HomeMy WebLinkAboutBuilding Permit #722 - 151 SANDRA LANE 4/12/2012 BUILDING PERMIT r1ORTH
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
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Permit NO. Date Received ,� �'�s R^TED
S/1CHUS
Date Issued: 1 Z-I
fl' �(01R_iTANT:Applicant must complete all items on this page
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PROPERT41(#�OWNER° — Tn
Sho tVlla `e es. no i
F.MAPIN® FARCEL ZONINGDISTRICT: _ x ' fHistoncl®istnct eyes o.
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non Residential
❑ New Building ❑ One family
[I Addition El Two or more family El Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
a4S pfic l µ: _ `' ®f_loodplam Wetlands v 0 '+Watershed.D_ istrictj
D Water/Sewer 1 - - -
DESCRIPTION OF WORK TO BE PREFORMED:
,�e�ove G��S'%�•v Fix%GAPS '7'ife �` �,eylL r,4LL drew �IxT�vec.�
,ye w f<& �� Iwo
SLio�vPrt .4d1P.¢ �Lorrst. /YPr�
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
tCONTRACTOR Name<. 9*14
Exp: f Date 7/G Lca� i
.Supervisor� tConstrucfion License: -
`Exp..
ARCHITECT/ENGINEER Phone: I
k
Address: Reg. No.
FEE SCHEDULE.,BULDING PERF$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ / r1 -Soo, FEE: $ 2-0
Check No.:
1
`�, Receipt No.: 1 `�
_ ._ -- _
NOTE: Persons con kacting with unregister,,�-ed cont`tors do not have access to the guaranty fund
Signaturetof`A
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 ❑
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
�I
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--3M Osgood Street
FIREIDEPARTMENT TbempDumpsterKoni ' eyes ino
�Loca'tedtafi 124tMaiiiStreet
jf
C..OMMEN TS -- _- ----
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
❑ Notified for pickup - Date
i
Doc.Building Permit Revised 2008
J
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
NOTE: Ali 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) E
❑ 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
a
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
i
Revised 2.2008
P"e No. of Pages
STEPHEN RQ. =SUNG
4 "Am& Remedeft
9 9th Steet West
SAsbtsy,MASSACHUSETTS 01952
MA Ur 027489 Home tom. 201946
Pie(978) 682-2072 * (978)465-4712
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AFiGTQiEtr DATEOFR.ANS - _ MBPH(7NE
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All—
P VLOPW hereby to furnish material ansa labor—complete in accordance with above specifications,for the sum of:
L-10L-10f le 300,
Payment be made as taltwvs !� 7 3 doh(S )-
10
Au rteaMM is WmuwftW W be as apex d M wmk to be caffoefed in a warto
accm*Mtostandard Atryat mrtA�Ia§w*mnatmve� AtitltorEed
h-MM ema costs"be e> 0*0 C*upon w ift orders,and%VM became an extM
over and above the est Aff ee11 1 etppn _
decays beywrd au corNai O�to raey i p my be toys
Our workers are taffy covered by wars Om�aam ktsur� vveStdra�m by res ff trot accepted wrfitm
—The above prices,specil'ications
and cxndetiwm are satisfactory and are taft accepbA You are autltor¢ed S'igrmhue
tQ do tfie work as Pa�rtrnntt q� be made as outlined above_
NORTH
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LAKE
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BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT.................. .. ......... ............ ......1!1! ................................................................................ Foundation
has permission to erect...... ...:............................ buildings on ...J.r.'.......... .�.....1.111060................. Rough
to be occupied as............. .�► .....�....�...........� .. .. ......................
C imney
provided that the person accepting this permd shall in every respect conform to the terms of the application on file in Final
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
Final
PERMIT EXPIRES IN 6 MONTHS
;L*� ,
CONS �' ELECTRICAL INSPECTOR
UNLESS r LESS Rough
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... r.Y................................ Service
::
i BUILDING INSPECTOR
Final
IOccupancy 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.
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Cont acturArbrtradaa
The Home kPOVewd CW=dWUWMMdes bnnoowmers with tleright mimtiafie an arbbt 2flon action(as an
aftmative to cant act)if 8hey have a&pne with a at>nhaetar. The salla tight is not altomdiealby affadad to a
oo rt,however 71we coMmAorwcold have toresolnany dispfthd9whaswidhalm in court
both parties agree to the optiond dam luovmed below lVa wodd*n*econm=mw&e=nefl&tD
arbitration as is affmded to the homed wncrby the Home hgpwvemaA CaulmetwLaw
The wand the homeowner hembymutuatlyagtee in advancer id in the event.the coonctorhma
coIIc=fiDgthsCt►nU=C.the coa actormaysobmittledispn6etoapriie3tearbihationfiemwhiclhhasbeenagp+avedby
Me Sezaryof&elixeumtiveOffice ofConnancrAffansandBAR andtheconsumer"besequned
to submitto such arbitration as provided In MRSMIUMM Geral 'M 142A_
Homeownces sigaaime s
NOTICE:She swudmes ofthe parties above apply only to the Weement of the patties to alternative dispute
1asoIU110n imtud ed by the ccubaitor-11chunuxomermw hhif altemnative resolution even where this
sectionis notsVinWelysigned bythewitm
/ Homeowner'sRights
A homeowne'sAghts undarthe Home lm l Contractor law(MGL chapter 142A)and other consumer
PMocdw laws(ire.MM 93A)may not be waived in any waxy,eves by agteemeat. However;homeowners
may be excluded from zighis ifft eon they dhoase is not ptopa fy registered as Eby lay.
Homeoweaswho seiaue their own building permits we automatically excluded fm®all Gumady Fund
the Home Improvement C Law. The comtrarxor is of
timely andworhmnmabilz m� Hom wwnets to d to orb ter camzpletiog the vwu�as des acWr s a
may be estitted to other specafific begah rigttfs ifihe
orpwvides an express warranty forte ordain.ht additiontoguarantees orwa sties
lxovidedby the all goods soldin ll cmry an implied vma, y of11 a , I and fitaetis for
a paztwular lonpose-An emlmagrotion ofaffiff an whirl,the homeowner and conuactor hawdnlly agree may be
added to the teles ofthe contract as long as they do sot reshict ahom cowmes bade comsomerdghts. Ifyon have
questions about your consumedlomeowner rights,contact the Consumer hiffiamation,Hotfine(listed below).
Execution of Contract
The coutmct ilmstbe exealted in 4MR11glLe and should not be signed until a copy ofdl exhaft and refereuced
dou>amlds have been anac ed. Parties are aim advised notto sip thedocamcat UnM an blank sections have been
Mod in or ma&ad as void,deleted,ornot applicabin One original signed aWofthe contractwith its into
bre given to the awRw wd the other kept by the conhutor-Any modification to the or4n t contact Abe in wti6ng
and agreed to by bothparties.Contracted wo&may notbegin unM both patties have received a fully executed copy of
the coating and the llnee day rescission pmiod has cWhed-
AaAerated expired-
APayments
A conhac;W may notdemand paymeois in advance of&c dates spedfied on tate paymentschedale in cases whetethe
hOmcownwdeemhm2&cmfftobefiamiewHymsecum i3ovuevay m mstanocs where a Jnr deems hnn&asdf
to be financially insecure,the eanbacturmay mquim that the balance offinds notyetdue be phased is a jaintw
account as a pmeqWSUD to continuing the conhacted wo& Vrdh avrl of finds fibom said accountwouldicqunotbe,
siVnImes ofbothpaties.
Additional Inf wmatiou
Ifyou have gel gciestious orneedaddibaual
information.about the Home ImpwVMcut Conhac for Law or other
conslOM rights,or ifyou wish to obtain a free copy of"A Massac uaseits Consumer Guide to Home lmpraverocu"
contact;
r
Constlmerinformation Hotline
Office ofCausumaer Atfims and Business Regulation
10 Pa&Phma,Room 517%h3osta%MA 02116-
617-9738787,08-293-3757or visit the OCABRwebsite at -tiIr"rr.::-;c.macS-savioC bs'
Ifyon wast to verify the reglshation of a contractor or ifyou have questions or need additional khmadon specificany
about the contrHtarreglshation corms of the Ham lmptovement Canuactor Law,coutact
Director of Home hWevement Coaractor Registration
Office ofConstancrAffaits and Bumess Regulation
10 P9&Pba s.Room 5170,Boston,MA 02116
617X973-8787,8W283-3757 or visa the Hicvabsrteatl,L =_s,.,2fwitlCai,
Go online to viewthe stahls of aHome bvwvemcnt Cis
i elf;r.%ids.sf ate.ma.us:�7C5RiL'iTI`.ii)�L'i2lCilt�tSCC(I5.^. tiSl.:rS`?
Regisftafimu-
For assistance wghmfonnal mon ofdisputes orto regime formal complaints against abusums,call:
ConsumerComplaint Section
Officeefthe Attorney General
617 7274MM
AND7OR
Better Business Bateau
50"524M 508-755-2548 or 413-734-3114
Yasionzi-ltr=2010
i i I I Brockway-Smith Company
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www.brosco.com
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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 ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
s�
Boston,MA 02I11
www.naa_ss govldia
A licant Information -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Le ibl
Name(Business/Organization/Individual):
Address:
• I
City/State/Zip:
Phone#: 97 do' 3/?-- eYf 7
[[:] 1
an employer?Check the appropriate box:
a employer with 4. Type of project(required):
❑I am a general contractor and I
loyees(full and/or part-time).* have hired the sub-contractors 6 El New construction
a sole proprietor or partner- listed on the attached sheaet. t 7• ❑Remodeling
and have no employees These sub-contractors have 8. [❑Demblition
ing for me in any capacity, workers'comp.insurance.
workers comp.insurance 5. 9. ❑Building addition
p ❑ We are a corporation and its
red.] .officers have exercised their 10.❑Electrical repairs or additions
a homeowner doing all work right of exemption per MGL 11.❑Plumbingrepairs or additions
lf.[No workers' comp. c. 152, §1(4),and we have no
12. Roofreance required.]t employees. ❑ pairs
[No workers
comp,insurance required.] 13•❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation
T Homeowners who P olio inf
submit this affidavitindi indihirecating post licyubmit a ormation.
G the are Join' then
ing suc
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractoroutside s and their workers'oampapol cyavit infotrmat on.
an employer that is providing workers'co
information. mpensation insurance for•my employees Below is the policy and job site
.
Insurance Company Name:
Policy#or Self-ins.Lie.#:
Expiration Date:
Job Site Address: ,
City/State/Zip,
Attach a copy of the workers'compensation policy declaration page(showing he 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 maybe forwarded to the Office of
Investigations of the DIA,for insurance coverage verification.
fP J ,
Ido hereby certify un t ze pa' s and enalties o er'u that the infornzationproviderl above is true and correct.
Signature:
Date: �—�/— 20/2.
'hone#: /�7 3/S�� ey-'5 7
FJ�ss:ulng
only. Do not write in this area,to be completed by chy or Town official.
n: Permit/License#
ority(circle one): ,
I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical 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 apartinents 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 sha11'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 ofpublic 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained to the city or town that the application for the permit 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/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 n (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 permit 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:
xhe COM-nwearm, of jVj1assachi,�se-tts
Department of h dustriEd Accidents
Office Of InVestigattons
600 Washington Street
Boston;NA,02111
W.#617-727,4900 ext 4406 ox 1.-877-MASSAFE
Revised 5-26-05 Fay,#617-727-7749
www.mass.gav/dia
�✓lze-Pan�no�uuea/,f/ o�,��.aaacccYaueelta .
Of0e of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
t = Registration: p101846 Type:
Expiration: 8/29%2012 Individual
.STEPHEN M.KEISLING>
Stephen Keisling -;
9 NINTH STREET
SALISBURY,MA 01952`vim Undersecretary
Nhis'sachusetts- Department of Public SafetN
Board of Building ReguIations and Standards
Construction Supervisor License
License: CS 27489
STEPHEN M KEISLING
9 9TH STREET WEST
SALISBURY, MA 01952
c—
J"'`� Expiration: 7/16/2013
('ununissi°ncr Tr#: 19624
Location�7, ��J/?l//�lI ���<
No.--)'7'Z— Datelob
* - TOWN OF NORTH ANDOVER
e
•
,. Certificate of Occupancy $
Building/Frame Permit Fee $ �
Foundation Permit Fee $
Other Permit Fee $
"L xy
TOTAL $
Check#
25174 Building Inspector