HomeMy WebLinkAboutBuilding Permit #133-13 - 766 GREAT POND ROAD 8/16/2012 BUILDING PERMIT
NO DTf/ qti
TOWN OF NORTH ANDOVER 032
APPLICATION FOR PLAN EXAMINATION _
b
3?� �
Permit NO: �— Date Received �s'`�Ra7ED IPp��g
Date Issued:
16-Zljr
O TANT:Applicant must complete all items on this page
..m.«,rR. -.s. Y"tSv�{€�` �. �r �r:°,"j ,,"�, " - "' '�.',.°" ¢ ' y,- `**yy."
w., .. »FZ yW'+'{`4,,$Y .:} .'1g.#,:`-} ".X3, ..14 t3�'u �5}.. kY`' 3t'• �� � YA^R
PL®tCATI®Nw k
. _
�..,."„`� .,.."•.,r' _ �+'7 a ,�.+c.*, •��- � P�Illt 'arm'.,,.� ar .�u,x-^ . ,.�* s�-.«' w�.�»" ,' s�, ''4:4
n
PROPERYQ
VV-Nhi
A FL
ER -
WA, N® -PARCELiZONINGDISTRICTHstonc4Distnct yesno _
1VlachineShopUillage esno
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: ( Commercial t
Repai lacement Assessory Bldg Others:
Demolition Other j
' Septics` ;�WellgS ~igloo ain sus Watersheds,District .
is
DESCRIPTION OF WORK TO BE PREFORMED:
C-
Id e tification Please Type or Print Clearly)
OWNER: Name: O � Phone: 7 4r� `�' 7v� `
Address:
FL ° --"*-tr+- 4 -r.sr-w.r-��f$w,=;-r+.kR�sa`r,•,a-.�..,..�-..�r.,f- s-�c.�,x,. :.=-� '�" -a.a m'q .e� -�r'-,zc c�`r �,y.f-�..- . v�:zpati,� § ..' a� ���� i
PONTRACT®R rName ._ u /mfr
�Address�
t Supeevisor s�Constructi®nliLicenso. ' 3 Expo®ate `�;�Z 9 / 1 ' �
- `E
�
sa q s�adx�.4A.+ ,tn=t � -
��'HomreImprovementLigerse } ICP � � # � � ExpDafe
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: $ FEE: $ �
Check No.: / / f?� Receipt No.: ���
NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund
Signature:of Agent/Owner "Signature of contractor.-
6e
y - .
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 PPROVED
PLANNING & DEVELOPMENT
COMMENTS �d v� '�1���y; IIU� 0-e yl
<4)
CONSERVATION Reviewed on I ► la Signature I U
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`D.6 , "t r on site yes
'Located at 124Main` eet
�4 'ti r r y ,-. .,..•r.e3,. ,1 i At +++Y i. xx P4 "Rt-'3"s tf t 'i
r. �. Str �.3 +e'`l.' a .x..tJ£`t 2 Y`£' '•-e,,� ,.{J� V..Y .J� +h' 1`+y5'by� .¢`�:
FireDepartment:signature/dates° _ � ,b_$ }. n
QOM IVIENT
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
i
Total land area, sq. ft.:
i
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
ii MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
I
L
I
® Notified for pickup - Date
----..........._...
...... --- ---- --— _.. —!
Doc.Building Permit Revised 2008
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 ll
❑ 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
MOTE: 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
I
Revised 2.2008
Location
No. �✓?�'�� Date -F I 2
• r TOWN OF NORTH ANDOVER
t •
Certificate of Occupancy $
`r Building/Frame Permit Fee $ 7
#* �� Foundation Permit Fee $
` Other Permit Fee $
TOTAL $
Check
y/
25619 uilding Inspector
� tkORT1�►
own o t Andover
No.
T �O LANi h ver, Mass,
COC NIC
'Its y�.
�d p04ATED
S V
BOARD OF HEALTH
Food/Kitchen
P E Septic System
MIT
/1 C' V �' S� BUILDING INSPECTOR
THIS CERTIFIES THAT ....
Foundation
has permission to erect buildings on .... ' � "'.��' ........
.... .. . .. ................ . .....................
� / C � Rough
tobe occupied as ............... ...... 'IV,............1.........y ..t' /\.............:................. .................... 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
pA
�/ MONTHS
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION S S Rough
Service•
.......................... r,.,., 4.............—:................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required 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.
SEE REVERSE SIDE Smoke Det.
-comwWMvea" 04�
Office of Consumer Affairs and Briusiness Regulation
10 Park Plaza.- Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
- Registration: 168661
Type: Individual
— Expiration: 3/24/2013 Tr# 210386
KENNETH SURETTE
KENNETH SURETTE - -
36 SEARLE ST - =
GEORGETOWN, MA 01833
Update Address and return card.Mark reason for change.
`
oAdd
Address Renewal Employment st Card
DPS-CAIca
50
M-04/041012 6
Office o��on�me' aii l�a�ines"s"Ylegg a"6on— License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: .168661 Type: Office of Consumer Affairs and Business Regulation
Expiration: ,W412013 Individual 10 Park Plaza-Suite 5170
----—__-- Boston,MA 02116
K 1=1 H SURETTE
KENNETH BURETTE
36 SEARLE ST g��
GEORGETOWN,MA 01833 Undersecretary Not valid without signature
- \1assachu-S tts- Department of Public Sai'ct%
Board'Of Buildin, Regulations and Standards
Construction Supervisor License
license: CS 23453
KENNETH P 1-URETTE -
36 SEARLE ST
GEORGETOWN, MA 01833
i £'
s
Expiration: 9P29/2012
L',nnmts�iuner Tom•
9135
JUN-11-2012 11:48 From:PINGREE INSURANCE 978 352 8078 To:9783528417
CERTIFICATE OF LIABILITY INSURANCE 0811 2001122
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGRIS UPON TETE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAWELY AMEND, ErnM OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICAYE OF INSURANCE DOES NOT CONSTMITE A CONTRACT SEMEN THE ISSUING INSURER(S), AtdfliORIZED
REPRESENYA'nvE OR PRODUCER,AND THE CERTIFICATE BOLDER.
IMP-0 'f'ANY: K ars c rrMcare holder Is an ADDITIONAL INSURED,the podcy(les)roust be eltdOlsed. ff BUBROGAYION 18 WAIVE ,supIct to the
terms and condillons of the policy.certaln policies may require an andorsemeaL A SMIMI on Edo COrtiftrate does not Confer rights to the
cornNcate holder In ileo of such andorsemant(s}
PRoor►ceR did{
N PlnW oe lmmnoe Agency hO Pitons •_-
24 East Main Street &AWL
Georgetmn MA 01833 _ IRAU AP►nRaRo cdv6Raoa _ NAtc v -
INsuINIa IaRAtWostenWOddinaatou� .__ ... _._ .
Kenneth Suzette s► imm a_
36 Sser;e street Daum c:
Georgetown MA 01883
. tN8
COVERAGES CERTIFICATE NUMBER: REVISION NUMB R:
THIS IB T4 CERTIFY YHAT THE:POLICIUS OI:INSURANCE LISTED 8EtAW HAVE BSN ISSUED TO THE INBURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N07VWTHSTANOING ANY REOUIREMEW.TgM OR CONDITION OF ANY CONTRACT OR OTHER DOCLMSNT WITH RESPECT TO WHICH THIS
0ERjV4QA-M MAY SE=UEO OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POL.f M DESCIHOW HQREIN IS SUBJECT TO ALL THE TERMS:
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE OEM REDUCED BY PAID CLAIMS.
riftopmuRAN40-• _ - .POtiG
AAkilluplTa
09WAL LAB m ti►PP8083748 11/03/2014 11MM012 c-ACt�0='RRwc i i,DOD,DDA.
X O MM I:W 4011;RA+.UABnmr p-- F�+ t _ a. . •-- .
el,Alrns-MAa€Q cccuR +
IV_N NALAADVKWY
td@N�iAIAlaf9R4ATt? i._ 2.000,000,0
cN3N1,AO[iRE0AT1i 6pwSf P APPLIES PER PROMON-i AGG i .=.Q00.OR
POLICY O' LOG 5
AUTOMMIMUMM �� 5
ANY AtrfOFF
CiOOtl.Y tF6dlRY IPerParmn) i __ ...
ALLUtMDAUTO$ —.-.— __...... .. _
aODS.Y IM AWY(Per B40 t l) i
8M--0=0AUT05 PROP L"PTYDAMAW
_ MKI)AUMS t. _
NO"W=AUTQt3 .-
i
UWRI%LA UA9 Coco L*ACH OG &Nt:R i ------ .
0ICa88UAa CtJUAiSbAADEFF
ABItDAIC� b . ._ _--
_ cc-mc 1e11' --
� 5
WORIrRRd GOIrpsm7m A _
ANA M04AWW LK NM Y I N
ANY PROPRIETORS(�'I MIA A r E r�AC60ENT S
oPAICERAtAmw GCGuatAa (__J Ot O�EAen-6A 3
r10r,datntll In NH
ree.dmlb6w ALOl t-POLICYLW 5
ocrui ommammmmyga . IFILl -- ---I- I I
o98cRl=NOPomRA=NGILOm T,oNsIVmt6M A406M ttaa7srtinri a.amero[!>robiifdquire4)
-CERTIFICATE MOL RtrANCELLATiON
eHOUL0 ANY OP TWO Aa0Y8 0EBCRI110 POLI M 00 CANCtttd.OD WWOM TH@
g1tPWAN)M PAT$7rMMK mY=WILL 112 ULIVI RL'e IN ACRORMNCU WITH Til"
PG=PRDVMKW
AUIM R ATNe
V,/
__- _ Tel W, RAYION. AB rl"MGM"
ACORD 28(2008109) The ACORD now and Iaga are named marlrs of AD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Le ibl
Name(Business/Organization/individual):
Address: („ �Z,/C
City/State/Zip: ���D � �46- Phone#: t
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.( I am a sole proprietor or partner- listed on the attached sheet. 7. EZRemodeling
ship and have no employees These sub-contractors have g, 'Demolition
workingfor me in an capacity. employees and have workers'
y P �' t 9. E]Building addition
[No workers'comp.insurance comp.insurance. 10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ P
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required_]t c. 152,§1(4),and we have no 13.❑Other
employees.[No workers'
comp.insurance required.]
*Any applicant that checks box#1 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:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 DIA for insurance coverage verification.
Ido hereby certify under thens' penalties of perjury that the information provided above' trueand correct
Signature: Date: 1 y �
Phone#: , P 4ga �`y
Official use only. Do not write in this area,to be completed by city or town official
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#:
Contract
........................................................................................................................................................................................................................
FROM: Ken Surette . No. 776
Georgetown Ma
Cell 978 618 8417
Fax 978 352 8417
PROPOSAL SUBMITTED TO:
Name: Susan Worthen
Phone: 978 808 9703 Date: Aug 14,2012
Street: 776 Great Pond Rd
City: North Andover
State: Ma Zip: 01845
1 propose to furnish all materials and perform all labor necessary to complete the following:
10' X 16' pressure treated Deck with stairs for 2nd mean of egress
Remove and replace water damaged cedar shingles in small area under rear door
Permits and structural plans
All of the work is to be completed in a substantial and workmanlike manner for the sum of$7200
$3500 deposit, 2nd payment of$3000 when 50% of work is completed. The Balance amount of
the contract is to be paid within 14 days after completion.
Any alterations or deviation from the above specifications involving extra cost of material or
labor will be executed upon written order for same, and will become an extra charge over the
sum mentioned in this contract. All areeme must be made in writing.
Authorized Signature
'00000-
ACCEPTANCE
You are hereby authorized to furnish all materials and labor required to complete the work
mentioned in the above proposal for which Susan Worthley agrees to pay the amount
mentioned in said proposal and according to the terms thereof.
Signature Date
www.socrates.com Page 1 of 1 SS4301-340-Rev.05104
N
cp
co
N tp
F
LU 35'
N
1:} 28'
co
O
z a X
J N
r �
o
� z
z0
c�
PROPOSED
DECK
l
�- F
LOT "D"
s
432956 S.F.
O
o P
r
�1
5 O
NOTE:
SECTION 7.32 OF THE
NORTH ANDOVER ZONING
BYLAW ALLOWS THE
PROJECTION OF AN
UNCOVERED PORCH INTO THE
REQUIRED SIDE YARD.
PLOT PLAN
#768 GREAT POND ROAD oHOF�gss9c
NORTH ANDOVER, MASS. andover �� PETER yes
Prepared forconsultants
DODw
N
"Lots A, D & F Great Pond No
Road Realty Trust" inc. y
,
o s
<LAND
P:\12\12-31\DWG\PLOT.DWG SCALE: 1"=40' August 14, 2012 1 East River Place, Methuen, Mass. Nq
zx
0197
IZA
T
7-/a - 1
��sa�
A I
1
o `,
48 .p � "