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HomeMy WebLinkAboutBuilding Permit # 3/16/2016 _ . .. ., , . ..... , ,i Baa as Tai BUILDING PERMIT TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION _ Permit No#e " fig Date Received ��p�RATEFo PPP` �oJ' SpCHUS�� Date Issued: ' "I&-PORWTANT: Applicant must complete all items on this page r r r „ 1 , r rrr rrrrr,rur .rrrii�,./,oai raa.i .r / 1 l , l / r l���/�1�r � � , c,✓D s c es / /,, 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 // , /Jc t//r/ /// ,r /❑ ,Waters ecf/D.IstrNct r /, or DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please'Type or Print Clearly OWNER: Name: 9 C. J P u Phone: G/?- V Address: Cir e t r o rg k r r r r ,/ r / //r � ,./ ✓ .,/ ,./r. /„ ,.tri r, � ,/. r /, r //.rr,rEr„o///rr/r/of.lO./l,/lD��lrr ,%�//�i/,/rt r� �rr/r���,,///rri„��:i,.�,.r�,r r,v r r/%r r o ia,r ,.�r rr„�i,r/r.�,r/,o�rr.rar✓/%r,,r�//.r/r r i Drr/ �/r/1,ar�//./,r//r:,.....rrr //!r�//�/r/�,/ r/r�//r�r r�/� r f/ , rr/rr r / , r r r r / 1 n /r r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 ER S.F. Total Project Cost: $ 5-00,00 FEE: $ --— d6 Check No.: 0z c Receipt No.:- /”7.01 NOTE: Persons contracting with unregistered contractors do not have access to the,gual my fpa>ad Signature;of Rgent/Owrier Signature OfLLcontractor Tow- n of ndover Cver, Mass, /6 o L^Ke 1. c oc Kic He wic x �® 0RAFE D s V BOARD OF HEALTH Emma Food/Kitchen tRm� � IT T LD Septic System THIS CERTIFIES THAT ...:.... . .L.. ..................... BUILDING INSPECTOR ................................................................. has permission to erect Foundation .......................... buildings on ...... ...... ..�.... . ./.'.��-:�.��,�.:...l.:f.................... all4r, Rough to be occupied as `� '� ��'�7�c 14, �" 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 ®NTS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough /� .. ° ° Service .D/ 1,,..n,.�........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Require to Occupy BuLldink Rough Displayin a Conspicuous Place on the Premises Not Remove Final No Lathingr Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. osa street YilrliWACl1 ' e ` 7 7=M9 Blll '0. Ship To Proposal Date: 1/412016 Gridtte a eau proposal M 63'1 Bridit�e tleVeau project: -26 : �Qai Street 2f}akSt 1 rttt Aodover,MADIM Nottlt,Andover,MA 01845 Perms 50150 itinn Description Est.Hours/W. Rate Total Labor Installation Laborfor a Pleasant Hearth Pellet 1 500.00 500.00 Stove and venting. I t I i (6.25%) $0.00 This proposal is good for 30 days from proposal date.Colonial Fireplace has a return policy of 30 days alterpurehace.Unit and or parts MUST be in new condition to ger full refund Total $5500.00 within 30days on materials only.Used parts and or unit customer will recieve refund minus a 25%restocking fee on materials only.Labor is non refundable. SIGNATURE E-mail Web Snr salcs@colonialfp.com Cotonialfp.com Date of Acceptance 3 6 Dimensionsand Clearances MODEL: PHSOCAB B. Clearances to Combustibles (UL and JLC) A. Appliance Dimensions 23-314(6031 A 4-112 i (1141 I r, 23-3116 15 0] Straight Back Against Wall inches Millimeters I A Back Wall to Appliance 10 254 B Side Wall to Appliance 13 330 Corner Installation Inches Millirnerers. C Walls to Appliance 3 76 �j i "'""NORIllilt ACAUTION e j 35-1/2 • DO NOT CONNECT THIS UNIT TO A CHIMNEY FLUE 19021 SERVICING ANOTHER APPLIANCE. • DO NOT CONNECT TO ANY AIR DISTRIBUTION DUCT OR SYSTEM. WARNING r/ r� HOT SURFACESI 4-1116— [1031 Glass and other surfaces arehot during operation AND cool down. Hot glass will cause burns. • Do not touch glass until it is cooled • NEVER allow children to touch glass • Keep children away 32-6116 • CAREFULLY SUPERVISE children in same room as �6z1r fireplace. • Alert children and adults to hazards of high temperatures. -g-'/z High temperatures may ignite clothing or Cather (241 flammable materials. Keep clothing,furniture,draperies and other flammable tom-22-11/16[6761 materials away. 22 7077-171 •July 10, 2012 6 Dimensions and Clearances C. Hearth Pad Requirements (UL and ULC) Use a non-combustible floor protector, extending beneath appliance and to the front, sides and rear as indicated. Measure front distance "M° from the surface of the glass OFm door. Must extend 2 inches (51 mm) beyond each p side of pipe (shaded area) USA Hearth Pad Requirements *L Exception for Horizontal Installations: CANADA INSTALLATIONS: A non combustible floor pro- Hearth Pad Requirements Inches tections extending beneath the flue pipe is re uired with K Sides 2 horizontal venting or under the top vent adapter with verti- L* Back 2 cal installation. M Front g USA INSTALLATIONS:A non-combustible floor protection extending beneath the flue pipe is recommended with hori- zontal venting or under the top vent adapter with vertical installation. Canada Hearth Pad Requirements Hearth Pad Requirements Millimeters K Sides 203 WARNING L* Back 51 If the information in these instruc® M Front 152 tions is not followed exactly, a fire may result causing property 6 damage, personal injury, or death. • Do not store or use gasoline or other flam- mable vapors and liquids in the vicinity of this or any other appliance. • Do not over fire - If heater or chimney connector glows, you are over firing. Over firing will void your warranty. • Comply with all minimum clearances to combustibles as specified. Failure to comply may cause house fire. 7077-171 •July 10, 2012 23 The Commonwealth of Massachusetts Department oflndustrialAccidents _. : . :a 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information // � / Please Print LeObly Name (Business/Organization/Iudividual): W t(5�1 {�(RC e Address: /"j1&in S City/State/Zip: 1�v; M i,. h U!�� Phone#: 5 7 -�`��-J-1 t 2 Are you an employer?Check the appropriate box: Type of project(required): i 1.0 I am a employer with__employees(full and/or part-time).* 7. ❑New construction 2.Q 1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 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.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other Pe lle f -5)$4 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submif Us 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-conirac4ors 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: L 2 /d m 2-';C-4 n Xin S e,ra-1 c e Policy#or Self ins, Lie.#: (�2._(,l F � 3%�i /y Expiration Date: / —16 Job Site Address: 0i(P Gr&At oak 57` City/State/Zip: rz.a M4 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certi under the ain d penalties of perjury that the information provided above is true and correct. Si nature: Date: 3'/S 6 Phone#: 579'-1rYh _ r/52 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#: COLON-1 OP ID:JD TE CERTIFICATE LIABILITY INSURANCE DA 088/05/05/220150/6 Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CNTNAME:ACT Wilmin ton Insurance Agency Wilmington Insurance Agency PHONE FAX Five Middlesex Avenue Unit 14 A/C No E t:978-658-3805 A/C,No): 978.657-5724 P.O.Box 1010 E-MAIL Wilmington,MA 01887-0580 ADDRESS: John F.Doherty INSURERS AFFORDING COVERAGE NAIC# INSURER A:Ace American Insurance Co INSURED Colonial Fireplace LLC INSURER B:Arbella Protection 41360 474 Main Street INSURER C:Ohio Security Insurance 24082 Wilmington, MA 01887 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL S B POLICY NUMBER POLICY EFF MM/DD�YY LIMITS C X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE FX] PREMOCCUR BKS66005897 03/14/2015 03/14/2016 DAMAGISES ES(Ea RENTEDoccurrence $ 10,000 MED EXP(Any one person) $ 1100 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY❑JECTPRO F7]LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 B ANYAUTO 1020028151 04/01/2015 04/01/2016 BODILY INJURY(Per person) $ ALL OWNED rX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X NON-OWNED PROPERTYDAMAGE $ HIRED AUTOSAUTOS paraecident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY X STATUTE X ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N 6S62UB2E12396214 03/14/2015 03/14/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ® N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 I(yS6 describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space,Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts -Cep „yen ct ?u ar" _ clic Sarer�! ;arty Oi Ca ' vull �i �C co- Office of Consumer Affairs&Business Regulation g"':tin;s and Stu ufS �, ROME IMPROVEMENT CONTRACTOR Construction Supervisor 40 _ registration: 181414 Type: License: CS-105920 -e- Expiration: 4!112017 Corporation A" COLONIAL FIREPLACE SCOTT M HAYES=6 CANTERBURY AVE Y Haverhill MA 01630 - SCOTT HAYES r 474 MAIN ST ' WILMINGTON,MA 01887r. �-"5f� ' '' 1 =xpi anon Undersecretary Commissioner 08/1912016