HomeMy WebLinkAboutBuilding Permit #502 - 919 GREAT POND ROAD 12/22/2010—s—
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO•�_V—Z--
Date Issued:
IMPORTANT:
Date Received
must complete all items on this
LOCATION 3 621 & Z /�
Print
PROPERTY OWNER - AC -h 1 C 1Yi 0 (, T - Z
Print
MAP NO: ' ° PARCEL: Gad ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non -`Residential
❑ New Building
❑ Addition
❑ Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Commercial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Other
❑ Others:
D Se tic®Well `
•''.`e' -:".:2;i' _ k q..
_Water/Sewers
k Tf
Floodpla_ i�W,etland
----^t a J -!` rt .% ' �' t°i1
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®_yVatershedDsct`-
.'€^a.,',�,
DESCRIPTION OF WORK TO BE PERFORMED:
L-7 ftC, it .,�f l r? JPS= l�n- o C- �ii�oftey
Identification Please Type or Print Clearly)
OWNER: Name: rke'J, /C M 0 t I Z Phone:
Address:
CONTRACTOR Name: je,�� o f 1 i Phone
Address: 7 Pe
Z- %lam I e,4,e JO 17 6 2e1'/
Supervisor's Construction License: / C)/ C) g 6 Exp. Date: 7-3-12,
Home Improvement License: / 6102,3 Exp. Date: L7 -/ 7 - / 2-
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ C� �� FEE: $_q,-2,
Recei t No.: �
Check No.: p
NOTE: Persons4conacting with unregistered contractors do not have access to thuaranty fund
F
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBody 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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
69MMENTS .
DATE REJECTED
0
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
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 no
Located at 124 Main Street
Fire Department signature/date
COMMENTS �.
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
I '
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 2008
Building Department
The following is a list of the required forms to be filled out for the appropriate pei
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
o 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
40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
iust be submitted with the building application
Doe: Doe.Building permit Revised 2008mi
Location l/ 64, '-I llo4z4e
No. 5-()2--// Date �� J
TOWN OF NORTH ANDOVER
L
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Certificate of Occupancy
$
.2 CHUB
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # 16
238'15
Building Inspector
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NEFPInc dba
YANKEE FIREPLACE & PATIO
140 SO MAIN ST
MIDDLETON, MA 01949
PHONE 978-774-1621 r
FAX 978-777-2683
FRANK MOLTZ
919 GREAT POND RD
N ANDOVER MA 01845
P.
S'Gl%r' SIP11
(978) 771-7891 1112212010 "*
01-001307 Account Number:
1112212010
Page
1 of 1
Y3603
Sales Person: Alan Davis
Part NtjrdhpI;
CUSTOMER HAS PURCHASffA REGENCY SMALL WOOD INSERT
SURVEYFOR
SURVEY. 1 1
0.00
0.00
JAV'
N
t=
`Fy
n
A $20 FEEAPPZ YS FOANYCHECKRETORNEO BY
OUR SANKFORANYREASON.
CUSTOM ORDERS ARE NON-REFUNDABLE. ALL
OTHER RETURNSARESUBJECTTOA20%
RESTOCKING FEE.
ELECTRICAL COMPONENTS ARE NON RETURNABLE
AND NDN REFUNDABLE
Signature
Sub Total $0.00
Ma Sales Tax 6.25% $0.00
Total $0.00
NEFPInc dba
YANKEE FIREPLACE & PATIO
140 SO MAIN ST
MIDDLETON, MA 01949
PHONE 978-774-1621
FAX 978-777-2683
FRANK M0LTZ
919 GREAT POND RD
N ANDOVER MA 01845
(978) 771-7891 1111612010
01-001307 Account Number: Work Order
1112212010
Page
1 of 1
Y3332
Sales Person: Frank
Mnn7innP
A $20 FEEAPPL YS TOANYCHECKRETURNEO BY
OUR BA NK FOR ANYREASON
CUSTOM ORDERS ARE NON-REFUNDABLE. ALL
OTHER RETURNS ARE SUBJECT TO A 20%
RESTOCKING FEE.
ELECTRICAL COMPONENTS ARE NON RETURNABLE
AND NON REFUNDABLE
Signature
1 1 /161201 Ov"a $1,500.00
11/221201 oVisa$1,993.94
Sub Total$3,349.00
Ma Sales Tax 6.25% $144.94
Total$3,493.94
Paid$3,493.94
Balance $0.00
EVERYTHING IN SJI AREA
S/N 326005227
CUSTERMER WILL CALL FOR SURVEY WHEN CHIMNEY INSPECTION IS DONE
11200S
11200 Classic Wood Insert SM L
1
1
1,215.00
1,215.00
850-141
Door SML C331F11IF24IS24/11100 Black
1
1
175.00
175.00
171-920
Faceplate & Trim Regular 11200
1
1
201.00
201.00
170-915
Fan 11100111200
1
1
0.00
0.00
171-936
Flue Adaptor Offset 12-314 in to FlueCL
1
1
81.00
81.00
INSTALL WOODIPELLET
WOOD OR PELLET INSERT INSTALL
1
1
1,000.00
1,000.00
PERMIT FEE
LOCAL PERMIT FEE
1
1
30.00
30.00
REGENCYPROM02010
1
1
0.00
0.00
REG948-625
REGENCY 25FT UNINSLULATED SIS LINER
1
1
647.00
647.00
A $20 FEEAPPL YS TOANYCHECKRETURNEO BY
OUR BA NK FOR ANYREASON
CUSTOM ORDERS ARE NON-REFUNDABLE. ALL
OTHER RETURNS ARE SUBJECT TO A 20%
RESTOCKING FEE.
ELECTRICAL COMPONENTS ARE NON RETURNABLE
AND NON REFUNDABLE
Signature
1 1 /161201 Ov"a $1,500.00
11/221201 oVisa$1,993.94
Sub Total$3,349.00
Ma Sales Tax 6.25% $144.94
Total$3,493.94
Paid$3,493.94
Balance $0.00
j ENTSTALLATION INTO A FIREPLACE j
Customer "'�� C-- Salesperson
AddressC O-4, 17 60h City,//1 A'DOJd State �``/'J _ Zip
1. The Fire place is a: Masonry Metal (ZC) Preformed Metal/Brick
2. racing material: Brick Tile Fieldstone_ Other
3. Is the Facing Material... Flat Protr ding/Rough
4. Chimney: Outside Wall Inside Wall -//(/
5. Clay finer In Chimney: Y t� N� Size of Tile )\ (If not sure approx age of house )
6. Chimney Height(From floor of where unit to be instal to very, top of the chimney) Q A-. 7
7. Type of Appliance: Free Standing__ Inner_LZ Glass Door
8. Is 'There a Chimney Cap: Y N If Yes, Tjype
9. ; Type of Fuel: LPNat Wood V Pellet Other
10. Stove Brand and Model being iustalle :
11. Liner: FullPartial
12. Type of House: Ranch olonial_�SplitGambrel Contemporary_ Slate`Other
13. Type of Roof: ShingleRubber Tile _ Wood Shingle Metal—Other-
14.
etalOther14. Would you like the chimney cleaned at time of install? Y N There is an additional fee of $
DRAWING A: Mantel Side View Drawing B
_....._TV-..
IVI
- - --.
......._
Drawing A:
Fireplace is: Rectangular Arched
A= Fireplace Width: Bottom3�33v', Tom°�
B= Fireplace Height: Left~; Right S --
Height to Top of Arch if Applies
BI—Height to Lintelr L! Y/ See Drawing B
C= Fireplace Depth
D= Width at Back 1/
E= Distance to Mantel S�elf (From Hearth or Floor) 6
F= Hearth Depth
G= Hearth Height S
H= Distance to Combustible Trim/ Legs 'tr 3/$ ( ,Xq1)
I= Distance to Combustible Wall_
WING C:
J= Height to Damper Rod vV � Drawing C:
K= Height to Breastplate ofYi tel N=Height to TaperG—-
6. ' V1 k'
L= Thickness of Breastplates_ O—Lintel Depth_
M=Depth of Mantel �� P=De th of Fireplace at Height of
Unit 4 a -q i �/i�iG)o JA
These measurements are a guide to help us formulate an estimate for materials to be used in the installation. You will be d
billed only for labor and materials used. Please see your salesperson for a written quote which will provide ,you with the
estimated costs of the installation. 1`/
Signature Date V
t
JI Office of+A—.wm siness egu� License
J HOME IMPROVEMENT CONTRACTOR before
Registration ; 1,„61023 Type: Office
: Expiration: 9i17X2012 Individual
10 Part
Bos torii
J P. WHITE-JP,"F
L
JAMES WHITE
9 BEAR PATH LANA'
HUDSON, NH 03051 Undersecretary I
r
1
19assacbusetts - Department of Public. Safety
Board of Buildim- Re"ulations and Standrit! (I
ConstrUdboh, Supervisor Specialty License
:i
License: CS SL 101090
v4Restricted to: RF,WS,SF,DM
JAMES WHITE
10 BEAR PATH LANE
IHUDSON, NH 03051 .,
i
Epiratton: 7/3/2012
('„imnsskinner�'F#: X01040
The Commonwealth of Massachusetts
r- ! Department of Industrial Accidents
Office of Investigations
600 Washington Street
i . e « I` Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print'Legibly
Name (Business/Organization/Individual): ,.i
Address:
City/State/Zip: ����J �N {'�/�/. Phone #:_16
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
— �oyees (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. ❑ Lain a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*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 acid 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.
Insurance Company Name: v� 1 �L !� f h ,f .
Policy # or Self -ins. Lic. #: VIV 0J 7 / 7 A Expiration Date:
Job Site
C1 / ,� (��
City/State/Zip-/ph f A R,,0,,0d //e /_
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 MGI; 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 maybe forwarded to the Office of
Investigations of the DIA for insurance*coverage verification.
I do hereby c ofy under the pains and peWies of perjury that the information provided above is true and correct.'
: /2- /-?- if
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 #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or -on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also -states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pen -nit or license is being requested, not the Department of
Industrial Accidents. Should you Have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pen-nit/license applications in. any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Tnvestiptions
600 Washington Street -
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB
Fax # 617-727-7749
Revised 5-26-05
. www.mass.gov/dia