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HomeMy WebLinkAboutBuilding Permit #748 - 127 GLENNCREST DRIVE 5/7/2007 i BUILDING PERMIT °* NORTH q ,tom•° ;°, �o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Receeii d r-- SSAC HUSH Date Issued: . 'O IMPORTANT: Applicant must ccOplete items on this page LOCATION PROPERTY OWNER e AAAX ---a' j Print MAP NO: tQ_q C- PARCEL: -6-S' ZONING DISTRICT: HISTORIC DISTRICT 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 n-Septic ❑ Vti/eII ❑ Floodplain :D Wetlands ❑ Watershed District b Water/Sewer . `. I DESCRIPTION OF WORK TO BE PREFORMED: 8',✓ G2 �YJx7-w ti l c.E' 2 Ac� 4,LA jA)6 6eo;., V 'X Y 7v P l e Identification Please Type or Print Clearly) OWNER: Name: 4!2: Phone: Address: " CONTRACTOR rName: S% s .v-;.,L'Pfs&,.7Phone: g /Y— YS Address::. Supervisor's Construction.License v 9 7 P'P!? Exp, Date: L -HomeImprovement;License: /©,fly Exp: ,Date: � ARCHITECT/ENGINEER 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. od Total Project Cost: $ 3 6 90. FEE: $ Check No.: 7 r1- — Receipt No.: C� y r NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature of A ent/Owner Signature of contractor Location o'� �- �ln CfZ�'�" J)ry No. Date NORT1y TOWN OF NORTH ANDOVER ►O. A Certificate of Occupancy $ �oowno�I.. Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $. r Check # 202 "1 1 - Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 ❑ i i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS D .E EJECTED DATE APPROVED CONSERVATIO �j `� COMMENTS S W DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street FIRE DEPARTMENT- -Temp Dum ster on site Yes ✓ no Located at 124 Main Street ata ' fro" 15"_r`JC0 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 I 0 Notified for pickup - Date ----.............-................... - --........................._.._-. ....-...................................---- ...-..............- - - ----� Doc.Building Permit Revised 2007 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 I NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application Li Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses Li 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 Doe:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 j I TH TOANM of Andover 0 0 C, 4 40 LAKE dover, Mass., COCHICHEWICK 0RATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT.....&,d....... .............................................................................. BUILDING INSPECTOR ......... Foundation has permission to erect........................................ buildings on.....1.4..•}...........1. .. ...................... Rough to be occupied as...........64 ....... J9.14nj........... Chimney accepting �Derw ;i�t A&er*n..... Final provided that the person accepting tit she in every respect conform t he terms IN thea an file in 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 qq doom PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU S S Rough <TtloinIN �R Final ........... Service BUILDING Occupancy Permit Required to Omtpy 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. GV�PS� _ .111 �1• h' n Y' E- 2yB. .cis. q� Y o ' Scale "_ '✓e:p ' Date of Inspection /` 7' 9� 92' Date of Plan /— //• Brockway-Smith Company www.brosco.com - '- 4 -4- 4- OtT � 7 ;� __. _ t 4-- -4 -4-L- -'-'t- T' It N 4.; + -4- 4— 60 00 T _T___ H17 __7 4+ t A_- ttCy 1 -4-4 1--__ T-4 1 1+ 1 1 L ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street. 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 Brockway-Smith Company www.brosco.com _J 'CP J J_ K Z ....... 7 J j ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV. 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le::ibly Name(Business/Organization/Individual): S ePs �J �I-rC1A,,2 e Address: City/State/Zip: g o LP 2 Phone#: 9 2oP 3 i%oP Ys 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2�2. I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,01(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 1311 Other *Any applicant that checks box#I 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. Tontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurancefor my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify un er the pains and penalties of perjury that the information provided.f p d above is true and correct. Signature: . �r Date: • 7"- D 7 Phone#: l'1 Official use only. Do not write in this area,to be completed by city or town ofj?ciaL 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#: I f FARM FAMILY CASUALTY INSURANCE COMPANY Issuing Office - P.O. Box 656 0 Albany, New York 12201-0656 CONTRACTORS ADVANTAGE BOP000916902 ® DECLARATION PAGE Policy Number: 2005XO431 Agent No: 3485 Agent Phone: 978.887-8304 UGONE -JOHNSON INSURANCE AGENCY, IN 10 S MAIN ST STE 208 TOPSI=IELD MA 01983-1834 Name and Mailing Address of First Named Insured: STEPHEN KEISLING 68 GLENCREST DR N ANDOVER MA 01845-1315 The Insured is: INDIVIDUAL Transaction Type: RENEWAL Transaction Effective: 03/21/2007 Policy Period: From 03/21/2007 To 03121/2008 12:01 A.M. Standard Time Business Description: CARPENTRY Total Limit of Liability Term ADDL/RTN Premium Premium Business Property Coverages Buildings Business Personal Property $5,000 $25.00 Business Income and Extra Expense Actual Loss Sustained Not Exceeding 12 Months Other Endorsements SEE SCHEDULE BUSINESSOWNERS LIABILITY Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Business Liability Limits of Insurance Bodily Injury/Property Damage $500,000 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 AGGREGATE FOR PRODUCTS/COMPLETED OPERATIONS HAZARD Medical Expenses $5,000 EACH PERSON Fire Legal Liability $50,000 ANY ONE FIRE OR EXPLOSION Other Endorsements SEE SCHEDULE TOTAL PREMIUM POLICY SUBJECT TO ANNUAL AUDIT: YES The Declarations, Schedules and These Forms and Endorsements Make Up Your Complete Policy: BP00021299 BP00060197 BP00090197 BPO1080398 BP04170196 BP04190689 BP04961001 BPOS140103 BPO7010197 BP10040498 BF3006110 3 BF40380902 BF40390303 BF41090204 F199020107 Countersigned By Page: 1 of 2 Authorized Representative ANX-3190 INSURED COPY Processed Date: 01/31/2007 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101846 Exp;,•at i o n: 6/29/2008 Type: Individual STEPHEN M. KEISLING Stephen Keisling 68 Glenncrest Dr. N.Andover, MA 01845 Dcputy Administralor ' ✓fze �ain�r�zo-nus o�✓j�aalac�itaeCle BOARD OF BUILDING REGULATIONS r License: CONSTRUCTION SUPERVISOR +, Number: CS 027489 Birthdate: 07/16/1953 ' y Expires: 07/16/2007 Tr.no: 14847 Restricted: 00 STEPHEN M KEISLING 68 GLENCREST DR ,- N ANDOVER, MA 01845 Commissioner 1hoposal Page No. of Pages STEPHEN M. KEISLING Building & Remodeling 68 Glencrest Drive NORTH ANDOVER, MASSACHUSETTS 01845 MA Lic. 027489 Home Impv. 101846 Phone 682-2072 PROPOSAL SUBMITTED TO PHONE DATE 7-91414-1 �jo f d' oG STREET JOB NAME a 'b P- CITY,STATE and ZW CODE JOB LOCATION na gm a-,..� )�r& ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: .... -.. . � ._�..... _h-1-.�.._ . t c� ..v e...,�- -4... . ,a ��._-�......2 x�,�, o�•- DO .._ ... a..X.%.�..... 3....._. .. - ..�i .�-......... .-.: . ( .................._'�`X..y.. ..._�..._c . ........a x y,, zc -- It ` ....................'......�.`....�....J.-�...®- ... .........._e���-�`" 5 ►" '0C)......... '-�....._�x� ................................. ................. ........_, ..........,, .., _ .......................... .. -� ...................................... ........ . . .................. _............. � .................................... .._........... .......................... . ...................._ht�Z` .. _�'a.�., 1111 Al. 9D, . 1111 .............................................. ........................................... ................... 1...1.1...1................... // cv ...._...... '�'..�..V _G ,......._/ 'D•................................................................................._.._................................._.._._.........._.............................._.........................................._......................................................_.................................... 0/4 . ......._......................................_........................................................._........................................_..__ ............. ..................... ........................................................................................... 1.111 ..................................................._..................................................... ................................................................................................ Hit prapm hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: ). Payment to be made as follows: dollars($ All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from above specifications Signature /K involving extra costs will be executed only upon written orders, and will become an extra g 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. ArrPptanCP 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 M be made as outlined above. Date of Acceptance: ���` �'/�� Signature