HomeMy WebLinkAboutBuilding Permit #509 - 168 CAMPBELL ROAD 3/6/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION ~
Permit NO: Date Received �a pATeo 'P
Date Issued: `
IMPORTANT: Applicant must complete all items on this page
LOCATION (6g P (6-2 k
Print
PROPERTY OWNER leo– Pc cL�� coq
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village .: yes
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:
aC Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
4.
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: mac. i ctc-r—A Phone:(co 65? -5 c3 (cn,
Address: V�5'
CONTRACTOR 'Name:*- Gs� lam(,"- Phone: Q1 t'
Addre5-� �+,, vtx,,ce t�NA- zo L gc. u r�� .
_ - E
Z.
-SgperVisoes Construction License;- 67,1 O Expo Date: Qlao/ G .-
;Horne Improvement - icense;
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.
Total Project Cost: $ L- FEE: $ Sri. Ll9
Check No.: 01/s—d Receipt No.: (; '� 5
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty Jud
4
Locationl'��-�'�%�
No. � a Date
NORTH TOWN OF NORTH ANDOVER
F 9
' Certificate of Occupancy $
;�s • t��'
Building/Frame Permit Fee $ ,
s�cNus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check it
209`?
-_ Building Inspector
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Conservation Decision:
Comments
Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Si nature & Date
Driveway Permit
Located at 384 Osgood Street
y ,
no
FIRE 'DEPARTMENT Temp `Dempster on site y .es
Located at 124 -MainStreet
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.$10041000 fine
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
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
o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
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MAR -06-2008 THU 01:27 PM SERVPRO OF LAWRENCE FAX N0. 9786877706
ode"bork in
Au, f'c4GL
AUTHORIZATION TO PERFORM SERVICES
DIRECTION OF PAYMENT rsTatvoaaDI
P. 02
..P. , herein referred to as t'Customer",
authorizes SERVPRO of �_ /7 o-%, et- , herein referred to as " ERVPRO".
to perform any and all necessary cleaning and/or restoration services on Customer' property
at:
4
�Kff�
And with respect to items that need to be cleaned at a remote location, to remove and clean
such items as necessary. Customer agrees that SERVPRO is working for the Custo er and not
the Insurance Company or agent/adjuster.
Customer authorizes Insuranep Company,
herein referred to as "Insurance Company", t6 solely pay SERVPRO directly for tht portion of
the work covered by Customer's insurance policy.
If for any reason the check for payment should be signed over or made payable to Customer,
Customer agrees to pay SERVPRO immediately upon receipt of the check from th Insurance
Company. Customer also agrees to pay SERVPRO directly for any amounts not covered by
Customer's insurance company, including deductible.
Customer agrees if payment is not made to SERVPRO within five (5j days of Custo er's receipt
of the check from Insurance Company, to pay service charges at one and one ialf percent
(1.5%) per month or the highest amount allowed by law, whichever is less, plus reasonable
attorney fees, court costs and all costs of collection.
Remarks:
I have read the Terms and Conditions of Service on the reverse side hereof and
agree to same.
Date
Printed Name -
G�� / Please Review Terms and Conditions On Reverse Side
white - SERVPRO Yellow - Adjust/er Pink -Customer
row �';� 51 w�. at Yj� s►� �r C�,'���e_ •te
Ir; ly �� 7 �:.�. ,�.. J.
28001 0104 f'• 4iif-7r/7-000 o), X aY
IG. G7f,"7y-7- 0 U06
$J d o�
BuddinReg
g ula
Dons°truction Superyise. CS
ns and Sta
ndards
Licens °r License
67690
Expiration-
20 02010
Res
trict�on; 0 Tr# 15168
GREGG M WHIrE
4 CHArBURN RD
WINDHAM, NH 03087
COmmissione �
Board of 13mlciin
# Rtgufaimrs as,si ShUldaras
HOME IMPROVEMENT CONTRACTOR
Registration: 158271
Expiration: 12/31/2009 Tr# 262759
TYPe: Private Corporation
KEJO CORPORATION
GREGG WHITE
8 BLAKELIN STREET
LAWRENCE, MA 01841
Administrator
' }
A',parft ien
600 H fl,5 !41:9?iTfd
til 1) el y,,..Coll-'Pens alaozl Jzzstl.]",lnce Aflida ii' p,11i1 l,�.1'S/t. !t�3i, .� as ;. '�,'lf,�•1 �
�5,1�1 � .=r t. %tzft► llt l:itzzli 1 iVjil113/1 �tta.Ialaeys
Le, eflj
�C�r�aulzation:Indivi.dual):c� �D
Addll-ess. laL4,,,�i.�
� i ,/;'tit /;� 1;� : L0. W �vt t� I ti� p � � l '�
[�llo.ae t: �� 68 g — D a -f. a
°A.1'C ' iDu al." ellployel'? �Iectile
a � __-------
! p2 cTp2 Fite lJo�:
1. I x111 LI employer with 3S 1 4. ain a general
_
Ln11710- (full a11d/orpart-time).
.I contractor nild t_
havehil-ecl llle sub-ci?nlraci:n
' ❑ :_ at -,-t a sole proprietor or partner-
listed on f he attached sheet.
sillp audhave 110 employees
I7.lese Sit[ e -Coll tractoj-s have
vvcrl:in for 111.e in any capacity.
employee; arld }lave vr.lrlsers
€o vrorkers' comp. insurance
comp. ills! Irance.
recuir'cd ]
5. E] We are a corporal 101.1 alld it-:
�. U 1. am ;: 10111cowner doing all work
of peers 11;Ice esercisccl thei
II1ysOl': i`do workers' comp.
right ol'e:;r' nlptioll PC(-
Ms,Ullfculce cequired.)
c- 152. y1(4), and we haves Ill,
e.lnp.lo\ms- [No
C0111p 11151�C711Ce r '
�1'�?#:Iltltt-o.ject(1-egttil'ed): —
ti. i New collslructiotl
. �_ _] Renlodelill;.r
;� 17etnolilion
Luildiug ar.ld,ition
11'.lcctrica! repairs or additions
!'lun.lbing repairs or additions
(Alii2r
1 -111
'An; ap,licaiit tl;at chucks box #1 must also fill out the section below slrowin. their worker.;'
-—--
Nwnco�, n�is inu suhmtt this affidavit indicating, they are doing all work. and then hire out:;ide unr, r , is :tul i : u'' �i,,( ianr',1 affida ;t indicntin�
,Contracto,o that check this box must attached an additional sheet showing the name of the sib-con(i,�cior: a,,:
employes. 1,. L e sub -Contractors have employees, they must provide their wr rl<ees' comp, policy n,,,i,h, 1 such.
::r; ' i .. iher; r not those elifilies have
i,� C1 e,tC t iS JI'OVidillrF
� )1%O7'�iC1.S ClITd1j)L'd7Sdit7(J77 dl€.`-TF7"(ITIC'C---
jtp;job Site
111�Li1�l;cc `.'00il)a]7)%Na7.1)e:� V\
1Dtpii.cv t;r �: -iiis. r #:
Job Site ccov
N,—frx0��vti?�{S
a Crr,�;� of Mile ,,tirorkel's' cal:lpensation polio' declaral ion ,,lir,= !- - -
A ,
failure to secure coverage as required under Sect' 25A of iVlc iL c, ?,sha>TT111.; tiie ..,,1,. <1ir,t1J}i t tt,f! e°lTiT ;]tion date).
li.rlc 41 to S, _50 �� 15_ eau le;l;� lu t: h'-,11 r:l'crinlir;;]-1 peualti.es o.Ca
I 1, vG.UO a d/or one-year ilnpri 0ultlent, as well as t:vil perlaltit s in tl f; 11>> , .I I ;l> ,
to J2�0.(i0 a day against the violator. Tae advised that ;1 c; pi' of ibis 1 t 11enlc.n! ulll I !. '..,Ir�ic�( lu�lhe Clfl c �RDFR <lld a fn.le
llv'c�r,�-ke�1s orale DfA for insurance coverage verification.
do f..t're" C?:"r'LZ, Gi Pains ajjdpe7lalfie'S----
/ %OTiFICdtTf'II t'1't)ty•j{�? lFjj.>, �' v; 'rue and Correct
!.; cti.. se olr.ipY. .Do ldvt lvrite iTi this nr•ea, to I}e conrp/etert Iil� (�itl� r}r iF111TI ,�.i �,rF..- _ _ .---,_
-it,, Q! 1'0!1':1:
issulllg Au'rhority (c8rcle olle): --- - -- - -- ----
l...�a�:l"cl ?J.L:i1t11 ?. Bitl'ltlill I)epal"1lIiellt 3, �ltV/TUTF11 Clerk !.'.'.leets'ii'<]i l,ii° 1,+E.'t'It> 1'tt!ndTill+_11,S ;{
`J. +Mil r Inspector
Recap by Category
Items
Total Dollars
%
CONT: CLEAN APPLIANCES
68.85
0.49%
Coverage: Contents
@
100.00% =
68.85
CONT: CLEAN ELECTRIC ITEMS
92.70
0.65%
Coverage: Contents
@
100.00% =
92.70
CONT: CLEAN - GENERAL ITEMS
1,041.31
7.34%
Coverage: Contents
@
100.00% =
1,041.31
CONT: CLEAN - HARD FURNITURE
372.59
2.63%
Coverage: Contents
@
100.00% =
372.59
CLEANING
5,574.42
39.31%
Coverage: Dwelling
@
100.00% =
5,574.42
CONTENT MANIPULATION
137.40
0.97%
Coverage: Dwelling
@
100.00% =
137.40
CONT: CLEAN,UPHOLSTRY & SOFT
1,152.48
8.13%
Coverage: Contents
@
100.00% =
1,152.48
CONT: CEILING/WALL HANGINGS
0.39%
Coverage: Contents
@
100.00% =
55.68
GENERAL DEMOLITION
4,541.15
32.03%
Coverage: Dwelling
@
100.00% _
WATER EXTRACTION & REMEDIATION
1,098.54
7.75%
Coverage: Dwelling
@
100.00% =
1,098.54
Subtotal
14,135.12
99.68%
Material Sales Tax
@
5.000%
44.89
0.32%
Total
14,180.01
100.00%
ACCIACCA
3/5/2008
Page: 23