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HomeMy WebLinkAboutBuilding Permit #836 - 28 HOLBROOK ROAD 6/25/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ?_7 Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Addition- Alteration One family Two or more family - No. of units: Industrial Commercial Others: Repair, replacement Demolition rxWr-a-- Sepfic UUell ,y °.; VWaterlSewer DESCRIPTION Assessory Bldg Other tom` Flood la�r� :Ak= . etland „057VI'/affflVstrict OF WORK TO BE PREFORMED: f - +� [.. %ems D mac- I� w c,�do wS e<,• e7' � tµf9- � �P y /�� /-.fie e �.c � N %� Identification P/lea_se T�Pe or Print Clearly) OWNER: Name: M R&Ruse A.)�i9N eA_Q AddrP-,G- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. c90 _ Total Project Cost: $ FEE: Check No.: ��% �� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have -access to thg guaranty fund Plans Submitted 1. 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 i COMMENTS a- Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 1 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street _ FIRE DEPARTMENT Tem Dumpster onsite `yesa __ Located at 12`4�IVIain Streets -� } +*� - - Fik -R epartment signature/t ��� �• s coy ''� -- ,'k`-'.�'"'�� '�F 3" -s�, "� ?r'� � -�:x�>-�- �"`..'K,.t, r"�� ��' }r, d r'�.T�� ^r,y 'd#.._•d f '1a.e'ak� e ' rte` �+a' 3 �S?`,'.ra.* y t,w° `S'. 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 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 _ ❑ 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 a 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 -2. Location -00 Z( " No. F56 — Date jORT" TOWN OF NORTH ANDOVER 4, Certificate of Occupancy $ Building/Frame Permit Fee $ CH Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Z�v_ Building Inspector U x A u u O w v cn o A 10 p w O c2 .� U G V. o n2 x w W a wa. w U) x o � w co x W .. w A w v � m z � cq Q 0 O cn 9 :.CIS CO C ;;C O O :.0 H p C � p i CJ V CLC A p = O O � m a F -- y W LL H Lr W C.3 _o L-- E� Ice .b CO C • ; m KI: I: : _... d N � o m ' v 0 Co (coy O m m b b GO LT m J a0+ m •O+ m a F -- y W LL H Lr W C.3 _o L-- L - CD L CD N c O in m Lr C" C m O cm C N m t O Z 0 co F. ) f v J z Oz �0 r 4 u c/) c/) / O ua U c/) F�=-1 O :W r/ i T 0 2 O O L 0 Z� C. O y � C I G3cmC C CA Q � (D H O O CO m L- H0 CD C CD L- M env o a CL ra CO2 o c cv ca CO 4-0 CO2 C z ca co 0 CL v vs � C c 0. COD cl V/ W W 12 W U) .Nc N m o.8� N m � CDC, Q Co (coy O m•Z C:220 � C m LO Z : h m C a0+ m •O+ m O'Or .y ==e m W •n= C E m N 0, • -o+ v v b Ci m .i Di IL R i y•O Z $ O..- m L - CD L CD N c O in m Lr C" C m O cm C N m t O Z 0 co F. ) f v J z Oz �0 r 4 u c/) c/) / O ua U c/) F�=-1 O :W r/ i T 0 2 O O L 0 Z� C. O y � C I G3cmC C CA Q � (D H O O CO m L- H0 CD C CD L- M env o a CL ra CO2 o c cv ca CO 4-0 CO2 C z ca co 0 CL v vs � C c 0. COD cl V/ W W 12 W U) �1ze �omz�n�nw�ea/d'.o�✓�iaaaoafivaek� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:. 101846 Expiration: 6/29/2010 Tr# 268336: Type: Individual STEPHEN M. KEISLI_NG, . Stephen Keisling 68 Glenncrest Dr. . - N. Andover, MA 01845 AdministratoY Massachusetts - Department of Public Safety Board of Buildino Re-ulations and Standards Construction Supervisor License License: CS 27489 Restricted to: 00 STEPHEN M KEISLING 9 9TH STREET WEST SALISBURY, MA 01952 Expiration: 7/162011 ('unlilt issipile r Tr#: 18542 issuing urrice - r.u. WX bob • Aioany, New York 12201-0656 CONTRACTORS ADVANTAGE B0Poo091 6905 ® 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 Policy Period: From 03/21/2010 To 03/21/2011 Business Description: CARPENTRY Business Property Coverages Buildings Business Personal Property Business Income and Extra Expense Other Endorsements Transaction Effective: 03/21/2010 12:01 A.M. Standard Time Total Limit of Liability Term ADDL/RTN Premium Premium $5,000 $22.00 Actual Loss Sustained Not Exceeding 12 Months 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 Medical Expenses Fire Legal Liability Other Endorsements , 000 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 AGGREGATE FOR PRODUCTS/COMPLETED OPERATIONS HAZARD $5,000 EACH PERSON $50,000 ANY ONE FIRE OR EXPLOSION SEE SCHEDULE POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM The Declarations, Schedules and These Forms and Endorsements Make Up Your CompIGLU r,,,,;,y: BP00021299 BP00060197 BP00090197 BP04170196 BP04190689 BP04961001 BPO5140103 OP07010197 BP10040498 BF30061103 SF40380902 BF40390303 BF41090204 BF41321008 F199020108 Countersigned By Page: 1 of 2 Authorized Representative ANX-3190 INSURED COPY Processed Date: 02/15/2010 The Commonwe¢Ith of Massachusetts Department o f .£ndustrial Accidents Office of Investigations 600 Wash:l beton Street Boston, M4 02111 Workers' Compensation Insurance Affidavit gaUa aplicant Information s/Contractors/Electricians/Plumbers Name (Business/Organization/Fndividual): Address: 2-4 J`1—,e-,-&7-- city/state/zip: %~i2PP/ City/State/Zip: S* Ccs 6 vey MA Phone #: ?7a' A6 -re .you an employer? Check the appropriate boa: 1. I am a employer with 4. ❑ I am a general employees (full and/or part-umej. * [ I am contractor and I have hired the sub -contractors • a sole proprietor or partner_ ship and have no employees listed on the attached sheet t These subcontractors have working for me in any capacity. [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a' corporation ;. ❑required.] I am a homeowner doing all and its officers have exercised their work myself. [No workers' comp. right of exemption per MGL C. 152, § I (4), and insurance required.] t we have no employees. (No workers' comp. insui-an 31 Y-- PY,T ? Type of project (required): 6. ❑ New construction ?• ❑ Remodeling S. ❑ Demolition 9. ❑ Biuldmg addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.[] Roof repairs ce required.] 13 0 Other ay zPPhcant that chis box.:al iris sr �o BE, eSt these I30IDCOWI2CIS WilO SllOIDIt this - --tiom be:OR! 8.^.CY.^.^.a '�-"•-=:r wcrti, y' coln,— 1:e :' affidavit 2IId1:2f7II� tile• 2: dorsi aL R'GI'}i anQ Y- .--Y..-C� •.' :.':.:a::atl�:y +Contractors that rhec), this bo.*. €� ire outside oo*2et :•�,. submit a new amdavit indi ating such. attached an additional sheet showing the name of the sub contractors and their workrrc' -- - �- - - -�.� •�« ��,s�sr yet nal� U provuting workers' compensadon insurance or m employ information. f Y employees. Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy dealara>1on pave (showing the policynumber. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to thimposition of and expiration date). 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 criminal penalties of a Of up to $250.00 a day against the violator. Be advised that a copy of this statem Investigations of the DIA for insurance coverage verification ent maybe forwarded to the Office of I do hereby certify and the p ' and penalties o er .fP iuU that the information provided above is'true and correct Signature: Date:_.. 4.117 Phone # 9,7 P 3 /. PY�§-7 Official use only. Do not write in this area, to be completed by city or town o fjiciaL City or Town - OJ # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. PlumuiaR 6. Other b inspector Contact Person: uhone #: Information an 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 tine legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association 01x7 other legal entity, employing employees. However the owner of a dwelling house having not more than three aparttrlents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maim(' mance, 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 bean employer." MGL chapter 152, §25C(6) also states that "every state or 10--ocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to c onstruct 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 of public work um -til 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 completeiy, 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' comp ensation 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 siure to si„� and date the affidavit. The affidavit should be returned to the vitt' Or io" rt that elle ait.'uliCaur3L for the per or lime rise in being requesF.ed, not the Depa' � e:rt. of Industrial Accidents. Should you have. any questions regarding the ;a;,, ar i you r�^i,:., d to oc-;ain a workers' ure compensation policy, please call the Department at the .uumbe:r 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#'Vestigations 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 officiaEY 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 perxnits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pert 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 oflnvestigations would Bice 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. _... The Commonwealth Of Massachusetts Department of Industrial Accidents Office of lnvestiaatiaas 600 Washington Street Boston, MA 027111. Tel. 4 617-72.7-4900 ext 406 or 1-977-MASS_A.FE Revised 5-26-05 Pax r 61-72.7-%749 UrVrIA7.mass.. gov/dia STEPHEN Me KEISLING Building & Remodeling 9 9th Street West Salisbury, MASSACHUSETTS 01952 MA Lic. 027489 Home Imp. 101846 Phone (978) 682.2072 a (978) 465-4712 PROPOSAL SUBMITTED TO PHONE DATE STREET J /�®® /l JOB NAME ` �C�7?L.�(m'Ja�'t,. �> CITY, STATE and ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for. P �r--- �,. r,, 0--'o '01 on 1712 -,.J --a— ;j a— _ 4, 4, We propDSP 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 guaranteedbe as specified. All work to completed a workmanlike manner according to standard practices. practices. Arty alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry tire, 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 Atr.eptunlrle Of Proposal— The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specifed. Payment will be made as outlined above. -'©o Date of Acceptance: Signature days.