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HomeMy WebLinkAboutMiscellaneous - 15 WOOD LANE 4/30/2018Location No.y� % 7 v Date MORT" TOWN OF NORTH ANDOVER i Certificate Occupancy $ of �'+ s'•^� ,t� wcMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ i TOTAL $ 0 Check # a 16431 ,G1-fe-I � v/ `—Building Inspect TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATf. OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: 010 a Q o 3 SIGNATURE: ("`' "" _ Buildin Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: /s- c��J LAS e ` 1.2 Assessors Map and Parcel Number: O Y& dvc) Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage fl 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Re red Provided lv7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 -Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT $2.1 Owner of Record 3�o�) 4 1A S'JC P,4f01aAJ /.S' Gyt0,:/ ZJLtia Name (Print) Address for Service : 97,P GS(,/ -33d"7 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor. Address Q 7 JP 6 P Z- 2-0 7 2 Signa re Telephone Not Applicable ❑ 0d 7c�� . License Number Expiration Date 3.2 Registered Home Improvement Contractor SAMe /4S .4laGt� Not Applicable 0 /G / P V G Company Name Registration Number Address Expiration Date Signature Telephone M M X ic z O O z�q M 90 O M r _r Y 9 \� SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... X No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ,`!� Addition . ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: :t'E+hov2 3 S e -P J'- SguiGo% 4iXSt pl.4TFy/tzn /11A & 2 s ie p S-7;014 r 9 (64io% A-7- ,6.¢C t I ob 2 0A.) SI'le cj-p B" LAI., C. SECTION 6 - FSTIMATF.D C0NSTRTTCT10N CORTR Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ON Y �.. - .: 1. Buildings �p (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (8) X (b) 3Q 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, .S % P //,-,J M . �P6 J�i� �r as Owner uthorized A en f subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief 6: Pri e Sioattire of OwneA en Date T. NO. OF STORIES SIZE BASEMENT OR SLAB SITE OF FLOOR TIMBERS 1 2ND 3PZ SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS IffIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I N 1 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ****** 'APPLICANT FILLS OUT THIS SECTION APPLICANT tO�/v.., ��e�f�i� PHONE ?7P 6 P2-2 a )'L ce)1 9%g - 3 (�/- 5,1 LOCATION: Assessor's Map Number 0 y� PARCEL SUBDIVISION jj LOT (S) STREET G� �d L,,i N ST_ NUMBER IS USE I HLGUWNDATIONS OFT-PWN AGENTS: ATION COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENT DATE APPROVED _ DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING 1NSPECTO Revised 9197 jm 03—_ TE I -+ r + - + t i- + - II � I I I 1I I II I I 1 + Iy I J '� Y` I I � i p t. Pil I 1 +---}- t- +- -r— --+ +ter '- + --+ '+---f— --+ --+ t - - + + - �•-�-�' + r- r t--'+ r 1 4- , t I • I I o i I i I , � I + —1 'P 7XP zoa yXy P� . I t - ... I I --� - t + — i� + t • + ._ + « t. .. + - } } I, 1 11I + ---I- --✓•--+ - � I , I I Ii I I ' I + + 4 I I 4 I I I I I ' r I I I 1 Farm DECLARATIONS PAGE 1 Family CONTRACTORS ADVANTAGE SPECIAL Casualty Insurance Company POLICY NO. 2005XO431 ® Glenmont, New York NAME OF INSURED AND MAILING ADDRESS: AGENT NO. 2591 OFFICE NO. 2591 STEPHEN KEISLING JAMES W UGONE 68 GLENCREST DR FARM FAMILY INSURANCE N ANDOVER MA 01845-1315 10 S MAIN ST STE 208 TOPSFIELD MA 01983-1832 978-887-8304 RENEWAL TRANSACTION EFFECTIVE 03/21/03 POLICY PERIOD FROM 03/21/03 TO 03/21/04 12:01 A.M. STANDARD TIME AT THE LOCATION OF THE DESCRIBED PREMISES THE NAMED INSURED IS: INDIVIDUAL BUSINESS OF THE NAMED INSURED: CARPENTRY-NOC LOCATION OF DESCRIBED 68 GLENCREST DRIVE PREMISES NO. 01: N ANDOVER MA 01845 PREMISES 01 BLDG 01 BUILDING MATERIALS / EQUIPMENT STORAGE BUSINESS PROPERTY COVERAGE: BUILDING BUSINESS PERSONAL PROPERTY BUSINESS INCOME AND EXTRA EXPENSE LIMITS OF INSURANCE 0 5,000 PROTECTION CLASS IS: 04 CONSTRUCTION IS: FRAME TERM ADDL/RTN PREMIUMS PREMIUMS 0 0 46 46 ACTUAL LOSS SUSTAINED NOT EXCEEDING 12 MONTHS INCLUDED INCLUDED BUSINESS LIABILITY COVERAGE: BUSINESS LIABILITY - PREMIUM IS SUBJECT TO AUDIT BODILY INJURY/PROPERTY DAMAGE 500,000 PER OCCURRENCE 1,000,000 AGGREGATE 500,000 AGGREGATE FOR PRODUCTS - COMPLETED OPERATIONS HAZARD MEDICAL EXPENSE 5,000 PER PERSON FIRE LEGAL LIABILITY 50,000 PER OCCURRENCE CODE DESCRIPTION PAYROLL TERM PREM ADDL/RTN 91342AA CARPENTRY-NOC 20,000 379 379 THE LIMIT OF INSURANCE FOR THIS BUILDING SHALL BE AUTOMATICALLY INCREASED BY 5% ON AN ANNUAL BASIS DURING THE POLICY PERIOD. ACTUAL CASH VALUE (ACV) - BUILDING OPTION DOES NOT APPLY. DEDUCTIBLE: $250 DEDUCTIBLE APPLIES EXCEPT WHERE NOTED IN THE POLICY OR ENDORSEMENTS. COUNTERSIGNED BY: BF 30 05 01 98 INSURED COPY PROCESSED DATE: 02/14/03 �ize'1`aanvnzanurelt� a��-G%aauzc�ac�aetla BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 027489: Birthdate: 07/16/1953 Expires: 07/16/2003 Tr. no: 12035 �nnelnn}inn _ PC • Restricted To: 00 STEPHEN M KEISLING 68 GLENCREST DR C4... I.1 Ak1M^%/C0 K11A AZOIC ^ ._ 'y ��LC I�IOYJUntO'J!•CIM,IILL/L 6�✓�iLICdP.�b y \ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101846 Expiration: 6/29/2004 Type: Individual STEPHEN M. KEISLING Stephen Keisling 68 Glenncrest Dr. N. Andover, MA 01845 Administrator Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02191 Workers' Compensation Insurance Affidavit Please Print Name: S' e P P ,J to /.S 6,0 G Location: od City /U0 D 41olf - Phone # 1�7-' G Z- 20, 2 a1 I am a homeowner performing all work myself. ® I am a sole proprietor and have no one working in any capacity 1, 1 am an employer providing workers' compensation for my employees working on this job. Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment as_weU-as_civil.penatties jnshe-fnrm d -a STOP w9RK ORDERS a fine-of_($]AO.OD)-aidayagainst.me_ I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. i, I do hereby certdy under the pains and penalties of penury that the information provided above is true and correct. PR Print name % r�/�p•y m .L`��d L�.� Phone.# ?2P -"P2-Zo'Z Official use only do not write in this area to be completed by city or town official' City or Town Permitticensing i Building Dept OCheck if immediate response is required 0 licensing Board 1 p Selectman's Office Contact person: phone #.• 0 Health Department o Other I North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number_ Z JO3 is that.the debris resulting from this work shall be disposed o in a properly licensed solid waste disposal facility as defined by MGL c11,S150A.. The debris will be disposed of in: /ii e ivP r✓ �?ft (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through. the Office of the Building Inspector 0 F=04 O 1 W 4 o A mv ° w° a cin ° U z Y w° `� :c u x a ° W Z am o w G x � W v W o w c% w x H z o d w z w A w v rii a z cin o o cn co cm I p� C •E CD m cc a� co 0 c0 O d C Q ca O � � c cc C Z CL V CO) C C■� C cc y 0 U) W CC LU W W VJ c o �asc vg� •ate dw m E i.' 0 Q' �oo y 1 m c0 �. �y y 40 o 3 fj", cm �:= � • L C y Em �v y �■ `:LL O c N Q x • o. a• _ = m �V y O ; •� Z o Zdon cm HO. CDC : N mCL C c o y m y LLZ O y oc O.Z C �E coa w CO) o LU L) a m��= g Z W .0 ` h= Q � _ 4- CL an 5 co cm I p� C •E CD m cc a� co 0 c0 O d C Q ca O � � c cc C Z CL V CO) C C■� C cc y 0 U) W CC LU W W VJ 2 �o�y � � � . :� . .�� � . �g /�= 2� . 2� \« ` « \{//2� . ?�mk- . . . ��//)� . ��� . � :�±§§ , . . . � �}� � \ \ ; � � . � .- � � � ` \ ©� � .� » <\. 2 �