HomeMy WebLinkAboutBuilding Permit #558 - 43 LISA LANE 3/6/2006 Ot NORT„,�
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: 1::53 Date Received:
Date Issued: 3-6-d G
IMPORTANT: Applicant must complete all items on this page
LOCATION 4.3 5 A F}N c
_ Print
PROPERTY OWNER /J 4) "?/4 1J LAL)/Li t d C' Z I C.
c Print
MAP NO.: '7F PARCEL: SCS ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
u New Building One family
uAddition E Two or more family C' Industrial
Alteration No. of units:
r?, Repair, replacement G Assessory Bldg E,Commercial
-� Demolition
Moving(relocation) E' Other i.=, Others:
=i Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
PO 1�lr4 sty t l A s'J72o Z 3 99°'
,IV AC
6 1111
w &LqsE� �,g��g W/�� t( A��L)44. aLi� r o�7-�
Identification Please Type ol Print Clearly)
OWNER: Name: Zitt9 2i e d E-2i c PC.- pjN Phone•9tZ i •62713JY�
Signature cc
Address: �3
L,1,S
A L�xJE J� , I�n3&0,0 C.,
CONTRACTOR Name: skjO �t�"r '�;O,t/ Phone- "2�-691-d?,())
Address: Z 1 1 h u1 ; 7T A o tj U 6 L /4
Supervisor's Construction License: b S g ZS Exp. Date: 3`a t — &i
Home Improvement License:. /O�� Exp. Date:
ARCHITECT+NGINEER Name: Phone:
Address: Ret;. No.
FEE SCHEDULE:BULDLVG PERMIT:410.00 PER$1000.00 OF THE TOTAL ESTI:111ATED COST BASED ON
.4125.00 PER S.F.
Total Project Cost :$ 13 D x10.00 =FEE:$
Check No.: , Receipt No.: /19®o f3
'TYPE OF SEWARGE DISPOSAL - Swimming Pools
Tanning/Massage Body Art
Public Sewer _
Tobacco Sales Food Packaging/Sales
Well
Permanent Dempster on Site
Private(septic tank, etc.
NOTE: Persons contracting with unregi tered contractors do not have access to the ghharantp.jhhn
Signature of Alen /Owner Signature of Contractor
.01
Plans Submitted ❑ Plans Waived ❑_ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF- U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Zonin`_ Board of Appeals: Variance, Petition No:
g Zoning Dec ision,'receipt submitted yes
Planning Board Decision: Comments.
Conservation Decision: Comments.
Water Sewer connection signature&date
Temp Duntpster on site yes
_Ino__ Fire Department signature,'date_4.
Building Permit ,approved and Issued by:
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided I
DIMENSION
N Umber of Stories: Total square feet of floor area., based on Exterior dimensions.
Total land area,sq. ft.:
NOTFIS and DATA—(For department use)
)I-040s
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
❑ Debris Removal Form
❑ Workers Comp Affidavit
❑ Photo Copy 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/Crossection/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
❑ 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
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 SERN'ICES DF.PARTME\'rMFOR,N105
Location 4V_3
v
No. .5 S Date ' °�
NORT1y TOWN OF NORTH ANDOVER
f
.. A
Certificate of Occupancy $
Building/Frame/Frame Permit Fee $
swcMust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ �
Check # 36„x'.7
f
Building Inspedler
NOKTH
TO" of : 4Andover
-
No. ��g
A
OCKdover, Mass.,
CICKEWICK
1 ��Q \V
�RATED
S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT..................t............................. .. ......... ,. Foundation
....
has permission to erect........................................ b ildings on .1/ ..... . ............?-L
..................................... Rough
to be occupied as e ... . ......... Chimney
... ................... ........... . ... .............. . ................................................................
provided that the person ecce this permit shall in eve pest conform to the terms of the application on file in Final
this office, and to the provisio of the Codes and By-Law sting 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 CONSTRUCTIO T S
Rough
.............. ... Service
........................................................ BUILING INSPEC'T'OR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous -Place on the Premises — Do Not Remove RoughFinal
No Lathing or Dry Wall To BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
.t The Commonwealth of Massachusetts
ME
aly
Department of Industrial Accidents
Office olinvestigations
Rp
' 600 Washington Street
Boston Mass. 02111
.Workers' Compensation Insurance Affidavit
NMI 1111011,11,11,
name: £ N t"�► !��E�
location: Z-1 t7 o Lo tF
city �J • 17Nd O OL's ohon # 9 72 6
❑ I am a homeowner performing all work myself.
L?I am a sole proprietor and have no one working in any capacity
❑ I am an employer providing workers' compensation for my employees working on this job.
ildd ress:
' phone#
j6iurince co.
❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
comp�n.v name..
address.
�' .phone#
insur'tnce co.�a� ? #'
a
address:
stty tihone#
insure ce co
t•t,wc�i�ddtti�nal,ee� ecessa,�ry�"', pol #
Failure()secure coverage as required under Section 25A of YIGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of5100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the its and penalties of perjury that the information provided above is true and correct.
Signature , Date G
Print name�'� N��� ..�?. ..1cE�. ..... . _. , .. .._ ._. ..._. (�
Phone# 69l� L
official use only do not write in this area to be completed by city or town official_:.:.... .
city or town: permit/license#
nBuilding Department
❑Licensing Board`
[]check if immediate response is required []Selectmen's Office
[]Health Department
contact person: phone#; Other
(revised}ins rJAl
3'nrF' i ',SzssF ;..
I e;. BOARD OF BUILDING REGULATIONS
-�icgnse: CONSTRUCTION SUPERVISOR
1 Number;"CS 058245
3irthdate 03/24/1943
i Expires =03!24/2008 Tr.no: 1-3436
Restricted'.00
KENNETH B KEENS
21 HEWITTAVE 1, f
N ANDOVER, MA 01845_='x_ I
- -Commissioner
Alie'Toomvrreaouuea�i
�.: Board of Building Regulations and Standards
i HOME IMP OVEMENT.CONTRACTOR
i..
Registrat � 408383
E per io?i 18/2006
F '
KEEN CONSTR flN9C(3 `' j
Kenneth Keen �
21 Hewitt
i ' No.Andover,MA 01845 Administrator
Mar 06 06 01:54p Kenneth R.Keen S7R-662-3231 P•2
N'-- 2627
KEEN CON5'Y UCTYON CO- PROPOSAL
• 21 HEWITT AVENUE
NORTH ANDOVER.MA 01845 U hem InWavrretam eonlraclara and subeonlraclon
Tol: (678)61111142111111 engaged In home imprarsment contracting, unless
Fax:(978)682.3231 specifically enhnpt from me wretlon by Provlsforns of
(](spiv?WA OI 0m 9s W pws,must!7e fegiSlePod tadM
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[J Mary ImpfovornON Contract Rel;iWatton,one Ashbuifen
Pow,Room 12M,Boston,MA 92l oa tit 727-B591.
Owners vita aecuets their awn eonetruction related
I-moi,-_✓l r+.dfllt yJA Permhs or deal frith unregistered contractors will
be excluded from the Guaranty Fund Provision of
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"I be made lot vAllt upon (978)691-5201 (978)682-3231 -
% ($ ) corrptodon of work undo(Mis contract. rn..s a—
Noom No agnoW"44 lar horns 1IFtPW rortfonl CmIractinp work Shap reglira a
>dodfn paymsrt(adtnnea aeposiq of more than on*thlfo of tho total rfoalracl pdee '4"'"�s•r""'""' fyy�
of Ole I",apaWnl al all dspa61%or payeterrs wrllaf III,carltraetor MUSI make.In
advance.w order m Wer othenvdso obtain dal6"of epoeial order materials and
c(I.Ortu o,witigho sm urgiiareamr. NwrTl,ir awyY.rn?wMpY.R..N. asFw"• MY"
Aoceptanoe of Proposal-1 love read bean w es at oto dDSanalm at sl atG eco oaufmcnit and acospl the pri".tpsalL,lkur.and mnagiW»stand.
1 unma2tr0 trod Upon IYgning,antproposal baov os a bnoing oROtad,You ate ourw ked to do the wort be sWXAa0.Partnetr will ore nwsae as oulYlMe* M-
You"the Buyer,may eancot tha&transaction at any lime prier to midnight of trio third busllles9 trey atict the date of
this transaction_Cancellation aWst be done in writing.
DO NOT SIGN THIS CONTRACT IF THERE;ARE ANY BLANK SPACES.
arwsr�„ y,o t 0 aew.a a*.e
- -IMPORTANT INFORMATION ON BACK W-