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Home My WebLink AboutBuilding Permit #323 - 42 ROYAL CREST DRIVE 10/29/2007 Ff BUILDING PERMIT 0.1 "°oT" A TOWN OF NORTH ANDOVER c? '`y 6,6 00^, APPLICATION FOR PLAN EXAMINATION 7D �J /d Permit NO: G Date Received 4f- f! Y Ky SSACHUS� Date Issued: ' IMPORTANT:Applicant must complete all items on this page Af '" t., LOCATION ` PROP,,ERTY GINNER t �_ Pnnt .. Pnnt? x MAP NO. PARCI=L: ZONING DISTRICT :_ :Historic District' yes no Machine Shop Village ryes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family industrial j Alteration No. of units: Commercial 'Repair, replacement Assessory Bldg Others: Demolition Other pt'ic, (Nell "` Floadplain Wetlan"tls Watershed District UVater/Sewer - DESCRIPTION OF WORK TO BE PREFORMED: to ov VC) �` Identification Please Type or Print Clearly) OWNER: Name: �J� - So v Phone: Address: CONTRACTOR Narne . � ' . P hone: (' Address: Supervisor's Construction license r Exp Date. Norrie Improvement License Exp Date:. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS BASED ON$125.00 PER S.F. Total Project Cost: $ � OL 6 QQU,C�b FEE: $ 1 � Check No.: ` Receipt No.: '� NOTE: Persons contracting i h unr ered contractors do not have access to the guaran and Signature of Agent/Owner Signaturewof contraCOW i i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody 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 DA EJECTED DATEAPPROVED CONSERVATION �%1 COMMENTS DATE REJECTED DATE ROVED HEALTH COMMENTS i 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 i ! I FIRE.DEPARTMENT =Temp Dum,pster onsite yes no Located at'124:Main Street f ire.-Depa:rtment signature%date COMMENTS i 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 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 ❑ 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 t itist be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 NORTH - Town of : Andover No. a'3 _ Pop LAK dower, Mass.,�� • -d COCMICMEWICK ADRA-rED pP�\ �C `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT 3 RoI A... .R-•C..1...... '..�'` c.�. ...... ........................... ... •................. Foundation has permission to erect........................................ buildings on ....... 3.......Z49 .k9'�...G�!�.0.r.... Rough 11 • to be occupied asfli�oi J .�:*A.0......�. ( �O 1� — N O Chimney . P......... ...... ... a� provided that the peccepting this permit shall in eve respect form to the terms o the application 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 CONSTR S ARTS Rough . ... ...... .............. .. .... Service 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. ACURDCERTIFICATE OF LIABILITY INSURANCE TREALLN aaTEtlnau°0O'rr7 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER I)F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kittredge Insurance Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 155B Otis St. , P,0, Box 1129 ALTER THE COVERAGE AFFQRDEp DY THE POLICIES BELOW, Northboro MA 01532 I Phone:548-393-7749 Fax:508-393-6983 INSURERS AFFORDING COVERAOIr NAIL# IINSURED IINNSURCRA: NAUTILUS ,INSURANCE COMPANY INSURER 6: Hanover InSUrGroup 22292 Tree ine Construction Trio, INSURER C: tJrooriaan Rama:usnranaa co. —_ 1.30 Wosthoro Street INStJRERO: Millbury MA 01527 - INSURER E--� COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN!S$UGO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTIMTHSYANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY ONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES OESCRII;EO HEREIN IS SUBJECT TC ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF$UCH POLICGIR.A('CGkEOATE LIMITS WOWN MAY HAVE BEEN REDUCED BY*A10CLAIMS. POL LTR NSR YYP1 F IH mHCE POLICY NUMBER DATE -FFEGYYE DATE( M LIMITS aEnSruLL.lmaLM EACH OCCURRENCE _ 41000000 A X 00MMERCIALGENERALUABIL1 Y NC1559999 04/21/07 04/21/08 rFREMlsfistEaoo�lreae i$100000 CLAIMS MADE uOCCURFXI i I ED EXP(Any ex Person) $5000 jERS SOMAL&ADVIN:uRv $1000000 . j !GENERALGREW15 s2000000 6EN'L A3GREGATE LIMIT APPLIES PER:I I PRO- I I PRODUCTS.COMPf(+PAGO $2000000 POLICY J&CT _ , LOC _ AUTOMOOLE LIA61LIYY COMBINED SINGLE!LIMIT $ ANY AUTO AFN838702401 07/27/07 07/27/08 1 (Ea sooldem) $1000000 ALL OWNED AUTOS X SCHEDULEDA�UTOS 1 BergNJ1jRV S I I (Peerrprrwn) X HIRED AUTOS i YX NON-OWNED AUTOS (Per W-adwt, �s PROPERTYDAMAGE S IPBI ecadent; GARAGE LIABILITY AUTO ONLY.EA ACCIDENT g ANY AUT 0 ER THAN EAACC $ AUTO ONLY: AGO 3 EJCCESSUMBRELULLIABIL!TY I I I cACr OCCURRENCE ffi —� OCCUR ^7 CLAIMS MADE i AGC,REG4TE S OEOUCTiSLE RETENTION S S WORKERS COMPENSATION AND rMPLOYERS'LIABIUITY RIES YO 16irr fiR G ANY PROPMEYORMARTNEXECUTIVE WC8579703 12/24/06 12/24/07 E.L EACH ACCIDENT $10:00000 OFFICERMIE11tBEREXCLUD6p? E.L.OI9EASE-EAEMI'LOYE S 1000Q0.0 It` PyyEC{.as, le oldie! M �� SAL PROVISIONS belvw „•/ E.L DISEASE-FOLIC"LIMIT $1000QQQ OTHER DESCR!PTION OF OPERAYION$/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT,'SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION FNOANDOV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Bfi CANCELLED BEFOR$YHE EXPIRATION bATB THEREOF,THE ISAVINO INSURER WILL ENDmAVOR TO MAIL 2 0_ DAYS WRriTEN NOTICE TO THE CERTIFICATE HOLDER NAMED T01I5 WT.BUT FAILURE TO DO So SHALL Town of Ngrth Andover IMPOSE NO OBLIGATION OR UABILITY OF ANY KIND UPON THE INSURER,11$AGENTS OR REPR TATIVES. North Andover MA AUTHIMPED REPRESEH TIVE '— ACORO 25(2001108) c�ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the fssuing Insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001106) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 y � M yv v www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers Applicant Information _ Please Print LeLyibly Name(Business/Organization/Individual): 'e-) Address: J City/State/Zip: ��/l ` �� t.5 Phone.#: 3K,- `761—2116 Are.you an employer?Check the appropriate tion: 4. Type of project(required); 1.El"I am a employer with L.�-�% ' ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These.sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp,insurance comp.insurance.$ 9• ❑Building addition , required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑dumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.E]Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 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 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ;'�� e<<,��=—y'r I S U AVN Policy#or Self-ins. Lic.#: ;Vie. 'j '720-3 03 Expiration Date: ' Job Site Address: y �cD City/State/Zip: Attach a copy of the workers' compensation—policy declaration page(showing the policy number and expiration date). ). Failure to secure coverage' a as required under er 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signafore:. J Date: Phone#' Official.use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board'of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Otheh Contact person: Phone#: ✓fia L69rLIrr07r rr ',� �xJrai^�iaa s BOARD OF 13UILD1IJG REGUTATlb N . lz License: CONSTRUCTION SUPERVISOR Number CS 077853 . - Birthdate:11/1811957 'Expires: 11118/2007 Tr.no: 9499.0 Restricted: 0.0 KENNETH E SALSMAN 2 ADAMS STREET, WESTBORO, MA 01581:. Commissioner t- �T ✓fie rra�rv»eo�eraea a ✓ ¢c""$"a Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 149914 Expiration:_ 2!2112008 `-Type: Private Corporation TREELINE CONSTRUCTION,INC. KENNETH SALSMAN 130 WESTBOROUGH STREET ��., �z,,✓ MILLBURY,MA 01527 Administrator Location T No. Date NORTH - TOWN OF NORTH ANDOVER 3? O L Certificate of Occupancy $ / E Building/Frame Permit Fee $ s�CHus j Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f Check #� 207 ; Building Inspector