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HomeMy WebLinkAboutBuilding Permit #353-14 - 55 STONECLEAVE ROAD 10/15/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: obs- I PORTANT:Applicant must complete all items on this page 4 PROPER,TrYFOVVNER�__ 'd 4A__� _vbo ,eretL¢- _ _ OO�Year©IdtSt�uctUre= e.s n MAPNO :. . � PARCEL:p ZONINGiDIS#TRICT _�� Hlstorlc District - yes A76, . sM achire�Sh.op Villag 5 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well. El 171000 E.WetlandS, - - 0 Watershed Distnet _O Wates/_,Sevuer,. DESCRIPTION OF WORK TO BE PERFORMED: 10, Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR `Name 7� 9 , Ad"dress: 9 p _� , - -¢ Y Su ervlsor s Constru A On License �Date:� _.. , w �tHome Improvement { ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. n Total Project Cost: $ � FEE: $_ /f Check No.: k(-7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner y _ , Signature.of contractor, a .... nc+.."_;4 _.j n E)I- 1A1-;,i-4 n ('or+ifior! Dln+ plan n C+mmnarl Planc n Plans Submitted ❑ Plans-Waived-F] Certified Plot Plan ❑ Stamped Plans ❑ .-TYPE OF_.SEwERAGEDISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑. . ..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 COMMENTS 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 !bPW TmvL, Engineer: Signature: Located 384 Osgood Street FIREt0ART�i-ENT =Temp Diampster on site yes no Located-at 124 Mair Street Fire'Departinei it sigrratu're/date f. 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 Doc.Building Permit Revised 2010 Building Department The foh3wing 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 cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn%-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Location � T�t�'Z._� ! �'M-c_J a .---- N L� Date U o - TOWN OF NORTH ANDOVER Y o Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Ka ti^ Other Permit Fee $ s r r '� TOTAL $ Check# 26993 Building Inspector � NORTy Town of _ : Andover 0 1 No. 3• - Y ih o `*- h , ver, Mass, () COCNIC"l-ICM ��• pORATaD S U BOARD OF HEALTH PERMIT LD Food/Kitchen Septic System I THIS CERTIFIES THAT .... r °� J. BUILDING INSPECTOR ................................. .............. . ....................................................... has permission to erect buildings on Foundation p .......................... ..,ate.....4��7.?I��.,G. .,C�c�u-�..._.�................. Rough to be occupied as ...U .. ..... ....... 1....�Mu.Kxf... . .......................... ... Chimney. acce tin. this ermit shall in every respect conform to the terms of the that the e Final on file in 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 CONSTRUCTIO TRS Rough I (T— Service .................... ........................... ............................... Final BUILDING INSPECTOR GAS INSPECTOR .Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE The Commonwealth of Massachusetts - Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorsfElectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_ Pye Address: City/State/Zip: S�Zls By Ry mA o/9S 2 Phone#: 9�2 P. 3/SV— J'7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).' have lured the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have 8. El Demolition working for me in any capacity. workers'comp.insurance. 9. []Building addition [No workers'comp.insurance 5. E] We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner,.doing allwork right of exemption per MGL I LE]Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance ]ired.re q uemployees.[No workers' - 13.0Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. I Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached anadditional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am 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.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby cert fy u eY t pains andl enalties ofperjury that the information provided a h o v e is true and correct. Si afore: Date: /D �S� Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.other - - Phntn p tf- Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-027489 STEPHEN M KEI$MG�`- A'�. 9 9TH STREET WEST SALISBURY MAr-01952 Expiration Commissioner 07116/2015 Vlce Uia�n�ua�rcoe{r�f�a��'(,�r69ac�rr3ef�4 Office of Consumer Affairs&Business Regulation 09t�ME1,MfR OVEMENT CONTRACTORgistra6on101846Type: piraton: 6/29/2014 Individual STEPHEN M.KEISLING- a , Stephen Keisling 9 NINTH STREET. SALISBURY,MA 01952 - _ Undersecretary - FARM FAMILY CASUALTY INSURANCE COMPANY Issuing Office - P.O. Box 656 • Albany, New York 12201-0656 CONTRACTORS ADVANTAGE BOP000916908 ® 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: 03/21/2013 Policy Period: From 03/21/2013 To 03121/2014 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 $21.00 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 $560.00 The Declarations, Schedules and These Forms and Endorsements Make Up Your Complete Policy: BP00021299 BP00060197 BP00090197 BP04170196 SP04190689 8PO4961001 BPO5140103 8P07010197 BP10040498 BF30061103 BF40380902 BF40390303 BF40861010 BF40910708 BF40921010 BF40940510 OF41090204 BF41321008 F199020108 Countersianed By STEPHEN M. KEISLING Building& Remodeling 9 9th Street West Salisbury, MASSACHUSETTS 01952 MA Uc. 027489 Home Imp. 101846 Phone (978) 682.2072 Cell (978) 314-8457 PROPOSAL SUBMITTED TO PHONE DATE 4�2.0 2,713 STREET JOB NAME <5� S 0., i CITY,STATE and ZIP CODE JOB LOCATION �D LAW G� ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for. __.. ....__.._._-... ......_.._----- ...-----.......__.._._.`.'_P.-_..._............_.. -- - .....G.......................... 61.�.�- ---_-..._-------7_------_------ ..........................__._....... L c?!r�..._-r.-e!d l/�2 -.._._.._...........------- t�uJ.- ..........._.._------- ....._.... _._... -_._._...._._...__-.- _..............._ f ._---.._...._..-.._._... � ..._..._.. -... ti --- __._ ..__............____ ......_..._____........__._..------_.............._...__ ---... ...__._..__-_._... _....... yrt -� .... ��. r✓30. _.._ ...-----...._.............. - _._._._:......._..__.�..._.:---------..___.:.-._._....- .._ --- ..._..._._.._......_...... _....._.. _ 3�.._.I.._._......-...___.....__.._..._..__.__. .... ..z©..........._......-.---......__.-.____.._.........._._...__......._....._.__._.--............_____._..._...._ .._........._......._..................................__..._.-_..._.................................__.......................__.._..._...........__.__.__....._....._._.._...............................---.__._............................................................ ._._.._..........__.__...._.__.._.._._...... --........_ n _.__----._.._.....___._-- --._._.._._... ..... .__.._..........._- _...___...._.._._..-----.._._..._.___......__-.. ___._.. ........_.. _....__..._._._..........._.._______....... ......................_.__....._.-......_......__.............------.._.....---...._......---............._.---..._................_..__....._..._....._.... ........................................... --------- .--. . n _Z�?__.........._....__._....__...__....._....... - _ 19P VTOPOSP hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: �a dollars($ 92 )• Payment to be made as follows: AD material is guaranteed to be as specified.All work to be completed in a workmanlike g specrf� p manner according to standard practices.Any 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 fire,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 days. Acre Mance 0f r0l][09tiI —The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment ill be/made as outlined above. Date of Acceptance:` �3 Signature