HomeMy WebLinkAboutMiscellaneous - 385 FOREST STREET 4/30/2018 (2)R IIS -I
Location�v `
No. Date
°RTN TOWN OF NORTH ANDOVER
►°. .. A
Certificate of Occupancy $
s�
cNus
�'�s'•CH Eta Building/Frame Permit Fee $
r
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2300,2
Building Inspector
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �J
Date Issued: / 10
Date Received
/ v �SLcv �6 ry
IMPORTANT: Applicant must complete
all items on this page
v
LOCATIO:I�,.
...
Non- Residential
New Building
One family
Address JLJfir
Addition
Two or more family
Industrial
nnt
No. of units: 1
Commercial
Others:
PROPERTY OWNER 1 P,
Assessory Bldg
Demolition
Other
MAP 21 D 1 � PARC EL;
-Print
ZONING D18TRiCT Historic Disti t
yes c
:11#ersled bstric`t
11, ater ewer
--:
.achine Shoq Ilacae
4F
ves�
TYPE OF IMPROVEMENT
PROPOSED USE
v
Residential
Non- Residential
New Building
One family
Address JLJfir
Addition
Two or more family
Industrial
Alteration
No. of units: 1
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic,- Nell
FloodplairWetlands
:11#ersled bstric`t
11, ater ewer
' utacrar i iuN ur- wUKK I U BE PREFORMED:
ss
f
{
Identification Please Type or Print Clearly) I
OWNER-- Name: Phone:
Address:
—�
xp. Date:c 1 Cb-
ARCHITECT/ENGINEER I )O Iy G 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: $ -,�>- b143. 4D FEE: $ 61
Check No.: / 2-1 Receipt No.: �)- 3 d
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
CO:NTR,��TOR Name
Phone:
Address JLJfir
.
Su.perviscir's'Constructlon L,Utense:
t
Home :"-Pro vementticer e
—�
xp. Date:c 1 Cb-
ARCHITECT/ENGINEER I )O Iy G 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: $ -,�>- b143. 4D FEE: $ 61
Check No.: / 2-1 Receipt No.: �)- 3 d
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Phone:
—�
xp. Date:c 1 Cb-
ARCHITECT/ENGINEER I )O Iy G 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: $ -,�>- b143. 4D FEE: $ 61
Check No.: / 2-1 Receipt No.: �)- 3 d
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
uocatea J64 us ooa ,street
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 APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
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:
uocatea J64 us ooa ,street
FIREDEPARTMENT T;mp Dumps x
tei-t�sl#e
yes :�
77
no
Located>at 124:Main Streeta' g
Fire:l3+epa.rtnieht7sligrrat' re/date
y,
Ae
'COMiUIENTS
�._
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
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 21 A —F and G min.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
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
o Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering. Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o 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
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
o 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
o Certified Proposed Plot Plan
Ll 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)
o Copy of Contract
o Mass check Energy Compliance Report
❑ Engineering Affidavits for 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: Building Permit Revised 2008
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cl)allmcllt Of a
.Niassac .Ulatiolls Id Standards
.dof Btlildin. R License
41
Bow- __+inn Sup
ervisOr
const, U- -
License. CS 36866
Restricted to: 00
JOHN i CALL
14 EDGEHILL RD
HA\JFRHILL, MA 01830
Expiration. 312512012
19471
sea" WORWORDER 0
1. WEATHMTRtPP1NG"UUU"G
Door tots O.,Lon or EgUIv.
Door Sweeps (Regular)
Door Sweeps (Automatic)
Regiaze Windows An.tnch
Window. Wea#,MV 8chleo per side
AWWassement bypess GOOM mwvW
Attic eeagng with 2 -part ►ow WOW
SUBTOTALS
35"
Revised 312010
cry
Dornesbo pipe Hot Water Tank let V
CtleM
0.00
address
0
CRY ►fawn
SM Two Part Foam w/ Fibargtass Batt
Contractor
0.00
QUANTITY
TOTAL
3
129.00
2
30.00
2
44.00
0
0.00
0
0.00
0
0.00
7
525.00
728.00
Que LA
385 Forest Street
NoM Ager, MA 01845
2A.INFILTRATION 11NSULATION
Dornesbo pipe Hot Water Tank let V
0
0.00
SII Insukdton R-19 CF
0
0.00
SM Two Part Foam w/ Fibargtass Batt
0
0.00
Drape Perimeter R-5 Anch. Sq. ft.
0
0.00
Drape DOOR R-8 Anch.
0
0.00
Tape Joints (Alums Grip onty) per hr.
2
124.00
Duct Insulation & Tape In. ft.
0
0.00
RW Foa rn Board Anoh. 1"
0
0.00
Hydronic pipe insulation to 1" R-8
0
0.00
Hydronic pipe Ine.1.25"-1.5" R-5
0
0.00
Steamplpe Ins. to1.26' iron pipe R-5
0
0.00
Steampipe Ins. 1.5"- 2" iron pipe R-5
0
0.00
StemMipe Iris. 3" Iron pipe R-5
0
0.00
Air Conditioner Meeting Rail
0
0.00
Air Condi inner Corer
0
0.00
Air Conditioner Cover Special Order
0
0.00
SUSTOTALS
124.00
2B. INSULATION
Open Unreetrkied R 49
0
0.00
Open UnraetrkW R 38
0
0.00
Open UnreWided R 30
1056
1377.80
Open Unrestricted R 20
0
0.00
Open Unrestrwed R 10
Resbkt FUSloped R 30
0
0.00
ReeW FUSloped R 20
0
0.00
Restrict FUSloped R 10
0
0.00
R-19 FO130.00
open rafter`lwalldlmsewaga
0
R-11 FOB open rafteralWaft11m9swaile
0
0.00
Attic Stafra(eiainvelt & OOmmon wag)
0
0.00
Cover Pug DOM StWm Therwedorrre
0
0.00
Site bunk pyg down stairs 2" foam box
1
175.00
0
0.00
W.S. & bet Hatch R-19 /0 -Lon or=
0
0.00
W.S. 8 but Hatch R-30 /0 -Lon or =
0
0.00
Kneswall R-12 cell behind Per.Memb
0
0.00
Open Rafter R-20 Cell. Nv poly
0
0.00
Open Rafter R-30 Cali. AN poly
0
0.00
Basemerd Overhead R-19 fiberglass
0
0.00
BesemeM Overhread R-30 fiberglass
0
0.00
C ounce Over < W high R19
0
0.00
Craw"ce Overhead < 4 high R30
0
0.00
Garage Ceiling cavity filed vr/ cellulose
0
0.00
Wood,StWw,Clapbosrd,Shinglas VIW
1368
2325.60
Asbestos (sIn& raid) / Asphalt
0
0.00
Asbestos (doub. Nal) / Aluminum
0
0.00
BrIck/Stuoco
0
0.00
Vinyl over Asbestos
0
0.00
Muiti-layered 3 or more layers
0
0.00
Drill rough plaster or finish wood plug
0
0.00
Drill finish plaeter
0
0.00
Test Drill Walls (all 4)
0
0.00
SUBTOTALS
98x3.40
2. INSULATION TOTAL 2A.+28.
9897.40
1 AUDITOR NOTES 1
3. STORM WINDOWS / DEADLITES AUDITOR NOTES
piwalees Up to 88 U_I. 0 0.00
Additional per UI over 88" 0 0.00
Other (Negotiated Price) 0 0.00
SUBTOTALS 0.00
5. OTHER MATERIAL
Ridge vent In ft.
0
0.00
Vents G" rectangular
0
0.00
Varipitch Vent
0
0.00
Vent Root 135 (1 eq 4 NFV) targe
0
0.00
Vent Roof 866 (A aq R NFV) Small
0
0.00
Vent Soffit Round
0
0.00
Vent Soffit Rectangular
0
0.00
Turbine Vents AM
0
0.00
Stook vent
0
0.00
BAFFLE VENTS
M
165.00
Permsble House Wrap
0
0.00
Vapor bwdw
0
0.00
Basement outside door only
0
0.00
Saasment outside door w/ jambs
0
0.00
Door Repl pre hung 32-W Sleet"
0
0.00
Door Rept irderlor solid core 28-32"
0
0.00
Door Rept pre hunt? 32-W wood'"
0
0.00
Energy Star R-4 Rigid Vinyl Roo to 73" U.J.
0
0.00
Energy Star R-4Rigid Vinyl Rep184-93" U.I.
0
0.00
Energy Star R-4 Rigid Vinyl Rept 94-101 U.I.
0
0.00
Basement Window Rept. Awning/ Hopper
0
0.00
Basement Window Rept. With a frame
0
0.00
Permits / Fees (Wap only)
.0
0.00
SUBTOTALS
6J7. E.C. MATERIALA ASOR
8a. HEALTH 8 SAFETY
Vent Bath / Kitchen Fan
Dryer vent w/ exhaust duct Heartland
Dryer Transition Duct only
Slower Door Test Pre Post -
SUBTOTALS -
8b. REPAIR MATERIAL/LABOR
Lockeet ( door) Schlage or equal
Repair/ Refit Door
Replace Side Stop
Replace Casing
Glass Replacement to 64 u.l.
Glass Replacement per u.i. over 64
Sash Sidelock /Top Replacement
Threshold (Wood)
Threshold (Aluminum)
Slide Bons
Plug Plate Cover
Cut / finish attic-kneewall access
Cut t close attic-Imeewall access
Labor Rate Hours
SUSTOTAL.S
TOTAL REPAIR t HEALTH & SAFETY
165.00
4890.40
1 85.00
0 0.00
1 38.00
0 0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0.5
GRAND TOTAL WORK ORDER # (A) 3570
Any alterations or deviations from the above specifications involving
extra costs must be cleared in writing before installation.
The Work Order must be complete within 15 working days from acceptance
date below:
128.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
30.00
30.00
153.00
5043.40
Page 3
AUDITOR NOTES
AUDITOR NOTES
Bath Fan through roof
AUDITOR NOTES
For pulldown work to accept thermodome
�CONTRACTOR/COMPANY: r �1 o "p .
ACCEPTANCE.�Cornpany/Contractor
AUTHORIZED SIGNATURE:
AGENCY APPROVALS:
Date
g -b -?-16
I
MA
The Commonwealth of Al'assac husetts
Department o f Industrial Accidents
Office of rnvestiowdons
600 6Vashinb on Street
Boston, M4 62111
Workers' Compensation insurance Affidavit: www-mas��ov/din
P Builders/Contractors/Electricians/Plumbers
� lieant Information
Name (Business/Orgmiiafion/individual):
Address:
•
City/State/Zip:
37.
Are y u an employer? Check the appropriate box:
L I am a employer with S 4. ❑ I am a or —
employees (full and/or part-time .* have eneral contractor and I
2• ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp: insurance
required.]
3. E1.1 am a homeowner doing all work
Myself, [No workers' comp.
insurance required.] t
u contractors
listed on the attached sheet I
These su'i`contractors have
workers' comp. insurance.
5' ❑ We are a corporation and its
officeis have exercised their
right of eX=13ption per. MGL
c. 152, § 1(4), and we have no
employees. [No workers'
nom
Type of project (required):
6• [3Nein construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10 -[]Electrical repairs or additions
.11.0 Plumbing repay oradditions
12•❑ Roof repairs
e required.] I 13•
i- ❑ Cher
'), �Iiaant that :.h_ rs box *1 must &6(,fill eet ice section �t P �uranC O
"Omeown= waffidavit indicating who submit this or• nov _�
ating the;, axe doing aL' work- and r " `_"_ r" , ` .• moa
!Contractors that the k this box must attached n ads hire outside contra tms must soba
additional
sheet showing the: Game of P �„kc �u s new ai*noavit indicating such.
s• n..r .. . r-- _'- �•'tvTa find their wr.ri..... • .
--- --1--v- ""u 1b provuun workers' com ensaiion insurance or m e - -- r• r��y mmcmanOn.
in f°,�x¢don• g p f
//'' J' rnployees; Below is the policy and job site
Insurance Company Name: (n (>G ✓� Tina ., _ /�
Policy # or Self -ins. Lic. #: C45/,5L30 /0 7 �-7
Expiration Date:D 3D
Sob Site Address:_fj5 /j
Attach a copy of the workers' compensation policy declaration .page (sho CnTy/S�/Zip:
Failure to secure coverage as required under Section 25A ofM � the policy number and expiration date).
fine up to $1,500.00 and/or 'one-year ' GL c. 152 can lead to the imposition of
Of up to $250.00 a da a imprisonment, as well as civil a � Penalties of a
y garnet the violator. Be advised that a cc, penalties m the form of a STOP WORT{ ORDER and a fine
Investigations of the DIA for insurance covers e v of this statement may be forwarded to the
g verification. Office of
I do
Official
•••e puns ani penalties of perjury th zt the informatioj. provided above is true and correct
Do not write in this area to be com
plefef
bJ' city or toN,n official
City or Town:
Issuing Authority (circle. one): Permit/License #
L Board of Health 2. Buil• .,
auze Department .3. Cify/Town Clerk 4. Electrical Inspector S. Plumbinr,
6. Other
b Inspector
Contacf Person:
Phone #.
Information alt d 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 dg other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartnz encs, and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mamte;:2=ce, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be cause of suchemployment be deemed to bean employer."
MGL chapter 152, §25C(6) also states that "every state or low licensing agency shall withhold the issuance or
renewal of a license or permit to opei-ate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of c0xnpliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions skull
eater into any contract for the. performance of public work um-t:fl acceptable evidence of compliance with the insu=le
requirements of this chapter have been presented to the contr-a.cting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and if
necessary, supply sub-contractor(s) name(s), addresses) and phone number(s) along with their certificate.(s) of
insurance. r .ir ited Liability Companies al q or Limited L' partnerships with no employees other than to the
��' p� iI-�) P Y
members or partners, are not required to carry workers' comp emation 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 confirmation of insurance coverage. .Also be store to sign and date the affidavit. The affidavit should
be ,returned to the city ar uswn tha the application for the perrmit or license is being requested, not the .Dena=mt of
Industrial Accidents. Should you have any questions regardirY_g 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 germit/liceme number which will be used as a -reference cumber. In addition; an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating currant
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 tine
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 permit not related to any business, or commercial velure
(Le. 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 than 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.fag.numben-......
The Comrmonwmltit OfMassachu;�,tts
Department of lmdustrial Assist=ts
Office of Inrecs.Libations
( 00 Street
Boston, M -A 02111
TeL ## 617-72.7-4900 ext 40.6 or 1-9 77-MASSAFE
Revised r -26-o5 Fu, # 6.17-72.7-7749
i1frVtrIT _mass _.a ov/dia.