HomeMy WebLinkAboutBuilding Permit #74 - 110 FOREST STREET 7/24/2009 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: / Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page,
LOCATION
Print
PROPERTY OWNER ,U&A/CV �R?t S c a
P nt
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
F- p W 1,91" A,41ty"y x4 Ae s'!2 P DI-Me O f4Jr X/e—,
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: Phoned 3 fY^ds"
Address: 91"C'00
Supervisor's Construction License: d -7 Yd'9 Exp. Date: -2-Al-- " 2-a 1/
w
Home Improvement License: /a/ov Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.-BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. E
Total Project Cost: $ FEE: $ tel,
Check No.: Receipt Receipt No.: =P,5)-4,5_V
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund G
i
ignature of Agent/Owner Signature of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
Location
No. Date /" ?v o
i
NORTq TOWN OF NORTH ANDOVER
�`?." • L9
+ ; . Certificate of Occupancy $
Building/Frame Permit Fee $
r.
Foundation Permit Fee $
Other Permit Fee $ a
TOTAL
Check # D
222-, J6 -
Building Inspector
i
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 - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH : Reviewed on Signature
COMMENTS
Ile Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
t
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.
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)
i
i
❑ 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
o 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
❑ 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
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
1 Doc: Doc.Building Permit Revised 2008
consmarzwealth of Massachusetts
f DeParlmemy Of Industrial Accident
of Investta ations
r 600 kilashhWMn Street
Boston
, 1U 02111 .
Workers' Compensation I.M' nce "4W.�Sgnv/dia ,
Affidavit Ew'Islets/Coatracfors/Eiectriciaas/PiQmbers
A '+cant Information
Please Print LeQN
Nan1B(RW'n"s/OrPni=6onAndividnal):
Address: j•�
-
•
Phone#: .
Are you an empioyer?Cheek.the aPProP�te•box: —
1.❑ I am a employer with 4. ❑ I am a Type of PrQj (required):'
1 ees general contractor and I t �:
�P oy (full andlor
pari-time. 6.. 0 .
..
2• I am.asole . ) have bsred the suh-cotthators ❑Now construction
Proprietor:or partner. listed stad
on
t�s the attached sheet t 7. Remo
de an Beim
d have ..
ship no employees ��` g
workingfor me in s�-coniractots have
. any capacity. work 8• (]Demolition
n' este' comp.insurance.
(No worlcen;'comp, insurassce 3. ❑ VJe are a corporali and its 9' ❑Building addition
qd] office; have exercised their
3.0 l sin a homeowner doing all work right of l 0.❑.$iectrical TeP m'additions
myself[No-workers' exemption p�fV1QL 11.❑Plum bin
MMP. §L(4),'and•we have no g repairs or additions
insrnance•required.];t •em. I 12.L]Roof .. us
P ccs. �
aY o work=,. t
*Amy applimarf68tecks comp. inauranccrequired_] I3.❑.pmry
chbox'#f mast atso flit out the
f tiomeowm*who submit this effi'davit seohmi below sho�g�r.v orkat'oornpensation oil in
tndtcating they am dying an worts end them hrte outside con P e fomtatiot4
_ tCoatract m that check this box rnustats ys artd.�tioasl shetstshow' _ �oo'mist submit a new af5davit irtdi°
mg the nan►�oftt�aih. o and their worhas'set^• :._ such'
1 ccasr.att e+apioyer that isataouraittlg:lvorF. •'co• on.
pr tor_ % =fin ensuaneeIor
� oe
e: Below low rste parCy .
rmdyob stir
Insurance Company Name: '
Policy#or Self-ins.Lie. #
Sob Site Expiration Date:
AAdrms: .
Attach 8 copy of the workers'camper safiiouCitylStatr2'ip.
Poiu3 declaration Page(sbowiag the policy number and expisahoa date), .
fine
up
to -1,50e eoveregc as required under Section 25A of I�m c. 152 can lead to the imposition of star'
fine up fo$1,500.00 andlor one-year imprisoiun
Of up to$250.00 a ;as wen as civic penalties m the form of a mal Penalties of a
�3 A-for t the violator. Be advised that a c of this statement MP WORK ORD
ER and a fine
Investigations of the DIA for insurance coverage verification. May be forwarded to the Office of
I do hereby certify un er the Osiris and penaftia a per,jury J*at the infnrma gon provided
Siabove is lace and Cor
red
Phone#:
Date: 7--2 Y-O
offAcial use onfy. Do not write is this•arra,In be mmp49ea!by 4*J'or town of}tcra(
Cly or Town:
#
lssuiag Authority(circle one): Permit/Licanse
a.Othei•. Board of Health L Snilt#ing Uspar anent 3.City/Town-Clerk 4.4.Electrical Inspector S. Plumbing 6 'i
lz'Spector
Contact Person:
Phone#:
Information a tad Ilis" tructions-
Mas=husetts
General Laws.chapter 1S2 requires all emp Ioyars to provide workers' compensation for their employees.
Pursuant to this statute,an entpleyee is defined as"..:every parson in the service of another under any contract ofhin,- .
express or implied,Aral or written,"
An er rlayer is defined as"an individuate partnership,association,corporation or other Iagal entity,errany two or more
of the foregramg engaged in a Joint enterprise,and including the legal representatives of a deceesad employer,oriho
retreiver ortnrstm•of an individual,partnership,associaticxi n or other legal entity,employing employers.'Rowewthe
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 maimt==ce,construction or repair wcirk on such dwelling-house
or on the grounds or building appurtenant thereto shat not because of such employment be deemed to be an employer."
MOL chapter 152,§25C(6)also states that"every state ow-local Beensing agency shall withhold the ismance,or
renewal of a lieeuse or permit to operate a baseness or *a construct buildings in the commonwealth for any
applicant who has aot produced-acceptable evidence of compliance with the.insurance covera„Qe required."
Additiona:Ily, MOL chapter I52,§29C(7)states"Neither tihe'commenweaifh nor any of its political subdivisions shall
enter into any contract for the pmfornanm of public wort-, nmtil-a=eptanlo evidence of compliance with the ins==
requiremeits.of this chapter have bean presented to the carttracting authority."
Applicants
Please fill out the workers'compmnsat on.afndavit completely,by chrbking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)r s=*),addiws(es):Mind phone number(s)aloe with tbcir certifi s of
insurance. Limited Liabil' Companies LL or Limited
� }
. n•3' mP (LLC) . �ited LrabrIity Partnerships(LLP)with no eanpioyees othct$►an the
members orpmttera,=not requied,to crony workers'oflTnpensatim insurance. Ifan LLC or LLP does.have
employees,a policy is required. Be advised that this affd.-x*h may be submitted to the Department of Industrial
Acciderris for confirmation of insuramce eavc:nv_, Also•tope sure to sign and-date the affidavit. The affidavit should
be retnanmd to the city or town that the application for the psi{or license is being requested,notthe Department of
Industrial Accidents. Should you have any questions regax-ding the law or if you see required to obtain a workers'
oompensation policy,please-call the Department at the•nurarnber fisted below. Self-insured companies alreuld entetheir
Self_Msurz?1cc P=Mc;Bumber on the'approp iate heir.
City or Tows:Officials
Please be sure that the affidavit is complete and printed 6Wbly. The Dmpart ment has provided a space at the bottom
of the affidavit for you to fill out in the event the Office or Investigations has to contact you regarding the applicant.
Please be sum to fill in time permittlicense numberwhich Will be used w a reference number. In addition,an
applicant
that must mbmh multiple P �cense MPPlieaions in
any given year,need only submit our affidavit indicating-currernt
policy information(if necessary)and under"Job Site Addr-ens"the applicant should write:"all locations in (city or
town)"A copy of-the affidavit that has been.officially stamped or marked by time city or town may be provided to the
applicant as proof that a valid affidavit is on file for futam permits or licenses. A new affidavit:must lie filled out each
year. Wheat a home
owner or citizen is obtain' a Iicens� '
or
y '� permitnat related to any business or commercial venture
(Le, a dog Iicenn or permit to bum leaves esti:.)said pmrs6n is NOT_required to complete this affidaviL
+ Tho Office:of Investigations would like to thank you in advance for your caoperation and should you have any questions,
please do not hesitate to give us a call
The Departments address,telephone and fax number.
The Commonwealth of Massachusetts
Departrnent of I3ndustrW Accidents
Office of Envesfivations "
600 Washington Stmt
Bosun, IDSA 02111
Tel. #617-7274900 i= 406 or I-8.77-1vCASSAFE
Fak 4617-727-7744
Bruised 5-?f-Q5 wwwaa2sS.gov{dia
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Massachusetts- Department.of Public Safety
I
` Board of Building Regulations and Standards `
.� .P GbriSiruction,Supervisor License
r�,iicense:.CS 27489
. fie moi•
a j ;STEPHEN 11� CEISLINC
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r i *; 9TH ST FST 11-F
' SALISBURY;�l A D'I962 f-(
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Expiration: 7/1642011 +
Conunl6ioneii i
i Tr#: 18542
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,
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
r rt: ` ist
f Reg ram 1 s�101.846
E - - — 9/2010 . Tr#. 268336. .
#� _ i dual
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STEPHEN M.KF c
.... f �
Stephen Keisling F.
t 68 Glenri�est
-N over.,MA 01845 5 °Administrator
r '� �-y ...,-cs �,_ � .,tip. .a,.�h .-X ... •. _ t.{
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E
NORTH
Town of . � _ . 4Andover .
0
1 ; �.�
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o A E = dover, Mass.,
I� COCMICMEWICK
7�p
ORATED
`s BOARD OF HEALTH
PERI T T D Food/Kitchen
Septic System
1104— BUILDING INSPECTOR
THISCERTIFIES THAT............. ..... .................................................................................................................. Foundation
has permission to erect........................................ buildings on ....//0......... ...01t... ..-41............................. Rough
to be occupied as ! Chimney
...........�..... ..... ........
provided that the person a epting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the pro ions 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 d
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
Ps. .,rrC . .....................................
Service
BUILDING 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. Burner
- Street No.
SEE REVERSE SIDE Smoke Det.
Proposal Page No. of Pages
i
17 7,7'
9 M Strut t 3es2
Saliskiry, MASSACHUSE11fS 01952
f y�ry 2
a t'ivno (073) 602-262 ('053)�r
PROPOSAL SUBMITTED TO� PHONE DATE
STREET JOB NAME
ZA
74
CITY,STATE and ZIP CODE JOB LOCATION
ARCHITECT v DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
�''4w�:.-r-f� �-13�^-'�-� r�f -���-rr E�.-''� �y�c.a.-�'r j /,,[.�•,--t �-c./ a�.J-�.:.. � C�'C�.
4'V��1 .AJ^'�^-N `�.^i/�.r 4_fi'f-�f• �,I✓^{S'!.'..,..� �L� ��'N} 4 � /I/ _ _ � �-ltii� .� ..7" i Lu
t 1 �-• � "V r .f fie �
i��,, . r r- mo o✓' X26
Hie propoSt hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
dollars($ ).
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a workmanlike - 1
Authorized
manner according to standard practices.Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra Signature '
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
Arreptance of Proposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
f�
Date of Acceptance: Signature " � 1 4,4
I
FARM FAMILY .CASUALTY INSURANCE COMPANY
'
Issuing Office - P.O. Box 656 • Albany, New York 12201-0656
CONTRACTORS ADVANTAGE BOP00o91E904
DECLARATION PAGE
,r u
Policy Number: 2005XO431 Agent No: 3485 Agent Phone: 978-887-8304
UGONE -JOHNSON INSURANCE AGENCY, IN
} 7 GROVE ST STE 201
`^ 6 TOPSFIELD MA 01983-1862
l
Name'and Mailing Address of First Named Insured:
STEPHEN,KEISLING
9 9TH STi W
' SALISBURY MA 01952-1702
The Insured is INDIVIDUAL
Transaction Type:IRENEWAIL `'`Transaction Effective: 03/'21/2009
4
�rPolicy'.Period: I From 03/21/2009 To 03/21'/20.10 12:01 A.M. Standard Time
a
t
. Business Description: CARPENTRY
(Total Limit of Liability Term ADDL/RTN
Business Property Coverages , Premium Premium
Buildings '
Business Personal Property ;` $5,000 $20.00
Business Income and Extra Expense., Actual Loss Sustained Not
Exceeding 12 Months
Other Endorsements a SEE SCHEDULE
j BUSINESSOWNERS LIABILITY ;
;,Except for Fired Legal'.Liability, each paid claim for the following coverages reduces the amount of insurance we
provide during,`the applicable annual period.
J, Business Liability Limits of Insurance
I Bodily Injury/Property Damage j
'$500,000 EACH OCCURRENCE
$1,000,000 AGGREGATE
000,000 AGGREGATE FOR
a; PRODUCTS/COMPLETED
OPERATIONS HAZARD
4 MedicalExpenses
$5,000 EACH PERSON
' Fire Legal Liability, $50,000 ANYONE FIRE OR EXPLOSION :y
�
;0ther.Endorsements^ � i SEE SCHEDULE
j
POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM
;The Declarations, Schedules"and These Forms and Endorsements Make Up Your Complete Policy:
' BP00021299 BP00060197 BP00090197 BP04170196 BP04190689 BP04961001 BP05140103 BP0701:r'�
BP10040468 BF30061103 BF40380902 BF40390303 BF41090204 BF41321008 F199020108 /
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