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HomeMy WebLinkAboutBuilding Permit #371 - 175 SANDRA LANE 11/9/2007 BUILDING PERMITOF AO oTH 'qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * . ^0 wy Permit N0: Date Received �-- ��SSACHUS Date Issued: d IMPORTANT:Applicant must complete all items on this page LOCATION a PROPERTY O:1lVNER-, Pant MAP NO: PARCEL ZONING D1�TR�CT IstorD�str`ict yes o ..Machine Shop Willage =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 1IVel1 F.ioodplir Wetlands Watershed Distract 1lUater/Sere _ DESCRIPTION OF WORK TO BE PREFORMED: ©fi e rr�v L1,o.� ;, g.,✓i% /=� ,-,;r Identification Please Type or Print Clearly) OWNER: Name: ti 7- 21, .S`I-e,ow Phone: Address: CONTRACTOR Name. F?honed- . >..a,- _ .., Address: p.� ;�41 Su. a y1sor s Construction License _P .. x. Exp [7a _ Lorne lmproa�ementlicense rid 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. ov Total Project Cost: $ a _I-Y15-1 FEE: $ f_ Check No.:_ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature tonrad 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS f 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 ,F12E DEP ►RTM � T . Temp:�umpster:onsite; "�resno ,Located�t 124:Main:Street=` , Fire De artmen#si naturelda#e P - , x x x 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 ❑ Notified for pickup - Date i Doc.Building Permit Revised 2007 I - 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 o 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 PP 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 ' l 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 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,S'%P t`Jxle,J 4e's tip✓ L", Address: 6R G1PMeILes i Cs 2 City/State/Zip: A,�)o 1,4 kZ�Q wag swA 019VS Phone #: 9?,P 3/V d'ys 7 Are you an employer? Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 ME] 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, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *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 than hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for 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. I do hereby certify under the paiinssaan�dpenalties ofperjury that the information provided above is true and correct. Si nature: Date: ll—c7,0 7 Phone#: 9;7 X 3 �P V-i- Official Official use only. Do not write in this area,to be completed by city or town officiaL 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 FARM FAMILY CASUALTY INSURANCE COMPANY Issuing Office - P.O. Box 656 • 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 TOPSFIELD MA 01983-1834 Name and Mailing Address of First Named Insured: STEPHEN KEISLING 68 GLEN CREST 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 03/21/2008 12:01 A.M. Standard Time Business Description: CARPENTRY TRY Total Limit of Liability Term ADDL/RTN Business Property Coverages Premium Premium 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 I 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 8P04961001 8P05140103 BP07010197 BP10040498 BF30061103 BF40380902 BF40390303 BF41090204 F199020107 Countersigned By Page: 1 of 2 Authorized Representative ANX-3190 INSUREQ COPY Processed Date: 01/31/2007 ✓`LC VO717/I7%OOZC(IB(ZGCIL O�✓!/LQ,OOp,!,�2udClCa ' Board of Building Regulations and Standards lug HOME IMPROVEMENT CONTRACTOR Registration: 101846 Exp"- 6tion: 6/29/2008 Type: Individual STEPHEN M.KEISLING Stephen Keisling 68 Glenncrest Dr. N.Andover,MA 01845 Deputy Administrator ✓fce �omvnwoxuiea�i o�✓l�Ga4aac�u[6e� Board of Building Regulations and Standards Construction Supervisor License Lice4se:,,4CS 27489 Birthdate;' 7/x6/1953 Expirati a 7/16/2009 Tr# 17077 R�strict�an 00�`# v STEPHEN M KEISLING 68 GLENCREST DR N ANDOVER,MA01845 Commissioner J 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 Q STREET (� p JOB NAME �7 J CITY,STATE and ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: r, , .........� �.± ....._.�_.o . ,,u�. � ce...-.. v ems. ��x�?� a-►�,c.> X11 t�- a. .............................. . .... ....................................................................................................... ............................................................................................................................................................................................................... .�.,�...... .�.. _..... �. - ......... ............................................................................. -),�� sya^ o0 ........................................................................../.........1111._.............................../.........._...._.D..._..-__.Q.......�.... _1._..._......111..... ........ ........._.......... .................................................................._.........................................................._.__._.............................._ .._,1 „,.. P..,i.G�o._. .r..,.,�tvY..O� �LIy-Q................................................................................................................................................................................................................................................... ...................................1.111......................................................................................................................................................................................................................_.............. ..............................._._.._._._.._._._......_._.........................................................._..._...................._. .......................... ................................................................................................................................................................................................................................................... .............................. . _......._...._._.._..._....................................................... We propOgr 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 manner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature �A� 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) Cand :Acceptance: aure of proposal —The above prices,specifications ns are satisfactory and are hereby accepted. You are authorized Signaturerk as specified. Payment will be made as outlined above. Signature ra0,�� Town NORTH of _ No.c.3 7/ l A K O dower, Mass., • COCKICMEWICK RATED �7 BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING.INSPECTOR THISCERTIFIES THAT.... ..... .......... .. ....eV4.4..#^................................................ ............. Foundation � �has permission to erect........................................ buildings on...r�.r..... ................., ........................... ........... Rough Chimne to be occupied as. ':...iilh .. .......................................................................................................... y provided that the person accepting this permit 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 ELECTRICAL INSPECTOR UNLESS CONSTRU TARTS Rough ............ .................................................................. ervice 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. Location No. Date 0 NaRT� TOWN OF NORTH ANDOVER f A + Certificate of Occupancy $ . ° ... b''•'°''���ss Building/Frame(Frame Permit Fee $ ',aNusE 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 20766 Building Inspector