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HomeMy WebLinkAboutMiscellaneous - Exception (763)Location CPO �--f No. (4 Date NORTp TOWN OF NORTH ANDOVER S 00 Certificate of Occupancy $ �� s''••°' E�`' Building/Frame Permit Fee $ AC NUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a13 Q Check #t% 746/ �- ^YJ`•`Buiiding Inspecto 1.1 Propert f-; 1..3 Z,oa4 The Commonwealth of Massachusetts State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards Massachusetts State Building code BUILDING DEPARTMENT 780 CMR APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Permit Number; ©3 6 Date Issued; Front 1.2 MA 44 L« 1107 Water Supply W0.1-C.40.4s 34� a P 1.3, Flood Zo Public rivate Zone 2.1 Owner of Record wc?c C r?, e I-�ovr�,s (oma Name (Print) Signature . , .lam MM 112 , .2 Authorized y: N a (3ldr Name t To Irl In 4a - 3.1 l"c-ensed Construction Supervisor: �.J Uh n 1 H 4 q-,. , Wt. I I rc, 3.2 � tired Ho e J e ant Cc tactor: �)` Mu � tc Company Name A� s l /l � �i)r��IQI^r C � L{,GltitlQ✓l Outside Flood Zone 1.8 Sew a Disposal System: 0 Municipal On Site Disposal Systau ---- 10 Wo>Cc6sy 12 4, Telephone 9-76 ,76 6 8 2 7093 Address W `( fit a n3 k a w o, Iayhr4 Telephone O (p 0///.,g i THAN 35 000 CUBIC FEET OF ENCI OSED SPACE Not Applicable Q License Number O 33��3 ICLV-L� Expiration Date 15 2Q'� � (o 2-0 ne q T� Not Applicable 0 Registration Number ' O l D( `7 Expiration Date I a l Z -q- I Zoo,, 5O � Co Zc7 e I I I I I II �I I I I I i I I � I I I 0 I I W I I i I I I 1 I I I I I I Ir^ II 1C1 �1 6I I 1 I i I I' i i i I I I I I I I .. I I I I I I I 1 I SECTION 4 WORKERS' COMPENSATION INSURANCE AFFu)AV1T P&G.L. c.152 § 25C(6)1 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No Ll SECTION 5 - PROFFESSIONAL DESIGN AND CONSTRUCCION SERVICES -FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Signature Telephone Expiration Date 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 5.3 General Contractor Not Applicable 0 Company Name: Responsible in Charge of Construction Address Signature Tel hone SECTION 6 - DESCRIPTION OF PROPOSED WORK check allapplicable) I New Construction E?dsfing Building Repairs U Alterations Addition j Accessory Bldg. Q Demolition Other Q Specify Brief Description of Proposed: CIO II i I SECTION 7 - USE GROUP AND CONSTRUCTION TYPE USE GROUP Check asapplicable) , BUILDING AREA CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 IA 1B 13i Q B Business E3 my behalf, in all matters relative to work authorized 6y this building permit application. Total Area 2A 2B 2C Q Q I Q I E Educational 0 F Facto Q F-1 F-2 H High Hazard 0 3A 3B Q + Q I Institutional Q I-1 I-2 1-3 M Mercantile E3 4 j R Residential 13 R-1 R-2 R-3 5A 5B Q I Q i S Storage Q S-1 S-2 U Utility Q S eci : I M Mixed UseQ S i S Special Q Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index 780 CMR 34 i. SECTION 8 - Building Hei t and Area , BUILDING AREA Existing (ifapplicable) Proposed Number of Floors or stories include basement levels i Floor Area per Floor hereby authorize 7 -C::- y-) to act on my behalf, in all matters relative to work authorized 6y this building permit application. Total Area Signature %Vner Date I Total Height R SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11 j Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , As Owner of subject property hereby authorize 7 -C::- y-) to act on my behalf, in all matters relative to work authorized 6y this building permit application. Signature %Vner Date revised bldg tomvstate JMC; I SECTION 10b - OWNER/AUTHORIZED AGENT DECLARATION I, zj-'� k jo T 14 Q �r" a , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name I Signature qY0wner Age t Date i SECTION 11- ESTIMATED CONSTRUCTION COSTS i Item Estimated Cost (Dollars) to be completed b permit applicant Official Use Only 1. Building(a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee (a)x(b) cq (� D 4. Mechanical AC 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number d TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ': .o "' l ,SSACMUS� This certifies thatm/ ... .. . has permission to perform,!.f�.. plumbing in/the buildings r .. !t-��.� * at .l.. J ..... Worth Andover, Mass. Feer�,!!U.. ic. No..- PLUMBING INSPECTOR Check # IN 6386 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location/,U Com, #/ 6yo>by eWR- " New 1:1 Renovation Owners of Replacement P FIXTURES I CATION FOR PERMIT TO DO PLUMBING Date J Permit # Amount ;�- Plans Submitted Yes 11 No (Print or type)Check one: Installing Company Name / Corp. Addr ss (� -2 ��� .ST�E�T Partner t'ISS 0;&, ,J Firm/Co. Name of Licensed Plumber: '-�y ygo (-tiJ (_S o n Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other, type of indemnity Bond ❑ Certificate 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 I hereby certify that all of the details and information best of my knowledge and that all plumbing work compliance with all pertinent provisions of theZI By: Agent ted (or entered) in above application are true and accurate fo the Performed under P 't Issued for this application will be in Plu ng o d Chapter 142 of the General Laws. I Type of Plumbing License Title/6 3 1 City/Town Icense lNumver Master D Journeyman M j APPROVED (OFFICE USE ONLY I t �iie �ar�zmaaruuecc� a`'�i�uasac�cuselra � BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR HFA Number: CS 033843 Birthdate: 03/15/1955 i Expires: 03/15/2006 Tr. no: 18496 Restricted: 00 JOHN T HAFFEY 3 WILLIAMS ROAD WAYLAND, MA 01778 Acting C mis oner t c O LO V 15 1 N W N 0Q..co 0� ca c cCf O rcn.1 0 n 00 w O O O c cd U :z U O ago a, cj U O � � o o (=� o b O � co 0 O O x V , v Cl LLI 00 m O C) UJ LL�� _ m —i n co > �o L v cq �U C cl N � o u a L c 0 (A clE t7 � v 7 cq N V E, W�m C O O M 2 N N " L 7 C q ° � c 0 b O R . L L � O C 7 e O U p I 0a Sao O y n > o'c c� w a u o 0 OL > ° O c c o 0 0 0 C) N V E, W�m Q F O _ M 2 9 C O .. U 0 4 w Z 7 e O U p 't wc O y n > o'c c� w a OL > ° O c c 0 0 0 c W o X 0 W co n c O ca x m o LL Q LL E, W�m Q F O _ M 2 V Co Z_n (n a Print name T' WWI :'a; AUS-effs Th C The qmmQnWq, Dedrtmebts p nt 6f 1, Office ofatlgns 00n" " et Boston S. 2111 'virli ;Ih this area to be completed 6y''c! o' 'official Workers' Compensation 1hibrance Affidavit Cft�'.qttown: �.i 6i c�nse # R Location: 01- 00CL R L &Lo, e - City: N 0 ncto tie r MA shone # C] I am a homeowner performing all work myself. C3 I am sole proprietor and. have no one working In any capacity I am an employer provldlpg''wo*rker . so compensation for my employees working on this job. Company name: j- —,'!HOCP�e{,r Address: 3 U, TY (ct gnig S- co ZD I (ko City: 2- phone # ED Insurance co.—A Moj� i� +4r1n1-12 policy # OJ C -to?-.- 4-T 3- 1 3 6 -Z$12 El I am sole proprietor general contractor, or homeq#ner, (clrclO one) and have hired the contractors listed blow who have the following workers' compensation policies: I Company name: Address: City: phone # Insurance co. policy # Company name: Address: We # City: p '6 noe co. I policy # rM. year's Imp . do . onment es well as In the form of a UTOP,y this statement may be forwarded to the 'Office of Investigations of tho'' do hereby certify under the pains and penaffles of perjury that the Int Si nature'V11 �4&6 6f:6drinInal penaltl6s"Of a fine up to $1,500,00 and/or one j'6aj*fid'Q',of $100.00 day agalnit hm I understand that at copy of j4 - �erlflcatlon. led above is true and correct. Co Z_n (n a Print name -KQ phone 1, offi4fuse only 'virli ;Ih this area to be completed 6y''c! o' 'official I Cft�'.qttown: �.i 6i c�nse # 13 -Building Department y. j4'tt ED .1cen'sIng board I .'E]dh4ck if, Immediate resp6nise'ls require CJ Health *ahm6htl peFson: 4: 1h ...t ..4;! -V �-,77777777�- q- �n qz: F North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number 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. The debris will be disposed of in: I a Q v)-nyn , m et s s- -&--110-n , c ►�©sa- I (Location of Facility) ig-nature ffbPef mit Applicant �& 7,Z_-wo y Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector LLJ zCL a i ' w a�a, A v A W C a' A �:.a� C to W m C w° 44 U w W. a°G w wcE LLJ zCL I v O 0 I tC cm C C403 per' CD L49 O O 'E m m It z CDO O LMO O a r a: cma ca Sc ev CL 0 as c Z CD CL V h O C (A ca W U) 19 W W oc W N O �:.a� C to W m C :t o �. �.. ca QE a Q 03 a d y E m t+i O C o� 0 s �b o ts mo': o m E O O a -m `�y y �► ♦ m y �3c% . C C 1 w A O -IC!_ y E ID •�' o �m CD com0 ' cmoa O�QCZ m �► : mom v v+ Z o H• :co`o cpCL 'c = m `mom S :nS0CC LN C O eo t • 0 "' C _, �. •� f.. Go E =Z�C azoo Z ID d CM O1 CIO •� 42 Go o = .9 CL I v O 0 I tC cm C C403 per' CD L49 O O 'E m m It z CDO O LMO O a r a: cma ca Sc ev CL 0 as c Z CD CL V h O C (A ca W U) 19 W W oc W N k I" 4 TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION This certifies that .... ..t.�(., / G L.......... has permission for gas installation !�-A ..e ........ in the buil�n s off/. !�.,�:.�l-1 . �..... ��� ��...... . at North Andover Mass. Fe -e .•.� . Lic. No.: % C� -• �', ��/ !?.A//`�,1a k # �AAiINSPECTOR Ch ec 9 MAS,SACHUSEM UNIFORM APPUCA (Type or print) NORTH ANDOVER, MASSA Building Locations 9 Oo L New ❑ Renovation ❑ FOR PU MPr TO DO GAS HIT NG Date Permit # Amount $ -r'sNameb11tWP,1LAQr ❑ Plans Submitted ❑ Check one: Certificate Installing Company ❑ Corp. ❑ Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter �A w A /A A C-CQY\ INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M— No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ 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 ❑ I hereby certify that all of the details and information I have submitted (or ent d) 0 abovp application are true and accurate to the best of my knowledge and that all plumbing work and installations perfod and Pe t Iss ed forAi i plication will be in compliance with all pertinent provisions of the Massachusetts State Gas�de C ter 1 f eral Laws. ICity/Town APPROVED (OFFICE USE ONLY) f Signature of Licensed Plumber Or Gas Fitter Plumber 6 2 j 3 ElGas Fitter License Number ❑ Master MJourneyman • A SEM ENT -B 1ST. FLOOR 4TH. FLOOR 17TH. FLOOR Check one: Certificate Installing Company ❑ Corp. ❑ Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter �A w A /A A C-CQY\ INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M— No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ 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 ❑ I hereby certify that all of the details and information I have submitted (or ent d) 0 abovp application are true and accurate to the best of my knowledge and that all plumbing work and installations perfod and Pe t Iss ed forAi i plication will be in compliance with all pertinent provisions of the Massachusetts State Gas�de C ter 1 f eral Laws. ICity/Town APPROVED (OFFICE USE ONLY) f Signature of Licensed Plumber Or Gas Fitter Plumber 6 2 j 3 ElGas Fitter License Number ❑ Master MJourneyman