MY KNOWLEDGE OR
NOT IS GROUNDS FOR REFUSAL BY THE BUILDING DEPARTMENT TO ISSUE A BUILDING PERMIT.
APPLICANTS SIGNATURE DATE
THIS FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION
v
Building Value Calculation - for Property at..... LOT#5
Room Length Width _Sq.Ft. Cost per Sq.Ft. Total Cost
Kitchen 26 17 442.00 65 $ 28,730.00
Living Room 18 16 288.00 65 $ 18,720.00
Dining Room 16 15 240.00 65 $ 15,600.00
Family Room 28 18 504.00 65 $ 32,760.00
Study 15.5 14 217.00 65 $ 14,105.00
Laundry 8 8 64.00 65 $ 4,160.00
Garage 34 24 816.00 35 $ 28,560.00
Entry 16 16 256.00 65 $ 16,640.00
Mudroom/1/2 bath 12 13 156.00 65
Sunroom 18 5 90.00 65 -
Sittingroom 18.5 20 370.00 65
foyer 7 7 49.00 65
Basement Finished - 65 $ -
Deck - 10 $ -
Screened Porch - 35 $ -
Sunroom - 65 $ -
Bedroom 1 34 24 816.00 65 $ 53,040.00
Bedroom 2 16 11.5 184.00 65 $ 11,960.00
Bedroom 3 16 11.5 184.00 65 $ 11,960.00
Bedroom 4 16 15 240.00 65 $ 15,600.00
Bedroom 5 15.5 13 201.50 65 $ 13,097.50
Bathroom 1 8 7 56.00 65 $ 3,640.00
Bathroom 2 12 6 72.00 65 $ 4,680.00
Bathroom 3 12 8 96.00 65 $ 6,240.00
Bathroom 4 - 65 $ -
Bathroom 5 - 65 $ -
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MAScheck COMPLIANCE REPORT
Massachusetts Energy Code Permit #
MAScheck Software Version 2 .0
Checked by/Date
CITY: Lawrence
STATE: Massachusetts
HDD: 6235
CONSTRUCTION TYPE: 1 or 2' family, detached
HEATING SYSTEM TYPE: Other (Non-Electric Resistance)
DATE:
DATE OF PLANS: _6
TITLE:
PROJECT INFORMATION:
Long Pasture Estates L vT a
COMPANY INFORMATION:
Crowley Construction Corp.
COMPLIANCE: PASSES
Required UA = 322
Your Home = 320
Are �-"or Insul Sheath ,Glazing/Door
Perimeter R-Value R-Value U-Value UA
-------------------------------------------------------------------------------
CEILINGS 2202 , 30 .0 2 .0 72
4ALLS: Wood Frame, 16" O.C. 512 13 .0 3 . 0 36
3LAZING: Windows or Doors 289 0 .350 101
)OORS 42 0 .350 15
FLOORS: Over Unconditioned Space 2023 19 .0 96
MVAC EFFICIENCY: Furnace, 94 .0 AFUE
-----------_ ,_ .,..:---------------------------------------------------------------
COMPLIANCE STATEMENT: The proposed building design represented in these
documents is consistent with the buildiitj -plans, specifications, and other
:alculations submitted with the permit application. The proposed building
Zas been designed to meet the requirements of the Massachusetts Energy Code.
rhe heating load for this building, and the cooling load if appropriate
Zas been determined using the applicable Standard Design Conditions found
Ln the Code. The HVAC equipment selected to heat or cool the building
shall be no greater than 125W of the design load as specified in
sections 780CMR 1310 and J4 .4 .
3uilder/Designer Date
MAScheck INSPECTION CHECKLIST
Massachusetts Energy Code
MAScheck Software Version 2 .0
DATE: 4-14-1999
Bldg.
Dept .
Use
CEILINGS:
[ ] 1 . R-30 + R-2
Comments/Location
WALLS:
[ ] 1. Wood Frame, 16" O.C. , R-13 + R-3
Comments/Location
WINDOWS AND GLASS DOORS:
[ ] 1. U-value: 0 .35
For windows without labeled U-values, describe features :
# Panes Frame Type Thermal Break? [ ] Yes [ ] No
Comments/Location
DOORS:
[ ] 1. U-value: 0 .35
Comments/Location
FLOORS:
[ ] 1. Over Unconditioned Space, R-19
Comments/Location
HVAC EQUIPMENT EFFICIENCY:
[ ] 1. Furnace, 94 .0 AFUE or higher
Make and Model NumberBR ,
THERMOSTATS:
[ ] Adjustable thermostats required for each HVAC system.
AIR LEAKAGE:
[ ] Joints, penetrations, and all other such openings in the building
envelope that are sources of air leakage must be sealed. Recessed
lights must be type IC rated and installed with no penetrations
or installed inside an appropriate air-tight assembly with a 0 .5"
clearance from combustible materials and 3" clearance from insulation.
VAPOR RETARDER:
[ ] Required on the warm-in-winter side of all non-vented framed
ceilings, walls, and floors .
MATERIALS IDENTIFICATION:
[ ] Materials and equipment must be identified so that compliance can
be determined. Manufacturer manuals for all installed heating
and cooling equipment and service water heating equipment must be
provided. Insulation R-values, glazing U-values, and heating
equipment efficiency must be clearly marked on the building plans
or specifications .
TITTOrr TVCTTT.TTTn'hT.
F :f,
[ ) I Ducts in unconditioned spaces must be insulated to R-5 .
1 Ducts outside the building must be insulated to R-8 .0 .
DUCT CONSTRUCTION:
[ ) All ducts must be sealed with mastic and fibrous backing tape.
Pressure-sensitive tape may be used for fibrous ducts. The HVAC
system must provide a means for balancing air and water systems.
TEMPERATURE CONTROLS :
[ ) Thermostats are required for each separate HVAC system. A manual
or automatic means to partially restrict or shut off the heating
and/or cooking input to each zone or floor shall be provided.
HVAC EQUIPMENT SIZING:
[ ) Rated output capacity of the heating/cooling system is
not greater than 125% of the design load as specified
in sections 780CMR 1310 and J4 .4 .
MISC REQUIREMENTS:
[ ) Refer to 780 CMR, Appendix J for requirements relating to swimming
Pools, HVAC piping conveying fluids above 120 F -or chilled fluids
below 55 F, and circulating hot water systems .
----NOTES TO FIELD (Building Department Use Only) -------------------------
_ � _ ..
v
I'
Town of North Andover 4ORTH
o
! Q
Building Department o
27 Charles Street
North Andover Massachusetts 01845 z .^
(978) 688-9545 Fax (978) 688-9542
q�R''1TlD .Pay,��J
�SSACHUS
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit# the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in/at:
Facility location
Signature e of Applicalu
Date
NOTE: A demolitionP ermit from the Town of North Andover must be obtained for this
project through h Office o� o gh t e O ce of the Building Inspector.
i
Ihe uommonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
" Workers'Compensation Insurance Affidavit
Please Print
Name:
Location: >
City W� '`� III Phone 9 d / 5
am a homeowner performing all work myself.
�I am a sole proprietor and have no one working in any capacity
I am an employer providingworkers'compensation for my employees working on this job.
Comr)anv name: 1) J
�� ! x J
Address 9"Y p
City: �I S Phone#. 7 "6
Insurance Co. /��i Poli .#
Comggnv name:
Address
City: Phone#
Insurance Co. Policy#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00
andlor one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct
SignatureDate cad v� O
Print name e. Phone#
Official use only do not write in this area to be completed by city or town official' E Building Dept
[3Check if immediate response is required Building Dept C] Licensing Board
F-1 Selectman's Office
Contact person:_. Phone A- ri Health Department
Other
FORM WORKMAN'S COMPENSATION
� _ J�C �697L�tp?t((JQpA,(/�. O�il6ZfWOQC�([tte�.uq
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 058114
Birthdate: 02/27/1961
Expires: 02/27/2002 Tr.no: 16172
Restricted To: 00
STEPHEN CROWLEY _/
' 138 VIRGINIA AVE
f LOWELL, MA 01852 Adminis#rator
rlki
1
i
f
�' � � ✓a L.omixn�e �f�aur�ascfLt
NOME IMPROVEMENT CONTRACTOR
Registration: 111,87
p Expiration: 8/11/01
Type: BOA `
{
} CROVLEY CONSTRUCTION E G.0
Gly �o ,STEPHEN CROVLEY
ADN'NiS�Oa 138 VIRGINIA AVE
LOVELL MA 01852 E
,,oRTM AUTOMATIC LAWN IRRIGATION SYSTEM PERMIT
oFs,�lo ,l+tio
w TOWN OF NORTH ANDOVER
MASSACHUSETTS
RATlO
�SSAC14US�
ALL INFORMATION MUST BE PROVIDED,BY A LICENSED PLUMBER,
PRINTED IN INK AND LEGIBLE.IF NOT THE PERMIT WILL BE REJECTED.
DATE: LOT#:
LOCATION: '57
NUMBER STREET NAME
BUILDER:
NAME TELEPHONE
NUMBER STREET NAME TOWN/CITY&STATE
OWNER:
NAME TELEPHONE
NUMBER STREET NAME TOWN/CITY&STATE
PLUMBER:
NAME TELEPHONE
NUMBER STREET NAME TOWN/CITY&STATE
LICENSE NO. EXPIRATION DATE: SERIAL NO.
IRRIGATION INSTALLER IF NOT THE PLUMBER
INSTALLER:
COMPANY TELEPHONE
NUMBER STREET NAME TOWN/CITY&STATE
INDIVIDUAL NAME TELEPHONE
The plumber,must install the connection to the municipal water supply within the building,the water line to the outside
of the building and the backflow device. A registered irrigation installer may then install the balance of the Automatic
Lawn Irrigation system.NO irrigation heads will be allowed in the right of way(near edge of pavement).ALL irrigation
heads MUST be at or behind the property line.All heads installed in the right of way will be removed immediately upon
notification and said plumber or installer will not be allowed to perform any future work on the municipal water'supply,
until the heads are removed from the right of way. Sign below that you have read this paragraph and understand it.
SIGNATURE OF PLUMBER DATE
THIS PERMIT MUST BE POSTED AT THE CONNECTION/METER LOCATION FOR THE INSPECTOR.
INSIDE CONNECTION METER(IF APPLICABLE) BACKFLOW DEVICE
RAIN SENSING DEVICE COMMENTS
F 1 049
A
APPLICATION FOR WATER SERVICE CONNECTION
North Andover, Mass. 1�
Application by,the undersigned is hereby,made to connect with the town water main in- �ia ' Street,
` subject to the rules and regulations of the Division of Public Works.
i J
The premises are known as No. 57 -J� date �,Street
or �subdivi ion lot NQ01
no. /eiJE' ao r.Jr1 NpR
P
2 F -
Owner
OSTM qti
O��`��•, CO`s R/
Contractor = v
M�SSAGHJ � ..•
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1
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R e' ..,...�••� epa m
PERMI' ANN\0 PPpCwa�t ..rrV {
The Board of Public Works hereby grants permit.
to make a connection with the water main at Street
subject to the rules and regulations of the Division_x-Public Works.
Com! Board of Public Works
By a
Inspected by
Date
See back for rules and regulations
fi r' ; 0z1 l � (
ORTH
Town o ,, Andover
0
No.
y 0 _- o ndover, Mass.,
T O � l A K E 1.
COC MIC KE WICK V
'�i9ssq 7E DU�G, �
CH
7 44
I T
FOR
EXCAVATIO N AND FOUNDATION
a/� T
THISCERTIFIES THAT ...................... ............-J3,---...//...............Ptb.......... .........> ..f...................................................
has permission to excavate and pour foundation at .�.Q ... ...�1� .. ... ...V rr...�..GL
for the purpose of.1trQp0),..... V �� A +y.). S�a��....l�!1� :�.t.:... .�.N .� ..... , I y
The person accepting this permit must return to the office of the Building Inspector a certified plot plan show
of building thereon before Foundation will be inspected. r 06 A P di
•
VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS
The holder of this Foundation Permit proceeds at own risk and without UNLESS CONSTRUCTION STARTS
assurance that a permit for entire building structure will be granted.
.....................................................................
BUILDING INSPECTOR
x.10 R T Iy
own of E 4Andover
No. /3 3
D� o�H w o dover, Mass.,
��p A°RATED
7S �
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
THIS CERTIFIES THAT..SAO� ......... /� O7 � �x v45 BUILDING INSPECTOR
. .../............. ........�.. ......................................... .............
"" Foundation
has permission to erect................./................... buildings on •r. L0413. ..k vr! Rough
II 1
t0 be occupied as.41..� .. ..�V1�. a '1�.. � s , S �11 VIN��f" �N '� A��) Chimney
i •
.................................................
........ ............. ...............
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspecti; o1je
Alteration and Construction of
Buildings in the Town of North Andover. M 1 0 6 A iP 4 ` sumPLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION ST S ELECTRICAL INSPECTOR
CRough
....................................................... .................... ... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fina,
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE smoke Det.