HomeMy WebLinkAboutBuilding Permit #787 - 80 HOLLY RIDGE ROAD 6/1/2007BUILDING PERMIT
TCVNOF NORTH ANDOVER
APPLICA FOR PLAN EXAMINATION
Permit NO: ��,� Date Received
RSSACHU`����
Date Issued:
DESCRIPTION,PF WORK TO BE PREFORMED:
/4, J�A���A t&j 04 ) 4 C /Z0L)Y1x G vh tT-6 fro 0 /
I entification Please Type or Print Clearly)
OWNER: Name: %�� `L 0 n 1 Phone:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAS,EDj ON /$125.00 PER S.F.
Total Project Cost: $ �J ® FEE: $
Check No.: ff Receipt No.: 2 O d►� ��
NOTE: Persons contr cting with unregistered contractors do not have access to the guaranty fund
h G' - n A
Plans Submitted Plans Waived ❑ Certified Plot Plan ❑
%r
Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ®
Tanning/Massage/BodyArt 0
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
CONSERVATIO
COMMENTS L
HEALTH
COMMENTS
,TE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
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
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 DATA — For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
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
o 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
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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)
Li Building Permit Application
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavitslfor 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 2.2007
Location /1 �a / �1`ti� d-i� "
No. --% Date
NORTH TOWN OF NORTH ANDOVER
F 9
` Certificate of Occupancy $
;�S'•�° Eta' Building/Frame Permit Fee $
S cMus
Foundation Permit Fee $
j
Other Permit Fee $
TOTAL $
Check #
J Building Inspector
Location 1 e Ul
No. Date 6yl
�oR,M
TOWN OF NORTH ANDOVER
0�...° '• �M1'�
• . , '_ OL
yam, _
'"" � -2 A1C _ R• \ c- R Y,\
9
Certificate of Occupancy $
cMus `�'
Building/Frame Permit Fee $
Foundation Permit Fee $
eil5 r Permit Fe $
F
�
TOTAL $
Check # 1 21)3
205-53
Building Inspector
The Commonwealth of Massachusetts
c i Department of Industrial Accidents
Office of Investigations
'I 600 Washington n Street
` g
gill;;
Boston, MA 02111
{ IN www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: 7
City/State/Zip:
A_!!fou an employer? Check the appropriate box:
1. I am a employer with /30
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
1 1.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.FEOther
Any applicant that checks box # I must also till 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. 1-1? _ Y / ,
Insurance Company Name:
Policy # or Self -ins. Lic. #: C/�I ,S5�/i�,J/ Expiration Date: Zj—
Job Site Address:01 City/State/Zip: 1,
Attach a copy of the worker 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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 #:
617 -
Board Building
of Regulations andS Standards
Construction Supervisor License
License: CS 76339
Birthdate: 7J7/1946
Expiration 7/7/2009 Tr# 16528
RestncGon 00 �`
ROB Ef2T J FISKEIr"
5 TANGLEWOOD PARK
HAVERHILL, MA 01:830` Commissioner
.Y^�.
it
Boardof Building Regulat
Y
ions and Stan
° HOMEIMPROVEMENT Cdards
ONT
Registration:` RACTOR
License
105485 l
Expiration ;
before1
7/17/2008
Board c
Type. Supplement Card
SOUTH SHORE GUNITE
One As,'
Boston,
POOL &
pbbt T FISKE
6
7 Progress AVe '
Chelmsford, MA 01824
Administrator
-�-
_
\l—
1
OP DCv
ACORa CERTIFICATE OF LIABILITY INSURANCE ' DATE
CUSTO-1 02/20/07
's : RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMIATION
f Eastern States Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
i �_gency , Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
' :-- P 0 t St t ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
ro..pec ree
v,)altham MZ� 02,453
3?hone:781-642-9000 Faxx:781-647-3670
Custom Qualit}� Pools, Inc.
P.O. Box 1031
Billerica 111, 01821
'OVFRAGFS
INSURERS AFFORDING COVERAGE
Ii`;'•UREI-;A. Hsnovc_ Inzusancc Companicz
nJ uRrr-:r- Central M-otual Ins Co
IN;•ur r_r, c
M111CARP
IIQSURLR D - "--
NAIC *
22292
11-11 1,01 BEEN 1`-;StJLG 1r,, 1HC 11JSURLf., IJ/ -,IACD I=,L-Citi[ FUI: IHF POLIC)' I'LldUI., INIAC1.iLL, NO INr-
/-,fJ -IE RI,6 UR CGIdDII IpP; Or ANY C0IJ7RP,CT OR OTHEh' DO( LIME 1,,1 V✓II 11 RF, PF C.l lY� 1NHICH I HI,'.. CI: RI I(If_p,l(: L5k1' f.f l�. ;1,110 GR
fill-INSI_IIJ-.NCf-P.fI C4;l>l-1a f71'lli(. 1'OLICI(_.Cr DL`;CI:IL'CG ILL I; IWKJ ..'..:U(/,ILLI i(BALI.IHf_l(1:1,41..,1_i:CLUSIUIJ:_: ANDCOND111r�P:` OI
I��i�l iUf, `� /-A,(,RL r>ha 1: L IIhI1::. ::HpVdN 141-.Y HF.VL t�LFla RL-GIJr C -D GY IY:IU CLk.l1�1`�
II.�R DD Ll — OITCY"[FF[[TIC/t`�(ITGLICY-f5'P7RLTIGld
I TR TiJSRG, TYPE OF 114SURA14CE POLICY NUMBER DP.TE (MMIDDIYY) l DATE (iVIWDDh'Y) LIMITS
GENERAL LIABILITY
EACH OCCLIRRLNCE
9, 1, fl fl o, 0 0 0
B
CUr,M11,1LRCIP.L GrNEw-.L LInG1LIlY
CLP8121857
02/01/07
02/01/08
00
-DP.7�hF:CoT�rJ-REIhIT=D
rf:Ei11•r'.Eaocwrc:nr:c-)�3?1o'c9
CLAIM- I,4AD1_ }� pCC'Uh
IAEG E):f= {!-.r,y orn- pc"'.3S
S' 000
PERSON/ -,1. 8 FSYJ 11.,1131:'\'
I:1,000,000
Gr_NEr-:Al Ac>eREc.a.Tf:
12,000,000
:2,000,000
C_EW'L AGGRE=GATE 1. 11,111 APPI. IES PER
PRrjULICI,• - CGldr•/UP AGC^
I
F'OLIC1' f I;O
UL<.�I LOC
EuLp Ben.
1,000,0013
AUTOMOBILE
LIABILITI'
CUL161NEG SINGLE L IhM1ll
9 3 i 0, fl Q fl
Ai,)y TG
aRq-8183318-02
02/01/07
02/01/08
(Esscuderfl
--
BODIL V IId,1Uf —
A.Lt ONIOIE G l-.7 110£:
v,
X
R
bCHi_DLILEDAUl O:.
(Pei Inc rson)
X
f'ODII 1' IN,Il1Ri
$.
HIRCI )AUl Ob
-
x
j ja
wOI1LOlh'NFI*)P.L11 U°•
(Pei scuds 'A)
f E:OPEf-:T1' Gl-A.4ArE
�
t.
I
{f vl sccudeni)
j
GARAGE LIABILITY
P.UiO ONLY - LA F.CCIDLNI
AWVAttIG
OTHEr-:THA1v EA!•.CC&—
-- --.--
Aul G ONLY AGC
5
.I
EXCESSW10BRELLA LIABILITY
EACH OCCURRENCE
I
i
7OCCUR aCLAIIwc n1ADE
AGGREGATE
S..
15-
DEDUCIBLE
9'
j
RETC-IJTION 8
'V„L
SIA V H-
{
WORKERS COMPENSATION AND
TORY 11116115 y EI:
EL EACHA.CCIDEWI
1500000
CANY
EIAPL OYER S' LIABILITY
WC8121858-10
02/01/07
02/01/08
F`I:OPRIETORR='Afa1JER/L=>:ECUl�1VE
EL DISEASE - EA EMPLOYEE
$:5001100
1
OFF ICER/MEmBERE.XCLUDED'?
If VeE, describe under
SPECIAL PROV ISIONS below
E.L. DISEASE - POLICYLIIAIT
5/500000
OTHER
B
Property Section
CLP8121857
02/01/07
02/01/08
Contents $5,000
B
Equipment Policy
CLP8121857
02/01/07
02/01/08
Deduct $500
f DESCRIPTION OF OPERATIONS ! LOCATIONS /VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
j
CFRTIFICATE HOLDER CANCELLATION
AroRD 25 12nni im
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION DR LIABILITY OF ANI' KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
OACORD CORPORATION 1988
rile
(76mmonwealth of Ma, z� c
Department afIndustriat Aceideni`i°
an" of
600 Washington Street, 7' Fivor
Boston fwass. 02111
Workers' Compensation insurance Affidavit:
RuiidinV71umbinetElectrical Contractors
address: ✓(! 1 d 'f iT L
ii
/ j � r
t t [ f {”, 1LY C ti _. state: A
1 ZS tone # /
,2 _- _.._._..
i am a homcowncr performing all work myself'. Project T),pe:
I am a sole ,proprietor and have no one working in any caluclty.
New Construction.
Building .Addition
{ I am an employer providing� workers' com#pensation Fo.r my employces working on this job.
/
rmm�anv name " fi-t El L I t " (°' " t/� "
10 i3�� /0
% (2�
0j rd-
All
0 9 F � �>
lam a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below miho have
the following workers' compensation polices:
company name:
addr4 ess:
cit_"ttane is
insurance co. tic
company name: _
addr •s:
city ditone i#`
iraeurattt;s cis _ h
Attach additional sheet i1 necessary .
E'ailnre to secure coverage as required ander Section 25Aof MGI p52 rant +t to the imposition ni criminal pcnatties of n line up to s1„500.00 and/or
one years' imprisonment as well as civil penalties in the form of a SFr)P woRK ORDER and a rine of 5100:00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of 3nvestiptions of the DIA for coverage vcriIIcatiam.
L du hereby certify ander the pains and peHahies of perjury that the information provided above is true and760
recL
J 7 ,
is -� f. ........ .
Signature_,_Date __--
Prins name�i` ' ( Phone �r� u 'L
r official use only do not write in this area to be completed by city or town offit
city or town
permit/license # (]Building department
l�ll,irrnsing 13oard
Selectmen's office
® check if immediate response is required n
[]f{eatth Department
contact nemon: phone #; QOther
Gmji adSeW. ZW3j
0
7�
ft
rA
W
s.
o
A
C
o
w
►'+
Z Y rl�,F-
1v O
e
a
a
a
�
v
Q
z
O
�o
AMC o
o�
O N
C
V V
'Q C
CL 0
A
O C
:L O
o�
Ea
. rD C
O
:
h
E�
:.30
42 CL
o�
ts cm
o c E
mm �
c N
ca
h �
` cm O N
S C 'O
NIP
co
• � � y C C
4
�mo c
o.c� m
. •v� � oc
40tzm o CD
0 c
�•C=L"' m
0
C2
o00 0,
C
Q � � dC Q
w 3 IV
H 00O2 r. y r0„ �'
m m
Z
W C �A�_
c
•to C="a=
�c
L3 *� N Z o 'C O
CA o
E- _ �awm
N
LLI
U/
W
W
oc
W
U)
Z Y rl�,F-
1v O
e
Q h
O
�o
AMC o
o�
O N
C
V V
'Q C
CL 0
A
O C
:L O
o�
Ea
. rD C
O
:
h
E�
:.30
42 CL
o�
ts cm
o c E
mm �
c N
ca
h �
` cm O N
S C 'O
NIP
co
• � � y C C
4
�mo c
o.c� m
. •v� � oc
40tzm o CD
0 c
�•C=L"' m
0
C2
o00 0,
C
Q � � dC Q
w 3 IV
H 00O2 r. y r0„ �'
m m
Z
W C �A�_
c
•to C="a=
�c
L3 *� N Z o 'C O
CA o
E- _ �awm
N
LLI
U/
W
W
oc
W
U)
M
�
U
Z
Cf)
J
O
al
F- C\j
J 00
Q C)
�- o
C� CoQ
O -t O
CO -0 O
00=
UIYn-m
C
O
y O y
b d ce
> L
C c
C
w w ❑ o
cl 8
>��
o � �
o GY CO,
r Cd Cp.o
O a O
w o
y o C o
,..ap�OPa
-n,
Y U o
o
C �
j tC Z Cl.
d0 C,) O
V Z m C m
W S
a w o a
m
o
fl O O CL
T
w NX
0 o W
m
W
a \)) o =
0
0
U
a
a
V
Li•
-- BoaMVPMingegula ons a�1d tan arils
One Ashburton Place - Room 1301
=� Boston. Massachusetts 02108
Construction Supervisor License
License C5: 40192
Restriction: 00
Birthdate: 1/10/1953
Expiration: 1/10/2009 Tr# 8388
ROBERT A BENT ---- ----- __----- - - . -
PO BOX 1031 ---.----------- ----- --- ----
BILLERICA, MA 01821 -- - -----
Update Address and return card. Mark reason for change.
[-I Address [-I Renewal F -I Lost Card
)!,S-CA1 C. 5010-05/06-PC8490
Brdofuc+ng �2egutatioe�s aadian arils
oa
Construction Supervisor License
License: C5 40192
Birthdate: 1/10/1953
Expiration: x10/2009 Tr# 8388
Restriction: AO
ROBERT A BENT ��—
PO BOX 1031
SILLERlCA, MA 01821
Commissioner
:h