HomeMy WebLinkAboutBuilding Permit #568-11 - 85 HILLSIDE ROAD 2/18/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
— 1
Permit NO: ` Date Received
Date Issued: — 1 ' l
IMPORTANT:Applicant must complete all items on this page
LOCATION Z�s/ 1-t l S i ae— :�2!,l
n (� Print
PROPERTY OWNER � 1C�rk SC,�%.LcP� ,tv�
q Print
MAP NO: I e, PARCEL: $�_ZONING DISTRICT: Historic District yes n
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resi ential Non- Residential
❑ New Building , One family
El Addition Two or more family ❑ Industrial
❑ Iteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other - -
"� ' pi's z e���" ri—m—i
® Septic `�WNW611 ®Floodplain ®W�etl ds Watershed District
.*V�9pSJ .•.-. ,�:,s'_.u_... ,._.r�. ...r.+i _r.__LtuG
❑Water/Sewer
DESCRIPTIONOF WORK TO BE PERFORMED:
fi .
Elocjz
Identification Please Type or Print Clearly) ,
OWNER: Name: s Phone: 7 / `2 Z,e
Address: k';;: 14, i f i t A
CONTRACTOR Name:_�,✓� - Phone: >� 7 '
Address: ro 1, -f eQ 1`1 tip ,d7
Supervisor's Construction License: ('�2 3ga i4 Exp. Date: —5�-—
Home Improvement License: 1050$r 1 Exp. Date:
ARCHITECT/ENGINEER 467 Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BSED ON$925.00 PER S.F.
i
Total Project Cost: $ I � � � FEE: $ �
Check No.: � "� Receipt No.: 3� D
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signa ul ;of Rg_`- ._._.:� er :.:,,_::<Signa ure:ofcontractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBody Art ❑ Swimg Pools-
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ' ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY 6
INTERDEPARTMENTAL SIGN OFF - U VORM is
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Sinature
COMMENTS
a
f
HEALTH Reviewed on Signature
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
I i,i
]DPW Town Engineer: Signature:
Located 384 Osgood Street
EN
FIRE DEPARTMT 'Temp--Dumpster on site yes no g
Located at 124 Main Street °
Fire Department signature/date
COAIMENTS
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 r
NOTES and DATA— For department use
® 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
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
D . Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Muss 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
Neter ConstructionSin le
and
( g Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses SII
❑ 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
DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
a all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording .
Lust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
i
Location
No. � ' f l Date
- F
TOWN OF NORTH ANDOVER 7
Certificate of Occupancy $
Building/Frame/Frame Permit Fee $
s�cMust 9
Foundation Permit Fee $
Other Permit Fee $ T
TOTAL $
Check X;
23902 Building Inspector
F NORTH,
Town ofAndover
7TQ7.
oLN
o Y over, Mass.,
O� COCMICMEWICK �t
Ao?ATED pPa\ "`C
BOARD OF HEALTH
Food/Kitchen
Septic System
.PERMIT T D
BUILDING INSPECTOR
THIS CERTIFIES THAT .. ..4..
........... . d... .. l�w.....,......................:............... Foundation
has permission to erect........................................ buildings on ..!. �. .......... ....... ..................... Rough
/ O D Chimney
to be occupied as.............. ! !' . ...................... .........c� ..' .................................................................................
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 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 MONTHS -
UNLESS CONSTRU7JN STARTS ELECTRICAL INSPECTOR
Rough
............................. Service
BUILD INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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. Bumex.
Street No.
SEE REVERSE SIDE smoke Det.
NORTH
F ,
® or' 4 over
0 . 1p
. ..... .....
C% o '� lover, Mass., to
0
cOc HIC HEWICK
2! A'4ATED
BOARD OF HEALTH
Food/Kitchen
Ali Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT..............Del. .. .. ..4... ..4,1�,'•a.....,.,,................................... Foundation
has permission to erect........................................ buildings on ..1.1�%.........tAN.k t.s.t ........................... Rough
O D Chimney
to be occupied as.............:8444./.�'��-�.........c� :..'4�....................................................................:.............
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 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 MONTHS
NLESS CONSTRU N STARTS ELECTRICAL INSPECTOR
UNLESS
Rough
..................................................... ............................. Service
BUILD INSPECTOR
Final
Occupancy Permit Required t0 Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or D !!Nall To Be Done
. g Dry FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner,
Street No.
SEE REVERSE SIDE Smoke Det.
r
i
The Commonwealth of Hassachusetts
Department of Industrial.Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
UV www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applican-t Information Please Print Legibly
Name(Business/Organization/Individual): n_ A?e4 se
Address:
DlC,
City/State/Zip: Phone#: 5 _21c�T 75_D 9 7 L{ r
Are yo n employer?Check the appropriate box: Type of project(required):
1.P I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(fall and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.? 7. E]Remodeling .
ship and have no employees These sub-contractors have 8. ❑Demolition
orlon capacity.
workers'com .insurance.
w for in anP
g Y 9. E]Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions
required.] officers have exercised their
❑ p
right of exemption per MGL I L Plumbing repairs or additions
❑ g
3.❑ I am a homeowner doing all work g P P P
myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs
insurance required.]i employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box 41 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 their workers'comp.policy information.
X am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: 7—&
Policy#or Self-ins.Lic.#: 'i� CT/ Expiration Dade:
Job Site Address: ) TJ� S L Zr City/State/Zip: A&4,,, M&
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 ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby cert i undert pains andpenatties ofperjury that the information provided above is true and correct.
�^
signature: Date:
Phone#: 7
FFOff7clal
e only. Do not write in this area,to be completed by city or town official.
wn: Permit/License#
thority(circle one):
I. Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
rson: Phone#:
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provi n of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
I OA.
The debris will be disposed of in:
gt�c.j DCS._ . �--
(Location of Facility)
Vtu Permit A licant
to Q Date
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• Building,electrical and plumbing code issues may increase the contract cost.
These are issues are unknown because they cannot be seen at this time.
• Glass shower door not included.
• Supply and install new base board model#8712 FJP or equivalent.
5
• Paint walls,wood trim,and ceiling with one coat of primer and two coats of
finish. Paint will be California and Benjamin Moore.
• All construction trash to be removed to G. Mello Disposal of Georgetown Mass.
• AS warranties their work for two years.
• All sub contractor work warranted for one year.
• All material is warranted by the manufacturer.
• Building permit not included., Estimate$250—$300. ,
1. Time of Completion—The work to be performed under this Agreement shall be commenced on
or about TBD after city permit has been issued.And shall be completed within a reasonable
time,weather permitting. Actual dates will be supplied by an addendum to this contract once
permit has been issued and schedule from sub contractors has been determined.
2. Contract Sum—The Owners shall pay to the Contractor for the performance of this Agreement,
the sum of$13,450.00 Thirteen Thousand Four Hundred Fifty Dollars and 00/100. The
Owners are responsible for paying any amounts due for plans,drawings,architectural work,
permits,and any other related fees.
3. Impossibility of Performance—In the event that any contingencies beyond the control of the
Contractor, now unforeseen, including but not limited to Acts of God, shall arise which shall
render temporarily impossible the performance of this Agreement by the Contractor,the
performance hereof shall be suspended temporarily until such impossibility is removed; and if
such impossibility of performance shall excuse performance by the Contractor and shall
discharge both parties from all obligations under this Agreement.
4. "Or Equal"Clause—Whenever any item in this Agreement,defined by describing a proprietary
product or by using the name of a manufacturer or vendor,the terms term "or-equal", if not
inserted,shall be implied. The specific article, material,or equipment mentioned shall be
understood as indicating the type,function, standard of design,efficiency, and quality desired,
and shall not be construed in such a manner as to exclude manufacturers' products of
comparable quality, design,and efficiency.
5. Extra Work or Changes—No extra work or changes shall be done except upon a written order
signed by the Owners and the Contractor. Such order shall state the cost of such work and the
time allowance for same, if any.
6. Settlement of Disputes—If payments are not made by the Owners and received by the
Contractor by the due date set forth in this Agreement,the Contractor shall charge interest on
the balance overdue at an annual interest rate of twelve percent(12%). In addition, if said
payments are not paid when they become due,the Owners agree to pay all costs and expenses
of collection,including reasonable attorneys'fees.
7. Entire Agreement—Except as otherwise stated expressly herein,this Agreement constitutes the
entire agreement among the parties hereto. This agreement supersedes any prior agreement or
understanding and may not be modified or amended in any manner other than as set forth
herein.
2