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Home My WebLink AboutBuilding Permit #577 - 24 TYLER ROAD 3/29/2010 BUILDING PERMIT 01* pORTF� "ti TOWN OF NORTH ANDOVER 3� ' `'' `-�`'° �� APPLICATION FOR PLAN EXAMINATION 7° Permit NO: Date Received 74��RAreo►� c5 11 A �SSACHU`��( Date Issued:e!J LM IMPORTANT:Applicant must complete all items on this page LOCATION 1 rint PROPERTY OWNER /+'1 t a 4-- Cr-i.v,4 PA Print MAP 210 12 2" -PARCEL ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE j Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial ai replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: 6-»A -- M I,ems A-901AN0 Phone: Address: C T ZC R-o14� 7i CONTRACTOR Name: Phone: 3'Y- 'S's7 Address: 91 �1 ;fi? Supervisor's Construction License: A? (/Pf Exp. Date: 7-/6-2-011 Home Improvement License: Exp. Date: 6- -2014 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. aCJ Total Project Cost: $ 791-i of FEE: $ h . y Check No.. ! Receipt No.: NOTE: Persons c ntracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor )4¢441 '�j 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 k 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 S. 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 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 2010 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 r ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit k ❑ 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:Building Permit Revised 2008 Location vA No. ' Date • �d NORTH TOWN OF NORTH ANDOVER AL f 9 Certificate of Occupancy $ ��s' •Eta Building/Frame Permit Fee $ ACMus . Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22UtJ3 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4 02111 www.m.ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibl Name (Business/Organization/Individual): �fPk-- P I L.N Address: 9 9 7J %w�C-7— City/State/Zip: /City/State/ZiP: 9w,q Z�S 6 c a /h/-� Phone#: G)],p 31y_ oplr7 Are you an employer?Check the appropriate boa: I•❑ I am a employer with 4. ❑ I am a general contr7sheetl Type of project(required): employees(full and/or part-time).* have hired the sub-c 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached ? ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance. 8. ❑Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition 3.❑ required.] officers have exercised their 10•❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself. [No workers'comp. c. 1521 4 ( ),and we have no 12.[]Roof repairs insurance required. employees. t [No workers POMP.insurance re13.❑ Other *`-nv ai-Plicant that checks box 4l must also lu out the secftoa beiov:shox ins*:heir v required.] Homeowners who submit this affidavit indicating the}'are dein all wort-and oricers con1P--Z" poli--3,:.,r t " Bien hire outside contractors must.submit a new affidavit indicating such. +Contractors that check this box must attached an additions]sheet showing the name of the sub-contractors and their workers,camp Policy information, I o 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: Sob Site Address: Attach a copy of the workers'compensation policy declaration pashowCity/State/Zip: ge( ing 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 end 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 cerlifjy under the pains andpenalties ofperjury that the information provided above is true and correct Si store: Date:._ —29— oio Phone#: 7 p /S!?Sr S-7 [[I-Bo�ard ial use only. Do not write in this area, to be completed by city or town official or Town• Permit/License# g Authority(circle one): of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector erct Person: Phone# Information aa d 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 apartments 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 shall 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 coxnpliance 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 of public 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 returned to the city or town that the applicadon 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 in (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 bum 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 andfax.number The Commonwealth of Massa&usetts Department of Industrial Accidents Of-lice of Investebafions 600 Washington Street Boston,MA 021.11 Tel. # 617-727-4900 ext 406 or 1-8 77-MASSAFE Revised 5-26-05 Fax #617-727-7749 mrvrm,.mass_aov/dia NORTH o Of t _ 4Andover s No. H .. E dover, Mass., cOCKIC KE WICK �� '7d ADRATED 7`s BOARD OF HEALTH PERMIT T D Food/Kitchen ` Septic System BUILDING INSPECTOR R41-t-A-0.... THIS CERTIFIES THAT..... ir'.!'h�a.l�.O............ Foundation has permission to erect........ ....... buildings on ..T.J. ... 0• •.••••-•..424................ Rough to be occupied as 5 dew. C10^014,T7...... ter ' .............. Chimney appI'katProvided that the person accepting this P shall in every respect conform to ion on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of C1 Buildings in the Town of North Andover. PLUMBING INSPECTOR w VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough e m Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STARTS Rough .................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Oca4py Building GAS INSPECTOR Rough Display- in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner i Street No. SEE REVERSE SIDE smoke Det. Page No. of Pages Pr o osal STEPHEN . KEISLIMG wMing 8, Ro. esi� °rte tt Salisbury, MASSACHUSMS 01952 Phone(978) 6 -2072 C�.`(378) 46 4712 PROPOSAL SUBMITTED TO , PHONE lDA STREET JOB NA E k C_.-' CITY.STATE and ZIP BODE } JOB LOCATJ ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for. Upis - �'-'.� .!✓ �-`' w.... �'s� f!�- .ate, �::.d:.y�g�c..'�.-' ...:. 1 ?�;�I �.�.aK't'ii�z �,. >(i.� f� �-P.se. �..,7�� 'i� �.i,-3�¢n.•`�G d't� j f„t, �'j 4 ��( ; � de- 14 Fie. ` aUTA —£ly•, �Fie�L J r�.��^ � � �!Ms��p�f 7.3S7 C 3 We FropoSt hereby to furnish material and labor-complete in accordance with.above specifications, for the sum of: Payment to be made as follows: dollars($ -` 10 All All material is guaranteed to be as specified.All work e be completed in a workmanlike { �_ manner according to standard practices.Any alteration or deviation from above-specifications Authorized invofving extra costs will be executed only upon written orders,and-xrill become an extra - Signature �'a� �� charge over and above the:estimate. All agreements contingent upon stnkes„accidents >!_ or delays beyond:our controL Owner to cant'fire,tomado:and other necessary uisurar�ce:' Note:This-proposal may be r Our.workers are fully covered by Workman's Compensation Insurance. Withdrawn by:tis if not.accepted within days.- . Arroneptaure of Proposal —The above prices,specifications and conditi s.are satisfactory and are hereby accepted. You are authorized': Signa e to do the-work as specified. Payment will be made as outlined above. Date of Acceptancev /y /0 Signature 6T Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR' . Registration: 101846 Expiration:-W29/2010 Tr# 268336 Type: Individual STEPHEN M.KEISLING Stephen Keisling 68 Glennerest Dr. N.Andover,MA 01845 Adntinistratoir �Niass<tchtisetts- Department of Puhlic Safer% Board of Building Rc!�ulations and Standards Construction Supervisor License License: CS 27489 Restricted to: 00 STEPHEN M KEISLING I 9 9TH STREET WEST SALISBURY, MA 019528 J Expiration: 7/16/2011 (ummi..iuner Tr#: 18542 FARM FAMILY CASUALTY INSURANCE COMPANY Issuing Office - P.O. Box 656 • Albany, New York 12201-0656 CONTRACTORS ADVANTAGE BOP000916905 9p, DECLARATION PAGE Policy Number: 2005XO431 Agent No: 3485 Agent Phone: 978-887-8304 UGONE JOHNSON INSURANCE AGENCY , IN 7 GROVE ST STE 201 Name and Mailing Address of First Named Insured: TOPSFIELD MA 01983-1862 STEPHEN KEISLING 9 9TH ST W SALISBURY MA 01952-1702 The Insured is: INDIVIDUAL Transaction Type: RENEWAL Transaction Effective: 03/21/2010 Policy Period: From 03/21/2010 To 03/21/2011 12:01 A.M. Standard Time Business Description: CARPENTRY Total Limit of Liability Term ADDL/RTN Business Property Coverages Premium Premium Buildings Business Personal Property $5,000 $22.00 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 POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM The Declarations, Schedules and These Forms and Endorsements Make Up Your CompicLo F„,,;,y: SP00021299 BP00060197 BP00090197 8P04170196 BP04190689 BP04961001 8POS140103 BP07010197 BP10040498 BF30061103 BF40380902 BF40390303 BF41090204 BF41321008 F199020108 Countersigned By Page: 1 of 2 Authorized Representative ANN-3190 INSURED COPY Processed Date: 02/15/2010