HomeMy WebLinkAboutBuilding Permit #201-11 - 65 GREENE STREET 9/8/2010 NORr
BUILDING-PERMIT of
TOWN OF NORTH ANDOVER `ttLeD '6t
APPLICATION FOR PLAN EXAMINATION y�
Permit N0:492/ Date Received 144TEp 011 Cl
�SSgC LIS
Date Issued. (/
IMPORTANT:Applicant must complete all items on this page
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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
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DESCRIPTIONOFWORK TO BE PREFORMED.'
4-Ald 40,04-10 4l 7
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$123.00 PER S.F.
Tota( Project Cost: $ �. /�� CPO FEE: $ or?asr
Check No.: C) - Recei t No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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areerifi0anmer :_; - __::, : ar_=S:a 'ra::ure=ogco :`rae: r :
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
j 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
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ iviass check Energy Compliance Report ()f 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
❑ Ce1.a'Cr n r: :Cs. n{_cnl
an.il{{ : r' 1rvi i
o
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 EnergyP P 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
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
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Sigriature
!\f'\� •\IIS\.[T f�
C..Vi�lIIVICIV 1 J
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
DPW Town Engineer: Signatiire:
Located 384 Osgood Street
} 7x iEFNA 45.13 _zaaite.-?m.�..•..,d' .�t:'::s.'C...=.a.(,�.....:...g.7rire.�„:ti'l:-'i.t...e.-.�... - - .Y.d+- - _:41`.r�,:..�.:
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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
Location
No. Date
&ORTp# TOWN OF NORTH ANDOVER
F A
9
�o a' Certificate of Occupancy $
s"cMus t�' Building/Frame Permit Fee $ 0 t
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #0—)O—�
(?I
234 ,137
Building Inspector
NORTH
ToNvn of Andover
0
C,0 _ LAK dover, Mass., $ • ��
2 COCMICMEWICK �1.
ADRATED P'P�,C��
7`S BOARD OF HEALTH
PER I T D Food/Kitchen
Septic System
BUILDING'INSPECTOR
THIS CERTIFIES THAT...... . ... .. .:...................... ......... .......opwa�... Foundation
has permission to erect........................................ buildings on .....� ........ lrrlev.....6+0......�:................... Rough
to be occupied as..... � ....................... ........ 4 ii .1. ► 5........................: Chimney
provided that the person accepting this perm' shall in every respect conform to the terms of the application on 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
aS " PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU ON T TS Rough
........... .. ...... ................................................................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occu y 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 S 1 D E Smoke Det.
Page No. of Pages
proposal
M STEPHEN M. KEISLING
3 _ Building& Remodeling
9.9th Street West
R fir. Salisbt#y,.MASSAOHUSETTS 01952 ;
MA Uc. 02"M89 Home impv. 101846
-Phone (978) W'44 -46�72 "712• (978) 465-4712
PROPOSAL SUBMITTED TO PHONE "x DATE
3 2010
STREET,C/ JOB NAME
CITY;STATE and ZIP CODE JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE
a ;
We hereby submit specifications and estimates for:
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We propuSE hereby to furnish material and labor-complete in accordancewith above specifications; for the sum of:
"I dollars($ )
Payment to be made as follows:
40 60.5 Go
- OOIJ. 00
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r -"All material is guaranteed to be as specified. All work to be completed m a workmanlike. `
manner accordinglo standard practices Any altefailon.or deviatwn from above specrf;cat;ons. "Authorized j
+� fZ�involving-extra costs will be executed only.upon written;orders,-and`w;ll become an extra Signature
x.- charge.over and above the estimate. Allagreementscontingent upon,strikes;-accidents
r
Note:This' ro osal may be
r I n r' ntr I:Owner to r fir • tornado nd other'ri ins r nc R P Y
o delays s beyond d ou co 0 0 a ca e o ado a ecessa u a e
t y y carry ry. withdrawn.b us if not accepted within days.
� Our workers are fully.covered by Workman's Compensation Insurance. -. y P Y
rreptaurP of Propind—Theabove prices,specifications '
and conditions_are.satisfactory.and are hereby accepted. You are authorized Signature Za _
o do the work as specified. Payme twill be made-as outlined above.
Date of Acceptance: ���n Signature
Milssachusetts- Delmi-tment of Puhlic Sat'cty
Board of Building Re- Il Itions and Standards i
Construction Supervisor 'License
License: CS 27489 _
Restricted to: 00
STEPHEN M KEISLING I
9 9TH STREET WEST
SALISBURY, MA 01952
o—
�"G– Expiration: 7/16/2011
('oroer�isio�eer Tr#: 18542
Office ofConsamer Affairs&B siness Regulation
qHEN
HOME IMPROVEMENT CONTRACTOR
Registration: .x:101846 Type:
Expiration_ -629/2012 Individual
M.KEISQI-N- 1'
Stephen Keisling
9 NINTH STREET
SALISBURY,MA 01952-, : _ Undersecretary
The Commonwealth of Massachusetts
I I Department of Industrial Accidents
' I W Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ye
Address: 9 9 %) s-/-X,P 0
City/State/Zip: S`A-Z(T &-� Phone#: 3/Y J-Ys'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(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. t ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I 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 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.#: 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 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 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•
Signature: Date: 2e/v
Phone#: 97do 3/1�--��5'�
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
Contact Person: Phone M
Information and 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 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 until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority." A
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 application for the pen-nit 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 pen-nit 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 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 and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia
FARM FAMILY CASUALTY INSURANCE COMPANY
Issuing Office - P.O. Box 656 • Albany, New York 12201-0656
CONTRACTORS ADVANTAGE BOP000916905
® 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 019$3-1862
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 ComplC« , ,,..;,y:
BP00021299 BP00060197 BP00090197 BP04170196 BP04190689 BPO4961001 BPO5140103 BP07010197
BP10040498 BF30061103 BF40380902 SF40390303 BF41090204 BF41321008 F199020109
Countersigned By
Page: 1 of 2 Authorized Representative
ANX-3190 INSURED COPY Processed Date: 02/15/2010
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