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Home My WebLink AboutBuilding Permit # 1/21/2016 tjoRTH BUILDING PERMIT 0". ,ED 6 '. " 16 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 4 Permit No#: 9-6 1 Date Received TED PIS CHLI Date Issued: 1,0 1ORTANT: Applicant must crhomplete all items on thisTrr page AN 101,4; ON Ell'"f m sagg gg g rr MINIM or WREN TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 0 Addition 1-1 Two or more family El Industrial P- Iteration No. of units: 11 Commercial klPiepair, replacement El Assessory Bldg El Others: El Demolition El Other S tic Weil f� ❑ Flood PI'al DES TO BE PER :ORMED, CRIPTIO� OF WORK "R 28 C� V,'V VUv. 4, e -- krkr-644--12! -644--12! (*to) ff/GPi®2 Ysek-a? Identification- Please Type or Print Clearly OWNER: Name: 0_a,, e 0-.:E Phone: Address: 87e, 49,11'415 A... ..... g 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: $ LO 4?p FEE: Check No.: Receipt No NOTE: P ons contract* ith(��r gistered contractors o not h ave�ss Vtguar ty. coritractor 306ri � �1pRTly . L _uown of Andover O Colh ver, Mass, �1 In 2a coc MIc"aw.c. SRATED JP'V' �S U BOARD OF HEALTH Food/Kitchen rr E R- MIT T Septic System C' THIS CERTIFIES THAT ... ..�� _ '. .... .. ............. BUILDING INSPECTOR ..... . . .... . ............. . ...... . ........ ............. Foundation has permission to erect.......................... buildings on ................................... ...... ........`°..... . ....................... ............ Rough to be occupied as ...'.... du .....��......!.........:..t... A.... 1re.W. 1 el......................................... chimney provided that the person accepting this permit shall In every respect 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERM]T EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS S R CTIO/."STARTS Rough ( Service ................. ...:..................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of masse-Ouselts Department of Ire USIFzal.Accrdents M X Congress street,Sure 100 )3oston,mA 02114-2017 9�4 www.mass.gov/dza 'workers°CoanpensationInsuran,ce Affidavit:Builders/Contractors/Electrcicians/PXumbexs. TO BE]FILED WCTH THE PEW&TTING A.UTHOMY lease Print Le •bl A licant Information Name(Business/Oxganization&divxdual)' Address- city/state/zip. Phone#: Axeyou an employer?C$eekflie appioprlafebox: Type of project(required): l.1,[]lam a employer with. .,. . P em to ees(full and/or part time)." 7• �New construction y 2.Q I am a sole proprietor or partnership and have no employees-Working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3. I am a homeowner doing all work myself'[No workers'comp.insurance required.]t 10❑Building addition 4.AT''aern a ho owner d will be hiring contractors to conduct all work on my property. 1 will 11.0 Electrical repairs or additions ensuretha contractors either have workers'compensation insurance or are sole 12•p Plumbing repairs oradditions prop.rietors withno employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. lG Other 6.❑We area corporation and ifs of gers have exercised their right of exemption perlvIGL c. - 152,§1(4),and we have no errnployees.[leo workers'comp.insurance required.] `.Any applicant that check;bo x#1 must also rill out the section below showing theirworkers'compensafionmusts bmit ation i Homeowners who stibi ii f this afC�rdavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. TContre ctors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ide their works'comp-policy number. employees. Ithe sub-coniracEozs fiave employees,linty Must pzov f I am an iployer•that is pi avidiragivorkers'compensation insurancefor my employees.'Below is t/iepolicy and lob site e information. Insurance Company Name; Bic ExpirationDate: Policy#or Self-ins, AJA City/State/Zip: (O 7 fob Site Address: mpensation policy declaration page(showing the p olxcy number and expiration date). Attach a copy of the vvorlcers' co Failure to secure coverage as reqs well ase r M penalties inthe fors a im oda STOP nat violation ORDER and a ane of up to$250.00 a and/or one-year imprisonment, p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA.for insurance coverage verification. Ido Xaer eby certify under tlae pains and hies _ treat thew orntution pr ovicled ab is frr e and correct Date: Si nature: Phone#• Official use only. Do not write in dais area,to be completed by city or town official. City or Town: Perxnif/License# Issuing Authority(circle one): 1..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other Phone#: Contact Person: NOTICE TOW TO a EMPLOYEESW EMPLOYEES IV The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts.General Law, Chapter 152, Sections 21, 22 &30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (IEUB-3F36793-7-15) 02-10-15 TO 02-10-16 POLICY NUMBER EFFECTIVE DATES M P ROBERTS INS AGENCY 1060 OSGOOD ST N ANDOVER MA 01 845 NAME OF INSURANCE AGENT ADDRESS PHONE# m � CENTER REALTY TR OF NO.ANDOVER 177 SALEM ST o= NORTH ANDOVER MA 01 845 EMPLOYER ADDRESS o= EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE "= o= MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and, reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 003101 W20PIG02 AdW TRWELFIRS 11 ONE TOWER SQUARE A N D HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (IEUB-3F36793-7-1 5) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 6512 NAICS : 531120 ------------------------------------------------------------------------------------ STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 582 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 250 TERRORISM 6 TOTAL ESTIMATED PREMIUM 838 TAXES AND SURCHARGES 31 DEPOSIT AMOUNT DUE 869 Minimum Premium: $ 272 EMPLOYERS LIABILITY MINIMUM : $ 50 DATE OF ISSUE: 1 1 -21 -14 AA OFFICE: SPRINGFIELD MA 354 PRODUCER: M P ROBERTS INS AGENCY CYV44 COUNTERSIGNED-AGENT AMk TRAVELERS WORKERS COMPENSATION ONE TOWER SQUARE A N D HARTFORD) CT 06183 EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (IEUB-3F36793-7-1 5) NEW-15 INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT NCCI CO CODE: 12637 1. INSURED: PRODUCER: CENTER REALTY TR OF NO.ANDOVER M P ROBERTS INS AGENCY PO BOX 876 1060 OSGOOD ST NORTH ANDOVER MA 01845 N ANDOVER MA 01845 Insured is TRUST Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 02-10-15 to 02-10-1 6 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A.•The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease; $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NUJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 1 1 -21 -14 AA OFFICE: SPRINGFIELD MA 354 DIRECT BILL PRODUCER: M P ROBERTS INS AGENCY CYV44 t missachusetts -Department of Public Safety Board of Building Regulations and Standards ._.: - ii�iaSii ii�ii0ii ouj�ci�i50i License: CS-075302 BENJAMIN C OSGbOp 69 Old Village Uw, North Andover AAA 0f8g5 Expiration Commissioner 12/04/2016