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HomeMy WebLinkAboutBuilding Permit #827 - 907 DALE STREET 6/12/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: C Date Issued: Date Received 4 — 12 ^ 0 7 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 D Sep (, We11 FI '00, n;F tlands � 1latershed VVaterfewee DESCRIPTION OF WORK TO BE PREFORMED: IA"W—_cii ti dec,r Ar,AAa/c s a aad 441 ZIA74: c-Z"k��-& ,mow �Zz comp &te tiA4 Aj l re 2F e o»Ze ,P,+lZilw6-r 19-A4 Identification Please Type or Print Clearly) OWNER: Name: 6o -o r44,ffm4,-7 SP3 - 736-1 Address: Q©% dRle �—leee 7 CC)NTRACTO�R Name Phoneffi AddresA o, { , a. Su erv�si or's Con truction�erise? �� Esc C1at p Home' Imrouement Lrcens.. .,&` 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. Total Project Cost: $ an, 00 FEE: $ Check No.: q � d Receipt No.: `� 30-3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sigrat, ure;hof "Agent/Owner a . Signature of contractor LocationlJ�l�t- S % No. d Date NORTM TOWN OF NORTH ANDOVER - "so:*.. 3? ` 6 Certificate of Occupancy $ ,SSAC14UStt Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 203L3' Building Inspector 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 PLANNING & DEVELOPMENT ❑El COMMENTS CONSERVATION COMMENTS HEALTH .--f COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: DATE REJECTED 9 DATE APPROVED DATE APPROVED El DATE REJECTED DATE APPROVED ❑ ❑ Comme Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street 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 o Copy of Contract o 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 must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENTWITORM07 Revised 2.2007 FARM FAMILY CASUALTY INSURANCE COMPANY Issuing.Office - P.O. Box 656 • Albany, New York 12201-0656 CONTRACTORS .ADVANTAGE BOP000916902 ® DECLARATION PAGE Policy Number: 2005X0431 Agent No: 3485 Agent Phone: 978-887-8304 UGONE -JOHNSON INSURANCE AGENCY, IN 10 S MAIN ST STE 208 TOPSFIELD MA 01983-1834 Name and Mailing Address of First Named Insured: STEPHEN KEISLING 68 GLENCREST DR N ANDOVER MA 01845-1315 The Insured is: INDIVIDUAL Transaction Type: RENEWAL Policy Period: From 03/21/2007 To 03/21/2008 Business Description: CARPENTRY Business Property Coverages Buildings Business Personal Property Business Income and Extra Expense Other Endorsements Transaction Effective: 03/21/2007 12:01 A.M. Standard Time Total Limit of Liability Term ADDL/RTN Premium Premium $5,000 $25.00 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 $500,000 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 AGGREGATE FOR PRODUCTS/COMPLETED OPERATIONS HAZARD Medical Expenses Fire Legal Liability Other Endorsements $5,000 $50,000 SEE SCHEDULE TOTAL PREMIUM EACH PERSON ANY ONE FIRE OR EXPLOSION POLICY SUBJECT TO ANNUAL AUDIT: YES The Declarations, Schedules and These Forms and Endorsements Make Up Your Complete Policy: BP00021299 BP000601.97 BP00090197 BPO1080398 BP04170196 BP04190689 BP04961001 BPO5140103 BP07010197 BP10040498 BF30061103 BF40380902 BF40390303 BF41090204 F199020107 Countersigned By Page: 1 of 2 Authorized Representative ANX-3190 INSURED COPY Processed Date: 01/31/2007 The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations 600 Washington Street Boston, MA 02111 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers u de s/Contracto A licant Information rs/Electricians/Plumbers Please Print Le ibl Name (Business/Organization/Individual): 40 A) Address: 1�p City/State/Zip: At✓��p,� o1cPYS phone #: ,1P -2P 3 iK^ JOYS' % Are you an employer? Check thea r o Fir prtate box: 1 • ❑ I am a employer with 4. ❑ I am a general contractor employees (full and/orpac�•* 2. 1 am a sole and I have hired the sub -contractors proprietor or partner- ship and have no employees listed on the attached sheet. _ These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' com, 5. ❑ We area cotPP. insurance requtred'� a ho 3. ❑ 1 ammeowner doing all n and its officers have exercised their work myself. [No workers' comp, right of exemption per MGL c. 152 1 4 � � ()� and we have insurance required.] t q no employees. [No workers' com Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. E] Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs p. insurance required.] I 13 0 Other '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-contmem- —A z am -- e comp. policy information. information. an corp oyer that is providing workers' compensation insurance for my employees. Below Is the policy and/ 'ob Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address; City/State/Zip: Attach a copy of the workers' compensation policy declaration e (showinghe Po Ic Page number and expiration Failure to secure coverage as required under Section 25A of MGL . 52 1 penalties lead to the imposition of crimina enalties of a datea 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. r d.. L..-.. IL - - wer rime paainsJ and penalties of perjury that the informatron provided above is true and correct thrt'P• X . Y _ Da e: -PYS-7 Offlclal use only. Do not write in this area, to be completed by city or town ufflclai: City or Town: PermidLicense # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Ins ector 6. Other p Contact Person: Phone #: BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: -CS 027489 Birthdate: 07/16/1953 Expires: 07/16%2007 Tr. no: 14847 Restricted: 00 STEPHEN M KEISLING 68 GLENCREST DR N ANDOVER, MA 01845 " Commissioner ✓!ie "LOam�nto�rtrrw.rt�� ry�.���%a:�aa�u;W,CZa y- Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101846 Exp; ration: 6/29/2008 . Type: Individual STEPHEN M. KEISLING Stephen Keisling 68 Gienncrest Dr. Q' N. Andover, MA 01845 Deputy Administralor 1haposal Page No. STEPHEN M. KEISLING Building & Remodeling 68 Glencrest Drive NORTH ANDOVER, MASSACHUSETTS 01845 MA Lic. 027489 Home Impv. 101846 Phone 682-2072 of PROPOSAL SUBMITTED TO PHONE DATE n--� �—W 7 STREET JOB NAME 9� ;7 -.!2r-4 J�� CITY, STATE and ZIP CODE JOB LOCATION ea - ARCHITECT DATE OF PLANS IJOBPHONE We hereby submit specifications and estimates for: 0 � . -4- 11 .e-" . "4a,2�1 , 1-. 1_ ' ................... ...................................................................................................... Z Xz A-,C,j9 Pages U e....._� ....ZZ14-..��................................ ~.......,.........._�'IO jy"Q���....._u r.�-�.�e ... . .....................`.% / . ZX2. ?�e�lazl ` We VraPUSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars ($ ). Payment to be made as follows: All material is guaranteedbe as specified. All work to completed a workmanlike Authorized manner according to standard practices. practices. Any alteration or deviation from above specifications Signature involving extra costs will be executed only upon written orders, and will become an extra v f J 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. Arreptaure of Proposal— The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: .51' V -0p1 Signature m m m x m y mm C2. y CD d C � 'D O C2 Z CO) G.O 0 � ? C CZ CO) C2 CD CDCL O cr CD CD O CD C CD y� Q v y O CO COD O S. to _ d � m y ® o H C7 d CCS, m Z �� H o o CL m mp m N C y .fl •� N orrm. m 2 CD CIO m m -O+• p p� o oZ y NO IS V W Cn c a o a �m m o m O H m nCD C C_ CL H •i• . 0 N ato d C o CA CL m U2 VJ Cl. co H� o H 3 w N 4 •"'�• m C, . oC.,: O mo� C •o 0 ;w W: CD C:, 4%o o m 0'.0. �r I CC•� n 0 � cn cn b7 d ?f o L 7d 0 `i? 5 op �°x Com'' nto � ?? �' = o x "ti r z a n ::r- o ° a a1 d r a h: rA W • I 0 c i I I Brockway -Smith Company www.brosco.com IV/VTM ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 PORTLAND, ME 04103 203 Read Street 1-800-442-6734 Fax: 1-800-443-0331 j t � = s � { 1 • r { = 4 � , c i I ICU j CIA 7 ; _.....,,.t.. .......... ._... 4 � f �•` — ki— `V�1 ' = i e 1 ; - t I + 1 I 1 ! —4-- ---t-.._. f 1 k Ali— i I I k j III II —E _ ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 PORTLAND, ME 04103 203 Read Street 1-800-442-6734 Fax: 1-800-443-0331 II Brockway -Smith Company www.brosco.com ANDOVER, MA 01810 146 Dascomb Road 1-800-222-7981 Fax: 1-800-242-4533 COXSACKIE, NY 12051 Hudson Valley Commercial Park 1-800-222-7303 Fax: 1-800-222-7304 r -"k HATFIELD, MA 01038 125 Chestnut Street 1-800-922-0191 Fax: 1-800-922-0296 PORTLAND, ME 04103 203 Read Street 1-800-442-6734 Fax: 1-800-443-0331 4 -- T 4-4 7- J- V- -4 + ANDOVER, MA 01810 146 Dascomb Road 1-800-222-7981 Fax: 1-800-242-4533 COXSACKIE, NY 12051 Hudson Valley Commercial Park 1-800-222-7303 Fax: 1-800-222-7304 r -"k HATFIELD, MA 01038 125 Chestnut Street 1-800-922-0191 Fax: 1-800-922-0296 PORTLAND, ME 04103 203 Read Street 1-800-442-6734 Fax: 1-800-443-0331