HomeMy WebLinkAboutBuilding Permit #873-14 - 675 GREAT POND ROAD 6/3/2014BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: %Is
Date lssued.-,�-3�'
IMPORTANT:
Date Received
icant must complete all items on this
0
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
w Bufildin
One family
dition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
sory Bldg
Others;
Demolition
Oth
00 519in f.,
"-3-hed"bf
atbr" 7 is n6f
L)LbL;KJtJ I 1UN Ur VVUKM IV Of= rKr-rumvir-w.
e C 3o X, q's, oma 0 2
J
Rt M a ved 0-r7 ('4?
OWNER: Nam
Identification Please Type or Print Clearly)
Icy Incl l-'atdAy Phone: 77 9 -6 F/- 00
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $ 'IrO 0 FEE: $ 2-5-
?� - � ,
Check No.:
-1 � �If Receipt No.: oc>- 7(,o 3 k
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature: of_Agent/Owner.- i< . � ;Signature of contractor .
I
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 Siqnature
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
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT .Temp Dumpster on site yes
Located at-112�4XMa n.Street N
�� � �'�. + 3y1 r k�$.
Fire Department signature/date } #, F � �3t -���' ���_ �3.� � � °��
f
?, ,� `; �. ��y t �,i• ext; "�'�#� `, t�, y �a1.,r t'�.-� .JE � -
:rz :s?4,.i rs +�
COMMENTS' t' �-�r r zt ���
M r-...., ,�� !. 'rte; :..5 `�, S -:••l '}e `. cv,' �:.'2
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 2008
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
+;
No. Date
Check #'37��j
2 7 6 3 8
TOWN OF NORTH ANPOVER
Certificate of Occupancy $—
Building/Frame Permit Fee $25—
Foundation Permit Fee $
Other Permit Fee
TOTAL $
Building Inspector
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NUMBER��APPLICATION `
INDIANA
FINISHEDI'l 40.1 MANUFACTURERS OF THE
G
Date of Shipment
5/12/2005
Fent identification
This is to certify that the materials described have been flee -retardant treated
(or are inherently noninflammable) and were supplied to:
657150
PETERSON PARTY CENTER INC
139 SWANTON ST
WINCHESTER MA 1890
Certification
The articles described on this Certificate havebeen 1.approved
chemical and that the application of said chemical was done in conformance with California
Fire Marshal Code. Ali fabric has been tested and passes NFPA 701! -9-3, CPAi 84, ULC 109.
Serial # 5109001 0)
Description of iters certified:
CENTURY MATE 30NVX45 SNYDER
%k HITE VINYL I6oz
Flame Retardant Process Used Will Not Be Removed By
Washing And is Effective For The Life Of The Fabric
SNYDER MFG NET PHILADELPHIA.OH�-
SPECIAL EVENTS DIVISION - ANCHOR INDUSTRIES INC.
10, !V--sSaC!nuse"'Oi �� a' �f i Of Puis Ssfe-.-.
`- Soard of S!,-Ading iR=.c:u12tions an.. Ci=ii.darcis
_:.._ns CS -060219
DL4RhTRAL\.4 -
s ,
33.HA2NTORD RD
Stoneham NLA 62180`
Comn;ss:c,. _, 0.".;27;2015
` Vl 1Lc (.iC-PiT>>C.J /G'�CLGJ ✓iLcT::l.',:f:�L/_'C�'
Office of Coasumtr Affairs & Busm°<s R.gutatioe
= iiri?ROV='"=NT CONTF;,'CTOR
--= -_z cistrJen: 522 _
.,niicil
M, -IRK P. T R ANA
MARK iF�=.I
3 -.-.v=ORD FD. — -
S TO im i=HA� 141, M,A 021, 80 `
IIaders>_cre;ar-
License or registr_*ion valid for inditiidul use only
before rile expiration date. If found return to:
Otnce of Consumer Affairs and Business R-,g,la -ton
10 Park Plaza -,Suite 5170
Boston, tiL•k 02116
Pot Valid tiFithhout signature
ACORO®
CERTIFICATE OF LIABILITY INSURAN E FOATE(IAR1/DDYYyY)/1/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPO THE CERTIFICATEHOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVER GE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE I SUING 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 SU ROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this ce iticate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER /
Bonacorso Insurance A ency, Inc CONTACT NA : Michael Bonacorso
ME
g r PHONE
83 Cambridge Street (78:L)273-3'00 FAX
E-MAIL A/C. No: (791)273-0600
P -O. Box 1502 ADDREss.mike@bona corsoins. m
Burlington MA 01803 INSURERS AFFORDING OVERAGE
INSUREDNA
INSURER A Acadia Insurance Company
IL #
Peterson Party CenterInc. INSURERB:C N A Insurance O,
36 Cabot Road INSURERcAIM Mutual T -------
Woburn
„ -__
Woburn INSURER E
MA 01801
COVERAGES✓ INS VRER F:
CERTIFICATE NUMBER:2013 Master
THIS IS TO CERTIFY THAT THE POLICIES UI INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N MED ABOVE FOR THE POLICY PERIOD
REVI ION NUMBER:
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC MENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HE EIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR
-TR TYPE OF INSURANCE ADDL SUBR
GENERAL LIABILITY
INSR WVD POLICY NUMBER POLICY EFF POLICY EXP
(MM/DD/YYYY
LIMITS X COMMERCIAL GENERAL LIABILITY '� IMM/DDlYYYY EAC OCCURRENCE S 11000,000
A I CLAIMS -MADE DAM GE TO RENTED
OCCUR X . X PA 5061026 10 0/9/2013 0/9/2014 PRE ISES Eaoccunence S 100,000
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space) is required)
4CORD 25 (2010/05)
N:S025 roninns m
CANCELLATION
SHOULD ANY OF THE ABOVE DESC IBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREO , NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PR VISIONS.
- AUTHORIZED REPRESENTATIVE
Michael J. Bonacorso
Tl,o Amnon 1988-2010 ACORD
of At-nQn
RPORATION. All rights reserved.
^, MED XP (Any one person)
S
AGGREGATE LIMIT APPLIES
PER NAL & ADV INJURY
S
1 , 000 , 00c)GEN'L
PER:
GEN RAL AGGREGATE
S
2,000,000
POLICY I ^ I PRO LOC
AUTOMOBILE LIABILITY
PRO UCTS - COMP/OP AGG
S
.2 , OOO , OOO
$
A ANY AUTO
COM IN ED SINGLE LIMIT
ALL DINNED X AUTOS ULED X
AU7GS
X .AA 5063173 10
(Ea a cident
BODI Y INJURY (Per person )
0/9/2013
I $
1 000 000
X HIRED AUTOS X NON -OWNED
10/9/2014 BODI Y INJURY
AUTOS
(Per accident)
S
i I
PRO R EP,TY DAMAGE
Per
X UMBRELLAX LIAB X
'
cident
I
$
OCCUR
B EXCESS LIAB
� Umns red motorist BI split Ilmit
S
DED I X
I
E EAC OCCURRENCE
�$
10,000,000
RETENTIONS 10,00
C WORKERS COMPENSATION
.5085496458
AGG EGATE
10/9/2013 0/9/2014
$
10,000,000
AND EIdPLOYE RS' LIABILITY
$
ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N
OFFICER/MEMSER EXCLUDED? IN
X C STATU- OTH-
R IMI T
ry/A
(Mandatory in NH)
EB
If yes. describe under
DESCRIPTION OF OPERATIONS
Z8006586
E.L. CH ACCIDENT
0/9/2013 0/9/2014
S
1 000 000
below
E.L. is BE - EA EMPLOYE
S
1 000 000
E.L. ISEASE- POLICY LIMIT
I
S
1,000.000
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space) is required)
4CORD 25 (2010/05)
N:S025 roninns m
CANCELLATION
SHOULD ANY OF THE ABOVE DESC IBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREO , NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PR VISIONS.
- AUTHORIZED REPRESENTATIVE
Michael J. Bonacorso
Tl,o Amnon 1988-2010 ACORD
of At-nQn
RPORATION. All rights reserved.
The Cormnomvealth of ,llassachusetts
Tr Department of Industrial. fccidents
—�
Office of'Investie (/tions
,� •
rr !600 6fashinw1orr Street
1 Poston, M/f. 02111
it, ).vw.fill ass.,olVdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/,Plumbers
licant Int"
Name i Business i�reanirtuon:Individual):
A ddrecc:
rt. 4_X celr7
City/State/Zip: bjD bu izto . fY f} cl/ �ul pholle r: %EI
Are �-ou an employer? Check the appropriate
box:
[� I am a employer with a CTZ_D
4.. ❑ t am a general contractor and 1
employees (full and/or part-time).'
have hired the sub -contractors
Lam a sole proprietor or partner-
listed on the attached sheet.
ship and have no employee,
These sub -contractors have
working for me in any capacity
employee, and have workers'
[No \v 01-ker'>- COMP. IntiLl l -a I1Ce
comp. insurance..
required.]
.:. ❑ We are a corporation and its
L I 1
_ am a homeowner doing ail work
officers hove exercised their
n?yself. [No \\orkeis• comp
right of exemption per MGL
, urtltce !'equir d.] .
c. 1 �2' 1t—'.,, and we have no
z:ntt;loN.ee. [No workers
con p. instnancc required.]
Please Print
"a 9 - Vo U --r-)
Type of project (required):
6. ❑Now construction
7. ❑ Remodeling
S. 0 Demolition
9. ❑ Building addition
10.❑ Elecu-ical repair, or additions
I Ln Plumbin_ repairs or additions
I �.❑ Roof repairs
:•,\n-.appllcam drat checks box _ I must ako fill our the section below Ocw in(-, ;!tcir a orkets' cnn-pe,tsation policy information.
-r • the . �u
I k,�nc,•,�.rn, rs tvltit :Conor this ;anda�;it mair::un_ they are doing al! wnrr„�i then. huc rut.idc coniraitoc. must .ul-:mit a rct� if old:,� it i•td:c_tin<u such
Contras:yrs that cbcck titin boy mint artacheu an additional dicot short mi-, rite pant:: of tit” silt -contractors and state ,titerher or nni those enliues have
enitflmea. It the ski h-connraitors hive ertt)tiovees, they mus-, pro%ide their •,corkers, cumin. policy nuirther.
I cmr arr cnrplc t•er that is prnvidir{{ rror'ners' compensation. insur•rrnce.lor m)• emplopee.s. Below is the policy and,job site
in for•mution.
insurance Company \!ante: 2 ///.��Fi�
Policy _" or Soli' -ins. Lic. aj(J{�72 p G"Z) (� }(,----- Expiration Date:_
Job Site address: 6 7.�- 6�e �OJ?i�
- CityiState:`Zip:
Attach a copy of tite "corkers' compensation policy declaration: pa -e (shossing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MIGL c. 1 can lead to the imposition of crirnillal penalties of a
File up to S 1.500.00 and.'or one-year imprisonment, as well as civil ;;e1,:alties in the form of a STOP WORK ORDER and a line
of up to 5250.00 a day against the violator. Be advised that a cop; of ;'::.is statement may be fortivarded to the Office of
investi_ations of the DiA For insurance coverage verification.
1 do herel>_i• certgj under the pains and penalties ofperjur)• ihat i' i;,;irrrntrtinn provided above is true curd correct.
Phonc 9:
�T
Official use onl)-. Do not write in this area, to be completed hp city or toren offic•tal.
Cite or Town:
Issuing :authority (circle one): --
1. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #i
3. Cite/ -Sown ( stir): 4. Electrical Inspector 5. Plunthiug Inspector
Phone 9:
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