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Home My WebLink AboutBuilding Permit # 11/23/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION %4ORT14 Permit NO: Date Received Date Issued:- 's CHU IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER 16 Print MAP NO. t_��PARCEL:./I j1069 ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICTYESo TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential 0 New Building ,-One family 0 Addition 0 Two or more family 0 Industrial 0 Alteration No. of units: �9 Repair,replacement 11 Assessory Bldg 11 Commercial 11 Demolition 11 Moving(relocation) 11 Other 11 Others: El Foundation only DESCRIPTION OF WORK TO BE PREFORMED J CA rorSLe Identification Please Type or Pknt Clearly) OWNER: Name: `,,,,) T)1, Address: CONTRACTOR Name: C"2tC0 I p dy> Phone: Address:_Z-1 Supervisor's Construction License: C S C I/ S Exp. Date: Home Improvement License:— Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE-BULDINGPERMIT•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASEDON$�25.00PER S.F. Total Project Cost :$ '0/0 oo o x12,00=FEE:s Check No.: Receipt No.:L Page I of 4 T77' ' tk RTH ' Town of Andover 0 . , ........... %,, .w )A� ver, Mass, . oL.AKII COCMICKEWICK ®�ADgRTED 94�,`'�5 S U DBOARD OF HEALTH Food/Kitchen PtRmmmIT T Septic System m THIS CERTIFIES THATf �,�„L. ,,, ,, BUILDING INSPECTOR ................... . .. ... .................. . . has permission to erect.......................... buildings on . .. .........FevAtsrc ... ........... . Foundation AOL Rough to be occupied as ........rr4D�this ...... ...... ...... ... ....®...................................... Chimney provided that the person ecce permits all in every re ct conform to the terms of the application 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 ® PERMITI IN ®NT ELECTRICAL INSPECTOR UNLESS CONSTRU.. AR Rough 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 Lathingor Dry Wall To Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke'Det. The Commonwealth of Massachusetts Department of IndustrialAccidents PEE E03 1Office of Investigations 600 Washington Street Boston,MA 021.11 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leyd__y Name(Business/Organization/Individual): Address: h-► J ,�� City/State/Zip:C lya) /t) �4 0'_3 ( Phone#: F� I '—3 E ' `1" 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer-with 4. 0 I am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2Q 1 am a sole proprietor or partner- listed.on the attached sheet. 7. EJRemodeling ship and have no employees These sub-contractors have g, []Demolition work' for me in an capacity, employees and have workers' � Y P tY� 9. ❑Building addition [No workers'comp,insurance comp. insurance.# - required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12,offRoofrepairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fUl 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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.Lie.#: 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 a violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of!Lenfbr!2A=ce coverage verification. I do hereby trfify and pains and penalffes ofperjury that the information provided above is true and correct S' e Date: / 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#: Gregg Keniston 40-4 Mulberry St Concord, NH 03301 781-389-4485 Client Address: Chip Mcallister 25 Ferncroft Cir North Andover,MA 01845 Job Description: Complete roofing with lifetime arch. Shingles, ice and water shields, 8"aluminu n drip-edge, 51b. felt paper,ridge vent. For the Amount of: s 10,0o0 Contractor � f Client TYPE OF SEWERAGE DISPOSAL Swimming Pools 11Public Sewer Tanning/Massage/Body Art ❑ g Well Tobacco Sales ❑ Food Packaging/Sales 11❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contract' ivith unregistered contractors o not have access to the guaranty fund Signature of Agent/Owne �' Signature of contractor 0)) Plans Submitted ElPlans Waived ❑ Certi Plot Plan 11St ped 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 Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection/Sianature&Date Driveway Permit Temp Dumpster on site yes—no— Fire Department signature/date _Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR gistratian: 163870 Type; piration: 81ri1201 Individual GREGG KENISTON GREGG KENISTON 40-4 MULBERRY STS CONCORD,NN 03301 Undersecretary Massachusetts Department f cubuc Safety Board of Building Re-gulabons and Slandards con%trucrion supe c ice se CS-0' 2535 Cw' o . GREGG R KENIST ONS 40-4 MULBERRYST"� CONCORD NSI 03301 i ra i n 0110602016