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HomeMy WebLinkAboutBuilding Permit #445 - 83 CAMPBELL ROAD 2/12/2009 (2) LF BUILDING PERMIT N. y�t�. c;'hb xa O TOWN OF NORTH ANDOVER 3 - APPLICATION FOR PLAN EXAMINATION •r - • Permit No#: �iLrr11�' Date Received gSSACHV`��� Date Issued: ORTANT: Applicant must complete all items on this page LOCATION / Print PROPERTY OWNER OWNER �C-06`e -V�D/`u.J /nq Print 100 Year Structure yes 3noo MAP �` PARCEL463/ ZONINGDISTRICT: Historic District yes Machine Shop Village yes. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial jl�-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other L7`Septic ❑V11e1•I DFlbodplain 0 Wetlands ❑ UVate shr di District, ❑Watei/Seuver DESCRIPT OFW RK BE PERFORMED: -j Identification- Please Type or Prnt Clearly OWNER: Name: ��c i ��crn�� .//d,� Phone: 9 Address: �-7-� 40�-,X, Contractor m 1'7� /YI ✓l e Phone: Email e f Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ' ARCHITECT/ENGINEER Phone: Address: Reg. No, FEE SCHEDULE.BULDIN PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. t Total Project Cost: $ 1i� FEE: $ 'C Check No.: 2'-5-51 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �. - - {{ � - ..� ,:• .+...a....a...aw�..,.�.w m:.:4Wr/F� �<is^'n..-+_.�-�k.re +«�.r.�. Location No. ' Dates 6 . - TOWN OF NORTH ANDOVER • • Certificate of Occupancy $ f Building/Frame Permit Fee $ x Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check# ZL6�57 28778 - Building Inspector �/Date. .. ...... r ,. NORTM 0f4„ao °11.0 o� TOWN OF NORTH }f�'e'NUOVER • PERMIT FOR GAS INSTALLATION UCMUSES This certifies thaw. . . . . . ��7� /T„ . . . . . . . . has permission for gas installation in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at ee?. . . . ./ !. . _ , North Andover, Mass. 7 Fee��.� Lic. No/.3./ GA* IN �. . . . . . . . . / GAS INSP T Check# 6925 Datel. . .c. . . . /F NCNTp y' 01 .'ti TOWN OF NORTH ANDOVER p PERMIT F"OR PLUMBING SACNus - .. .. �--fG'.. ../' This certifies that . . . . . . . has permission t,o perform - °-rte. . . . . . . . . . . . . . . . . . . . . . . . plumbing in the`buildings of �. .��r• h e f' . . . . . . . . . at . . . . : ' . . . . . . . . . . . . . . , North Andover, Mass. . Fee`- aL�^icJ.� Check / PLU1 / INS PECTOR 8262 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 4 U FORM PLANNING cis DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments t Conservation Decision: Comments ZWater& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Di umpste onsite yes` no Located at 124 Main Street Fire Department signature/date '�C.OMMENiT�S , 4 4 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 I NOTES and DATA— (For department use) i i ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 6 Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 4� Copy of Contract 4, Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products ISIOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application d= Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses { Copy Of Contract 46 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application aCertified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses I Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a. Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 thea appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording PP P must be submitted with the building application Doc:Building Permit Revised 2014 r -i - NORTH - w: 1 : � E ic . " ve,0r o�h ver, Mass, coc.. 1/4 u„emcr y1. A�RATeo Okfo S u - BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System • THIS CERTIFIES THAT ........... ..t�. .��.... .Ta�.ft....... ..�.-� BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .9b...... .��.►.!t f. ......... �...... Rough Oaft to be occupied as ..... ....... ..... ... .. ............. .. .. .... ....... ............ Chimney provided that the person accepting this permit shall in every respect conform tot 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 EXPIRESIN 6 MON HS ELECTRICAL INSPECTOR UNLESS CONSTRU N RTS Rough Service ....... ....... .... ...... ......................... Final BUILDING INSPECTOR GASINSPECTOR 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. Smoke Det. 4 wary TOWN OF NORTH AND OVER 01WICE OF 600 OskoodSIZ'eatBuff ding 20'Suite 2-36 7 �R3jkD FY�t [5 a -NoithAndover°Massachuse#s 01845 - Gerald A.Brown � � Teleplione(978)699-9:545 IMP ec-torOfDIIdiugs - Fax (978)689-9542 . HOMMWNBR•LTCENSE MykTION ' l'leaseprinf " DME: . JOB LOCATION,, �J Number St w'tA dress MapJZ of Name. Hornel'3aorze WorkPhone �1, 6 �� v -d T The current exemption for"homeownexs"was extended to?nelnde owner occ7ipied diveliugs to t4vo units•oX;ess an_d to allow such hom-o itis to engage an Lr'-dividual-for hire-Who does no acts as supervisor). possess a licea7se,provided that the owner state,DU tiling (Code Section 7{)83.5.1) - ]]JEEIN.LTION 0FROMEOWNER Persons)who Awns aparcel ofland on which helsheresidos or iuteuds to reside,on which there is,ox is intended to ' 7�e,a one ortWo fazniIysttncfures. Apersob.who comtMets mom iat�onehomezn ai�a hfhero is,ox is afandr lnot be considered ahoxneownez The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other .Applicable codes,by-law;rules and-xegalatiow. The undersigned"homeowner"aezt les that helshe understands the Town Of 9011h Andover-Building DepaxAment mum inspection yrocedures and recluireznents and that Tae/slze will compbr with said procedures and requirements, . ROAMOWX9RS SIG ATME -� APPROVAL OF 33DMD)NG OFFICIAL Revised 7.2809 Form-Homeowners Exemption BDARD OFAP,PFAM 688-9541 CONIURVAT70N 699-953Q � H3EAT.'TH3'698954Q PH,.�.T1NIhIG 689-9535 The Commonwealth of Massachusetts Department of IndustrialAccidents a i d 1 Congress Street,Suite 100 Boston,MA 021142017 www.mass.gov/dia i1M Sv�v Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Pleas Print Le ibl Name (Business/Organization/Individual): 3 / r Address: b City/State/Zip //0, t/ Phone#: ? 2 6 ,-z� y�7/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.;I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.�I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12, Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6. W corporation We are a co oration and its officers have exercised their right of'exemption per MGL c. 152,§1(4),and we have no 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 ployees,they must provide their workers'comp.policy number. employees. If the sub-contractors have em 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ver(fication. I do hereby certify under the p ndpenalties ofperjury that the information provided above is true ands cco-r-rect. Si ature: Date:_r Phone#• - g 7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense# 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#: Cunningham Lindsey U.S.,Inc. P.O.Box 703689 Cunnln ham Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 / CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 769 T3 P1 95000058959 Building Commissioner or Inspector of Buildings 120 MAIN STREET { N ANDOVER,MA 01845 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 3083624 00 Policy Number: 3083624 00 Company Name: MERRIMACK MUTUAL FIRE INS LO Cause of Loss: ICE DAM LO Date of Loss: 3/4/2015 Insured: THOMAS FALLON C) Property Location: 83 CAMPBELL RD Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B.,No insurer shall pay any claims (1) covering the loss, damage, or destructions.to,a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss,`damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code,to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. I � MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FrrnN (Type or print) Date /--)- G a l NORTH ANDOVER,MASSACHUSETTS f Building Locations O �.J{U` ` Permit# Amount$ _ Owner's Name New❑ Renovation ReplacementEf Plans SubmittedrA ❑ � zW W W W p 00 �, x O WVj 1- W 9 C C � C w H CY. ow U W x vs z F a O W d x a a' W W F W F x a C� F z H F EW W U p > W E. U .a �. W Z d W d a ., d >+ QO �q z O z O m x W > W p z cx d d O O W .-i O W F x O x w 3 0 U x > o a F O SUB -BA SEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR Name or *typ Check one: Certificate Installing Company n - .l rn [] Corp. Address � ° /-pod El Pier. usmess a ep one Firm/Co. ' Name of Licensed Plumber or Gas Fitter "C)C INSURANCE COVERAGE Check one• I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked Yes,please i cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond 0 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent. Owner ❑ Agent a I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State GWddhapter 1 f the General Laws. BY: ignature of Licensed Plumber Or Gas Fitter Title Plumber I Z� 741 City/Town Gas Fitter License Numner aster APPROVED(OFFICE USE ONLY) Journeyman • t ..� %'U"xrjrarsz weatt`h ofMnssachrrsetts Department of,industrial Accidents ace o ''Q 6,C�, � f i►avesu,atwns 600 Nrashi TMU Street e orf Boston, M4 02111 Worken, Com natioa �' s�guv/dirt Pe 1Bskr'anee..M d aVi L- B uRders/Coat2 acfors/Ef a cis A iicaat Iaformaatiian ns/Pitcmbers Please Print Legibly NaII1B(�T��'gar+iaafioMndividuet): ✓� / Address: Ste' City/sta#e/Tjg. %me 47 �' �r� c-✓c� �� Are you an emPloyeri Cheek.the appropriate ro -_-_— I:0 I-am e I PP pr�te•bo�: . mnp oyer with 4. F] I ern a general coxtw- to.r Type of Project(r"ffireo: =7*Yees(mull and/or )* hired lite subs- and I Part-time. have �ckn. 6. "New construction . 2• Ell am.asole proprietor or partner_ Iistad ori'the attached Shea 3 7. Remodeling Ship and have no em I working forme as P 7w....st,&cotrtractors have 8 WTY capazh•Y• woricecs comp.insurance. ❑D"moiition [No v'Qrkars, COMP•iastas ee S. Q we area corporation and its 9• ❑Bwlcling addition Office= have exercised their 3•❑ J sin s homeowner doing all work ri • 1 Q.O.EIectrical TPm or additions myself[No workers' 1 of exemption Par MOL 11.0 Plumbi mfin �P, §1(44 and-we have no T°Pm or additions insurance•regnired.]'t . •OMPjoye_—&[No workers' 12.[]-Roofr i* coni•P• insurancc recluiro& 13.Eroffi r • o eP wneir Vhat cheeks bcW l coact also fiII ottt the l action below xho , t Kmas who sdhrntt this sidavit indi8y an wile fheirwarkert aosapeocetiot,pole,in Fnrmafion 4CoaMtftrs that ebealt this box react dome w=,k nd thmi hue oaratdo contractors rye add an ad&60nsl h0w+ g ties creme of tier cub- and. it a new af`ridavit indiadias neat' I ar:r�r cA ii4y,r j&V LSPr?ViQ�g:w0r,�..r.v ._ fi-P '`�"M'r ri s is oa. Insraance Cote --e Fo gra lob;.� . Pany Name: Policy#or Sett'-ins. Lie.#: - 2��ior Date. Sob Site Address; 3 SIS 1 ------------ Attach a cOPy of the worked co cnY6�JZrp: mpeQsatiot, Policy decFaratioo Page(showiue the poiiry number and e Far'iure to secw-e eovcragc as required under Section 25A of, xpiretioa dash:), . fine UP to 51,.500 DO and/or one-year im J'`d�-c. 152 can Iead to the imposition oft ritzal Of UP tD 5250.00 a prisonmer as wail tis civil Penalties in the forrn of a of a �3 A-for i lite vrolai�or. Be advised that a copy of this STDP WORK ORDER and a fine investigations of the DIA for insurance c:ov stalzrrtent may be forwarded to the . wage venin-mon. Offirw of I do hereby certify un e p penalfi�ae P 7w7'bilin`am infarwmdaa pmvrdWab Si Pf h and aonrcL Y DatC: Phone#: 4ffAcid=r only. Do not wr&e in..fh&area,m bt aantpt � ' ,of. town.ofrcio( City or Tows: Essuing Aatbo '>zPermit/Licease# f} (circle one): L Other of Besith Z Boiltiing DaparEement 3.City/Town Clerk 4. Electrics[Inspector 5. ns Plam6iug I CL Pectar Contact Persorr: Phone*L MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSE`,�S _1 3 OA vi 9-C � I/•� Date Z� �- Building Location wners Name C.O Permit 3 a.... Q� p�( Type of Occupancy l�{ Amount �i��C' New ri Renovation Replacement d Plans Submitted Yes ❑ No El FIXTURES w � � rA cc Cn a w w w w LI q rnq 1E MOM M FLOCIZ M IrOCIZ 4M HB t M KOCR 6M)"r-OCR F - 71 H FLOOR SIH RDD (Print or type) Check one: Certificate Installing Company Name !� Corp. r Address J?CD4 J a,)/)t ��+ ❑ Partner. usmess Telephone 3 2 ej�— Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the twpe of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pe 't Issued for this application will be in compliance with all pertinent provisions of the Massachus to u ing de d Chapter 142 of the General Laws. rBy: igna u o icense um er Type of PI�bir}g License e/Town ns um er Master ' /�' JourneymanPROVED(OFFICE USE ONLY �1 The Commonwealth of Massachusetts ( Department of Industrial Accidents 1, office of Investigations �r iii:#► 600 Njashinon Street �,�r Boston, MA 82111 rz W"nV_massgov1k a . Workers, Compensation lwkrance Affidavit guilders/Contractors/Electricians/Plumbers APPlicant Information Pie ase Print La 'bf Name (Business/Orpoiza6on/Individual): � e f� lam, ,cam �l Address: . City/State/Zip: Phone# Fa employer?Cheek.the appropriate box: employer wi#h 4, F[3oject(required): ❑ I am a general contractor and I Y (full and/orpart-time).* have bred the stub-eorttraco:s construction.sole proprietor.ar partner- listed on the attached sheet iodelingrep d have no employees These su}i-contn:etors haveg for me in any capacity. workers' comp.insurance. olitionorkers'wmp.iasr>rrsDe 5. ❑ We are a corporation and its ing additiond_] officers have exercised their rical3. I sin s homeowner doing all work right of exemption per MDL biru repairs or additions myself[No-workers,co g T'eP�or additions insurance required, t c' t52, §I(4),and we have no oof repairs .employe:e:s. [No workers'comp. insurance required..] mer •Arty applicant that checks brnttt l must also Fitt out the section blow shoVv'g their workers'oompensation policy information _ t Kor►+eownecs who sabmit this affidavit indicatin th an doing all ;ContiactnIs then check this box Must etre g t- workand then obe outside contractors must submit a new affidavit indicating such. Attached an arfcFitiaasl Shaer stwwit .the narrtE of the sub-contractors and their workers comm. oli -:am ane io,er in .r.. r- 1 F ^t raforraeiiOn. 1 rsr.:�'J.�airsgT:iftGFKaJS'compensadaft insurance or informafiom f )w Mployeec Below is the poficy grid job site . Insurance Company Name: Policy#or Self-ins.Lie.#: > j l Expiration Date: Job site Address: crty�smre/z,p: A)" Attach a copy of the workers'.compensation policy declaLnI ration page(showing the policy number and expiration dsi*e). Failureup to secure coverage as required.under.Section 25A of MC3L C. 152 can lead to the imposition of criminal fine up to$1,500.00 and/or one-year imprisonment;as well es civic penalties in the form of a STOP WORK ORDER and a fine Of up to 5250.00 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 u e e a P penaLfies f perjury that the information provided ab is a and toned Si Date: Phone#: t�`icial use only. Do not write in this area to be� � city or Town.o CW City or Town PermWLicense# Issuing Autborify(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector Lfi.Otherntact Person: Phone#: