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HomeMy WebLinkAboutBuilding Permit # 3/24/2016Address: \ \( rey Permit No#: Date Issued: LOCATION PROPERTY MAP 7 BUILD! G PERMIT TO N OF ORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received PORTANT: Applicant must complete all items on this page 2-)<A110.3n OWNER "A 0 EL:Lb 6-7911/4'' "L\ 9-9/(NA9V99\ 9W9999t, Lk-S.1s,t no no no Print 00.Q g'?„, , Print 100 Year Structure ZONING DISTRICT: Historic District Machine Shop Village TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 171 New Building El Addition D Alteration 0 One family Li Two or more family No. of units: Li Industrial D Commercial Li Repair, replacement LI Demolition LI Assessory Bldg El Other fr/ 0,(fig 11; 0 0 If 41°111A'9$9''C '191( \;0i1111919 r1P9,959i1;1‘,?‘ \\'f pc',)11N1 ,194,111(,/ „Ihhhhhhhhhi hhhh hi, Li Others: '')11111 14'(::171;rir DESCRIPTION OF WORK TO BE PERFORMED: v-T-E NIT- a 67,44 Identification - Please Type or Print Clearly OWNER: Name: N koQs Address: C350 i hroP Ve-- Contractor Name: \ 0-y-t Phone:( (6)(4 )1'0,9 CA 5- 11 Phone: 4:7 e" Email: GY 6; AR Et; - (Y\11-. C.,cr) -1-1" XI- / 114 / 0 is Li Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ Check No.: NOTE: ersons contractin FEE: $ cxr Receipt No.: hii9999.2,„ . with unregistered contractors do not have access to the guaranty fund 79,7 • 0. • 0 r<W77ffld 19 '7,,'97 /fiffgr',77"7797797 '',974/77,91,9979747747.7,557:1777 7,797,7'r'4447.;,9797,777.,77 ,99f,r, , , 97y7,, 9:,:.:9421,7919$917' hat ret Iii6Rtra'406fil/ 03 0) cn C) - C = ci p 0 -0 0) • 1:1)i • N CD sy CD • —11 CD 0 CD CO W . � N cam = 0 cn CD 0 :v CD 0 CD woo of palm w 210103dSNI ONTO c cn cn m cn 0 cn cn VIOLATION of the Zoning or Building Regulations Voids this Permit. 0 O O -� c s CD CD -cri Co o_ = yO o= O CD CD O O O CO g y O. O = Cn Cn 'a O CD 0 O Q. • CA O o- CD O C.) 0 O. 03 cn 1 1 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE, PERMITTING AUTHORITY. Applicant Information Name (Business/0rgani7ation/Jndividual): Address: ('IAA()c111-) City/State/Zip: I \J 0r7r4.Jerr 00c G Phone #: Are you agsrfiployer? Check the appropriate box: 1 I am a employer with .,/ employees (full and/or part-time).' 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑ 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 proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sib -contractors have employees and have workers' comp, insurance.t 6. ❑ We are a corporation and its offscers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no.,employees. [No workers' comp. insurance required.] Please Print Legibly Type of project (required): 7. ❑ New construction 8. [] Remodeling 9. ❑ Demolition 10 0 Building addition 11.❑ Electrical repairs or additions 12. El Plumbing repairs or additions 1311 Roof repairs 14.Il Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensatio r 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: }-tAi�TF Policy # or Self -ins, Lic. it: , h) 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 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. ���penalties .fpedal)) .f p •� above is true and correct. painsand enalties othat the information provided I do hereby cent\zfy uncle t te� . �1Date: �'"�� • Signature: Phone #: -79 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 #: C -;TIF ICAT OF LI, ILITY I U AC OP ID: DC DATE (MMIDD/YYYY) 03/24/2016 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(ies) 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 Platinum Insurance Agency 418 Massachusetts Ave Arlington, MA 02474 Niru Bhatia Yadav INSURED Bollywood Grill Inc. Malkiat Gill 350 Winthrop Ave North Andover, MA 01845 CONTACT NAME; PHONE (NC, No, Ext): E-MAIL ADDRESS: FAX (NC, No): PRODUCER BOLLY-2 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE INSURER A : Commerce Insurance Co NAIC # INSURER B : Peerless Insurnace INSURER C : 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. INSR LTRINSR TYPE OF INSURANCE ADDL SUBR WVD POLICY NUMBER POLICY EFF (MMIDDYYY) IY POLICY EXP (MMIDDIYYYY) LIMITS B GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR BKS55786233 10/01/2015 10/01/2016 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RE�I TED PREMISES LEa occurrence) $ 100,000 CLAIMS -MADE L J MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $ 1,000,000 POLICY PRO-LOC [ JFCT $ A A A A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BBDM21 08/20/2015 08/20/2016 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (PER ACCIDENT) X X $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ below E.L. DISEASE - POLICY LIMIT $ B Liquor Liability BSK55786233 10/01/2015 10/01/2016 Liquor 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Liquor liability is included $1,000,000 limit 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 Niru Bhatia Yadav ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All righ The ACORD name and logo are registered marks of ACORD reserved.