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HomeMy WebLinkAboutBuilding Permit #530 - 23 GILMAN LANE 2/9/2006NORTH Ot4,�•° i•�ti0 3,t r• ;r. .... • OL p TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ,SSACMUStt Permit NO: '5> 0 Date Received: Date Issued: 9 0,6 I IMPORTANT: Amlicant must complete all items on this page LOCATION_ go(rnart Print PROPERTY OWNER MAP NO.: /07 /1 PARCEL: TYPE AND USE OF BUILDING e ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building D Addition 47/Alteration - One family D Two or more family No. of units: D Industrial epair, replacement D Demolition u Assessory Bldg C Commercial D Moving (relocation) D Other D Others: D Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) ~ OWNER: Name: 1� `C'lio,r d N1 e P1 kh cJI Phone: 97 Y'(.M -,29/6 n Signature Address:. a(3 U /n, c.1 Z✓t CONTRACTOR Name: Address: Supervisor's Construction License: CS 073316 Exp. Date: 9= (,-06 Home Improvement License: /2 2,1&,V Exp. Date: �, / r - ® 7 ARCHITECTrENGINEER Name: Phone: Address:' Reg. No FEE SCHEDULE: BULDING PERMIT. $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $12.5.00 PERS.F, Total Project Cost :$/ r% SSBI 0 a xI0.00=FEE:$ Check No.: Receipt No.:�`'7 -�z -2?y Location No.Date Check # 18972 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $ r/7S"-C/� / Building Inspector TYPE OF SEWARGE DISPOSAL Public Sewer Tanning/MassageiBody Art ❑ Swimming Pools J L Welly 171 Tobacco Sales Food Packaging/ Sales Private (septic tank, etc. Permanent Dumpster on Site 1—: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner<� Lam, Signature of Contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS DATE REJECTED ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED HEALTH' ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Water & Sewer connection signature & date Comments. Temp Dumpster on site yes—no— Fire Department signature,,date Building Permit Approved and Issued by: DATE APPROVED Building Setback Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided "11VI .i'431vtl Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: Nu I GN and UA I A — ( For department use) I Doc: INSPECTIONAL SERVICL S UEPAR I y1f:N'faiPl OIiM05 .reated.INIC J.m.20N, Building Department The following lis 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 ❑ Debris Removal Form ❑ Workers Comp Affidavit ❑ PhotoCopy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Form U ❑ Surveyed Plot Plan ❑ Debris',Removal Form ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/C rossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application - - - - -- ❑- Form. U, j ❑ 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 i 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:BPFOR\105 11 t a •co a CDe a .; O C h O V w° U z a c w° U w W � CIO W � W U a W CD o 11 t C C O•— y p O CO2 O O 'F m m = O � �3 'O O O ca OL 0a Q� Q OCcC �ZCD CL V y R i. C CL■ C y 0 uj U) 19 W 0 W U) •co CDe .; O C h O C O • p, C LO to r.. c O � CD .E f r ra N w IK =1E E 0 3 y z N O� r N C �.0 m s N N 00+ W a �co CLmm omc =o .vc O a Vs �O • : mor CSO m 0 Z CO CL. co CC Q m N m CW CD 31 ~ 0 r+ y 010- N m COD C M �m .�+ CM LAJ �W o 5 CIO n o� H 0 a...m� C C O•— y p O CO2 O O 'F m m = O � �3 'O O O ca OL 0a Q� Q OCcC �ZCD CL V y R i. C CL■ C y 0 uj U) 19 W 0 W U) The Commonwealth of Massachusetts Department of Industrial Accidents [ Office of Investigations Ei 600 Washington Street " Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Na' me(BLisiness/c)rganizntloll/II1lllVl(lual): q Address: / 6 r Fri' h 0 6. r4o/r" /0, lJ © 3 O 6--7 City/State/Zip: Phone #: (a o3 51,312 - 5�%%O Are you an employer? Check the appropriate box: 1.21 am a employer with A— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ i am a sole proprietor or partner- listed on the attached sheet. , ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ i am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. eRernodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ 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 most submit a new affidavit indicating such. .Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and (heir workers comp. policy information. I am irn employer that is providing workers' compensation insurance for my employees. Below A the policy and job site information. i Insurance Company Name:�r� i (L,&C A L 61 r �1 Policy # or Self -ins. Lic. #: WC oy KI 3 13 S')o 0 Expiration Date: /Z -1 k2 06 '3 [' h -/t.. City/State/Zip: Job Site Address: �v /r�e.n.—��e�1%Gt 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 pains and penalties of'perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by ei(v or town njftcial. 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 i Contact Person: Phone #: ✓!ze �omvnxanuse �✓a%uaelt Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 129364 Expiration: 8/18/2007 Type: DBA K • A. T Constuction Scott Lapointe 9 GRIFFIN RD. _ Londonderry, NH 03053 Administrator EGBOARD OF BUILD NG ION SUPERVISOR License: CONSTRUCT G Number: CS. 073316 Birthdate: 0710611965 26112 Expires; 0710612006 Tr. no: Restricted: 00 SCOTT J 9 GRIFFIN RD NH 03053 Commissioner # c, LONDONDERRY _ 1 acoRoCERTIFICATE OF LIABILITY INSURANCE OP ID DATE (MM/DD/YYYY) f PRODUCER Santo Insurance - Salem 224 Main Street Salem NH 03079 KATCO-1 02/07/06 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone:603-890-6439 Fax:603-890-6521 INSURED INSURERS AFFORDING COVERAGE NAIC # INSURER A: American International Group K A T Construction, DBA 9 Griffin Road Londonderry NH 03053 INSURER B: Nationwide.Companies INSURER C: INSURER D: COVERAGES INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRINSRC TYPE OF INSURANCE POLICY NUMBER GENERAL LIABILITY POLICY EFFECTIVE POLICY EXPIRATION DATE MM/DD/YY DATE MM/DD/YY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR PREMISES (Ea occurence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO_ JECT LOC GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG $ AUTOMOBILE LIABILITY SINGLE LIMIT $ 500 (Ea accident) , 000 B ANY AUTOCOMBINED 51BA1151833001 ALL OWNED AUTOS X BODILY INJURY (Per person) $ SCHEDULED AUTOS X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY (Per (Per accitlent) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLALIABILITY OCCUR a CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?, WC6932743 12/28/05 12/28/06 X TORY LIMITS ER E.L. EACH ACCIDENT $ 100000 E.L. DISEASE - EA EMPLOYEE $ 100000 If yes, describe under SPECIAL PROVISIONS below OTHER E.L. DISEASE - POLICY LIMIT $500000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER ,. TOWNNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Town of North Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 400 Osgood St REPRESENTATIVES. North Andover MA '01845 AUTHORIZED REPRESENTATIVE eCnan -34 /,3nne moi James A Santo --' UACORD CORPORATION 1988 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at:is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit (Location of Facility) ffm Si afore of Permit Applicant ---7-,96 Date T:# -uoatpuat I*— — aq of vmow lou s[ g -ugmap aye 900Z/9/Z=Pa4u�d /"fJ $3a0a1aw y�3i ;o aauP�eadde V--'gay1;o uo sdiaio# 9007J6/I =P !�Q L,rfl oz oz 2u.—eiP -u =aioN 7 'THIS A.ti�� t ,,j,a- ,r led � 'jw atm D.k aid I I 4 ftl ` 'Y1 ulessdh,Jim ifix; wmtuww aw ihc .foltOW I O the W01'k Ofid worm all zhe t motor shall fish l � UAW fe$ � oilv rawiriMAW wait tb be pOr&rA*aOjjpTOpetat 23 ijuU it. N. AWuvu Y A�Wit 21, Time qL`coInpimIw .{ ba[j V.w'* wl LVbe i't t%b7! it11 iA'iFrOk *�� iriiiti:''Z�Gt'uv L�s35X b33t�J5 Liii W. jy �ipf �,Irn d`, Oq 16 TiM ig of thc ONYM6i iii.+ i'AOWift of cfi; WWW bil tw. m imv WdAeR � MM, the - 'SM Witt _tA�i� �::��e,, 3 tthecdoumt law is i t. a :E�£S�i Vw4t.�i �J't° ii pay the �LrO`MMO � of ift mri+#fii si,Ad '1 4 /���! �►yy,'yy��A . �yp�1��1��. ��1¢}d� ��t((}�6t��a��jy��(�j'}����yy}�i�di ��j���Fy#i6tt¢+'� y�yS�3�bi�s'vs 4g Y • 1Lr��iL`ubjed 10 IWML'iSJm id d+r`iii/E�t,7 1iLl7ii4�s 4 \illi+v Y #•• F Aftiolc 4. PWWW 3 poyajvlt Smnof cabi J viii mass i rk .... ...... r ..........: 5 sun mid �`: �'yy�r/.-{y�� q�/'F .'`m';my: )7 p� {�¢ tii:t.::rruits-icc..ti: Ya'ymnt. 6 on-aavletion o olk... ... i.. ...... ......... Any 'A teratiOn Of &Viattft M)ffl the AbrM SOWIfitittiM, inotuditig bU€ W ItOWto MY squeh,aiMMIoNM &Vi : hg volving -a wh ionat muff WI aaiw tabor wsts, witf be u� e':�i gdy..w1ma dudll OW -1, tai me, Sipi by t��r Atlitut, ti ii' t ri is qtly Owe-* Agits�-ra ngy of &v1atiok-the afttionai ChW Vii be added to the cu mc"&, &R 40M if Oayment is not mWe wi - &L,* . tommuff May SOPMwork on t� job ul swh tim -ft�i mos4ue w w bma&, A. �1 t to As"YMM fot a riud m expel settys fim t4 � to of the ymm shall i mad a. ii bteUh of T's �. - afttm the 10110wifig Wit" m'siow up1y� . Arlwmk AA be OmO� M4 WO&WWRO M -vu --WA' aRa Ift amu u wiltIl i 2. T 6e. cun mcqur- Cit i Wtw.�h speriof for tune i upwwwalw, a 4kw6pli'm of .t_I w mterWto te used and the equi ot. to USed or jj�P?Okt gkj the apgdAf-W fi t -o0. Acct dW Wti& 4, for may at k d , rw'or.etm subcon :mors to peftrm work vinare, wracwr s 'ail W-IIV pay, subccm=bx and fft R1i iMMM TeMaM emminmbio for tho pr-cr wwlofton of this omtrt., i commis i,� l i ga hof WOW*. 6. con ewt s at bis umme obtain W1 permim neomsary fim ft wwk to be.wft. WM' 7. oftfw. ftv" 8grAftti w teowiw 01debtis'aw to " dafi 9, Ila ih� eve -fit comm- - She`d f`j �g to pay gnfy ()I hwaffmcla PUYIMM (ftx &Y ceauh' wje&wf twomh PuAing payment or resolution of any q.C(yr&Wt,Or ill not �* jjatgj,- &tly &Ilky &t to &P-MgMneeg *OTW itS Mfti , for inellOng q-q*es., ouaml aftoaflubft 14). Co www wanw-ts - All w4T- k:f4Wa wfit d12 -Mon" folflowkig OMPMM be Any work M -tinned hY MIYSU b- W-tm-OWS nOt b-l:TCd hY K -A -T COnSMCt'On VV fl not Ca� R, . -tk-T r-OMIMIclif's by k II.T Suw h64ft#gMr all item that me to bc iodfoyfttilem, And IWO 444M fife to be OW RdIg. Tile coitmctor rewmts that fi 1w pwvtdltiswgwwawwS dui fbM tot the mon tat tne parimmawe'Of me wom, or tin Swbi wngw Mr, rageement, in a comms or toMpRI&S laWrwfy uuWOW&W to do 8qWred ' ' ' by Ous -- busk"- in- he SMW off sw1ust .SuL:hjnstu=,x as w -W, pmtwt K -A -T "iW"4wit MIA fl* I Owneft Of 01 -* lito *M cwMS for loss OT iwwy, V6011 Mi ght an Sept outof 'Ot rt,41#t from thA. coftwwt I g opemorbe 1) I& ut&,t tMs pwjw7L w1wther Suell opuow Y dw cullimow"If Ofby ifts Siftolumewn. AM, Wie. 7, Stan 4Wa R- U-1 4wfulAOUM daw- Thc "I Stffit GaW WtdCOMVleti0ft MOM MY VAT—Yr UW Lu ContMI. Stleh aS permits tWjjtq igg jfWjej-AtM -We"Cff, WL Ori WaWifti&5 whWided- WWwfious cm. Lrpons i&m:l p gt- t ape'w pay for the, above stated Ayo& fm is to be. peffoMW wt&r tuO within- C;"Ow4-r algautute. FROM :DERRY KITCHEN AND HATH FAX NO. :603 437 5551 Jan. 27 2006 11:27AM P1 A�n'. oc�w�,m J AU Am=m iom ,mss Aeaippeoo� f;� �e j d V=Ukadm a job:ee and � �i� ar.dieiom. Tbw is as crhpsd demise sod .nok sur bo nis»ed ON owkd safes, fico las haps mid —job oder Nioed. I