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HomeMy WebLinkAboutBuilding Permit # 3/30/2016 BUILDING PE MIT tAORTH TOWN OF NORTH ANDOVER 0 as APPLICATION FOR PLAN EXAMINATION Perm Date Received 0"ATC:I D it No#: Date Issued: 1� PoRTANT:Applicant must complete all items on this page LOCATION )A(nvo 4S �x Print PROPERTY OWNER t 1g)" �<Z g", 1 o Print 100 Year Structure yes n I MAP (-3" PARCELP-'A�'l ZONING DISTRICT: Historic District yes no Machine Shop Village yes no r C­0) TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential---- El New Building VOne family El Addition El Two or more family El Industrial El Alteration No. of units: El Commercial El Repair, replacement F1 Assessory Bldg El Others: [I Demolition [I Other V60 t,g' Lvil�- —,`� ,""'"' ,gg;�V��gg WaL "loocip g /M., 11!sil I DESCRIPTION OF WORK TO BE PERFORMED: 'q JIg & �A A Identi 1 t Please Type or Print Clearly /LA tA IV, OWNER: Name: Phone: Y"N' Address: "71) 7 Contractor Name: IQ ,i/y/Ji, Phone: Email: —: ? Address: I I L') �, Supervisor's Construction License: , Exp. Date: Home improvement License: 761>11 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. 's Total Project Cost: $ FEE: $ - Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund .....----------- ----------- gigna iire,, rin � NORTH v'% dA-4- ver own of No. QS-261 Y n h very Mass, *f(Ak ftl2A&p O tw.ct COC" M!W.Cx x.95 RATED ll BOARD OF HEALTH Food/Kitchen ® ® Septic System THIS CERTIFIES THAT .......... .. BUILDING INSPECTOR .. ..... ............ .. ... ......... ......... .............. .. .... .. ... ... .. .. . ... .... ..... has permission to erect ....... .................. buildings on ............... Foundation .. .. ... ... ..... .. ® ® Rough tobe occupied as .. .. .. ..... .. . .:. ................................................................... 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 PERMITI I T S ELECTRICAL INSPECTOR UNLESSTI S S 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 Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedy the Building Inspector. Burner Street No. Smoke Det. READYTOSMEDULE A14 J rpat awe RISE£aBlncarin8 RISE Iuconvauotlugp�enw 1 dtal3an of tA7cM1!'awjarrri+>P Ct GG�mSar W E1 WEMVGt safe,«pyii'a3pa:.f'„ma.lkl CONTRACT dp�0 i i 1'RIKiH,111 3 CMA-IIF1 �avim'»rra iwswninmi`��ia da,nw cmtwea a,vs urc .mu rnsn (trim Kaa;nni I9781_=94-9734 0I 283016 32n41_ OW2 ,+sv.ta,rcpa: was nen, $99 Salem Stmt 598 Salon carat K,rKp an,arw.m eu+es em.n.nm '... North AtWoN m MA 01845 North Andmtr,MA 0180 JOn DUCRCPTTON -�11R 4::1Lt\l1.lTw cake Ldar,bl mxtrd.b,w-alan.,•1),vnMan:arm:„,t xa+:-'1ui.ra�.w katrr I)n.uaq;alii Pc pnGwnSi in mv-en uuh Mr mr 4l:y.-:ial uvh sxG Jss}'nbc icw b,a+.a:tAv..au':rnu 4.:1 tc ltt•a:M a hcp'.:WW is 1 a�Y ',.. a+bcPiafa trsl Mdrr na gnatp>..11aa^na:.P.h aacJ Pa.rai}.utas::m l�k�k n.tLt 4um mzl n}4T tmvwYl i'nmz) Y Yc fM s9lifp IR:FAit ai(1331EfR 4+b1.\talKbY.tW.Y.W:II:J•r'.ac.>,1 L:J fXPtt mh;,tic'd;gid Ixlydaw1 J+r�nf y:A9.,61 n}droaa,l-i'1>u<4ril nquur 7M5 u,+Auip h:v.�rcJn:l:,•s.R cub,:lair nnrnridm:af..+:nfi;aai,'.n wdl i,,:-cr.kms:d,.•.a:d N ftc vnq+Y•n.•CiM u,•y)xrwytF.i r.4i,nsi m a..nJ•1n.rui:..N n,4:<?::•�r.'-�unr..a ima:bE..uct;oar r-3.•t+wa4 ix,s safen'n:cla.nxA tr acdacL\I P?IP3 w+P•-.:fa.'kt6,etY..f��r ln:s%tit.�l d'<vah�^.�ta{:.ia) -tPflrin't ;l�lht\Ik1c:MwaK bNr aaJ r.+au iataa.CpUli a:'_`b+-a.YF,t%neG'a:rJ fiM ria++l+>s+r.,t t%:wraar fari Gr I:.,rra l+aR*rc A17(L'-1AS-Pn»Ide UMx ant nrtr rte.%+site:(an%'Lg:n.a'R.Y L;1+i t'cC+:av^a,k,!:o t!:,tu 14t,wa k t Rlryrn aii.. +Da-� Ai7)t.'ACL'1;SS.I•nxtds:alw r%t malxtuir as ImuLa<iha iuk vfl'1 a:.Ilarh xak2'r.;iJ 1?•ma\SwJ il'ctiknury•flr. ',. pchnwYri '., jtyl ia+ 1'C\•TRAIR)\I},n i0.lel+.Y mdinplenaha,t4plitliip4dafati tlAamlhoae P.a�iUittp hiia.ran fzr+l «;117• vW711.AMON ItalfdnW„4 ani nLanila a,:n4ati acM�.atlat:iwt.+in 1.>alranee hx_.to msimavl�rufm S�toU 0Y1=R1L1Nfi.Yrol'1J:LIN.-4 nutaetda b:i-+ 3it”R-17d,ra.•:)lal.a-dLl-1CrCukwe Et.tm—tv 17.1 1,U.N f,11'If e\x,xv.riaYaap ta�Q M#nap WafN lt.nr arc:.P)dnl7mp ta+4 in iPc.un�:^:n..r.M%ro 11,>i�.ti JlJMiudlkp:itF•.•,1 ',. MP/?4a hcscdcJ cart!alma gxa3r yaa;kk and kft n n nYsxd)�manA awbtwa fn:"i>aWug a•.(.nil aT rvven:;;'pur64q:utUMtFd wsicsrai mlm4k4ry ',,. Lt:y It: RBE t:n��)x�qzM a9:ppla+Pk.a'..^-d•ta¢:.�Ini4 P•tPn a�le,tt.l'w 4:Uari)4i+i:N:Pc�.ti;nmua t`mrax\. ked�iPic Iga,r•:aa.ki•Enebu t..+4llin'Y:mta-ninn rx:n cued S:.irvl r-r u.4ut t)rv.zrJ xn m.dane„f trwt.%r J.r Av";dr,`.naa4sa up n•the r"Srik)sd ars alJtikRW SNI!.lrr nqe+xe ja-uYwW M i14 aaltw tir itx safe)sa`14m411,of}:Iw hsur'.m.S.x as yny'gy,xrue'l M:,rfv++.rRp a hPn+a d.ca A.bvnn:A iP:aa:nrLst m Aaw w b.—hA b,4w ihr—L ' wit;i.x 4a+,'I 1�.v16catlan:'�F-!)'M').v kryilNj+yl'ra Mdxa'YrP:lfe.live hf�dal`Y a�1S5Yr sa)if.il ni.C.ti:IJ)•sr I,Mal:id4a lke xaYfasvataa iw,rrp:ae 1+S)A In sem /w J FEB 2 2016 .. ............ _ R RfuF.nRtnccring rte.Law. S.R,twy td'i WLAtb+•c�wmiv, ws CaPrR<�ao-rhM tq ENGINEERING cr EgpttLW RepftarmMlw �unMsot 1 pif.l.r'tnl..M,ti t faap:xaaian t\�fnu-u.a-1r CONTRACT Pao. i ETl A-iliti iNLaiow:i:�"avir�ia � a�a19ML iiHik 41 w� Brim):asanti Yt ts»nr fr�6)3ya•'I taa ff ltIIkMiG .129412 Ixxlry3• ' SLJE 3aMm'4111 59E tiakm Slrect '. .iMm,(tY[v,tlS,t SY ktmh A"w v.NA 01844 ad,...LA a..a.,. \nfd,Aninix.VA 01lH5 308 I)F AWRIPTIU.N Total: 32,756.50 Program MlcsnWs, 32.2)7.55 Cuatomar Total: 3569.63 Ma syMff Nmm tOKWaSM HR.KSS-<OcnfMr�a.zr+l62�{pv1M MtY�f Srt�KaMaf rWa frt awM —Mv#Nuntlrsd Fifty t 53n90 Poiiars '669.63 h�NR�Hw�TrtMN>M Ys�w,.iiurgair Ys�aMMis�tti r��.wf�i�V Nc.��tLn6�t�w0G+NKwM��ir:Kh� i�% L'i�7 NOi Et61tTNECOM1AACtV iNERE Mf.1/V�Y6l.�/at VACYY . Wit fnt C4�NaLtµa.t{utaYawrobvte.gttcc✓ttomwM Ort Y�cLf.fw:[ /_��^/+� �l7 N=1.4atL V CDV..aat M1.LIt H<fi iN W ut4it u9f.Y�i:�1 Yt � YVtciyL i.9wtyl Nil i�Yu4uf��itGf�AG.I s,f�.ItaTS Wabl.wlq.fi The Commonwealth of Massachusetts Print Form � Department of Industrial Accidents Office oflnvestigations 1 Congress Street, .Suite 100 Boston, MA 02114-2017 Fs a wwii rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): guilders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03063 Phone #: 603-324-1974 Are you an employer? Check the appropriate box: Type of project (required): I. ✓❑ I am a employer with 100 4. ❑ I arnn a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E] New construction ❑ listed on the attached sheet. 7. E] Remodeling 2. 1 am a sole proprietor or partner- ship and have no employees These sub-contractrn-s have g. F1 Demolition ees emp y to and have workers' working for me in any capacity. 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.❑ Roof repairs insurance required.] T c. 152, §1(4), and we have no 13 0 Other Weatherization employees. [No workers' comp. insurance required.] Any applicant that checks box#I must also lilt out the section below showing;their workers`compensation policy fi l'ormatim. Homcowners Who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicatir7g Stich. =Contractors 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. I f the sub-contractors have employees.they must provide their workers`comp.policy number. I am an empl'Qper that is providing workers'compensation insurance./or nxy employees. Below is the policy and job site information. Insurance Company Name: ACE American Insurance Company Policy 4 or Self-ins. Lic. 4:WLRC 48151553 — Expiration Date:6/30/2016 Job Site Address: _ t 1" City/State/Gip: 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 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. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby cera under the airs and penaltigs of perjury,that the irj formation provided above is true and correct. Si mature: Date.E�7 Phone 4: 603-324-1974 Of ricial use only. Do not write in this area, to be completed by city or totvn 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#: ® I DAT /24�Dt6YYY) CERTIFICATE OF LIABLI `Y INSURANCE 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 BETIAIEEN 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 SUBROGATID14 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). z; PRODUCER CONTACT NAME: 2 AOn Risk S2rvices central, Inc. PHONE ?) FAX Southfield MI office (A/c.No.Ext): (866) 283-71-. (A C.Nq.) (800) 363-0105 m a 3000 Town Center E-MAIL Suite 3000 ADDRESS: o Southfield MI 48075 USA INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A Old Republic Insurance Company ?4147 TopBUild Corp. INSURER B: ACE American Insurance Company 22667 260 Jimmy Ann Drive Daytona Bea Ch FL 32114 USA INSURER C'. ACE Fire Underv✓riters Insurance CO. 120702 INSURER 1) INSURER E' INSURER F. COVERAGES CERTIFICATE NUMBER: 570058348882 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. Limits Shown are as requested INSF1TYPE OF INSURANCE LTR INSD VWD POLICY NUMBER MODDNYYY I(MA01/DD/YYYY) LIMITS Ax I CAMMERCIALGENERALLIA.BILITY MI+2Y304834 Uu/30/2U15 6/3 !01 EACH OCCURRENCE 52,000,000 CLAIMS-MADE X❑OCCUP. DAMAGE O N EO 52,000,000 PREMI5ES Ea ocmnence) MED EXP(Any one person) S25,ODO PERSONAL S ADV INJURY S2,000,CDC) GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 14,000,000 m X POLICY ❑PRO- JECT ❑LOC PRODUCTS-COMP/OPAGG S4,000,000 OTHER. o n A AUTOMOBILE LIABILITY P71�FFB 304835 OG/30/202 5106/30/20161 COMBINED SINGLE LIMIT 55,ODO,o00 ' (Ea.cadent '.. I ANY AUTO BODILY INJURY(Per person) Z ALLOV✓NED SCHEDULED BODILY INJURY(Per...denl) m A___ AUTOS '.. X HIR AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per acodenl O '.., N UIEHRELLA LIA.BOCCUP. EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE '.. DED P.ET'e NTION B WORKERS COMPENSATIONAND VJLRC48251553 06%30/2015 06/30/2016 PER OTH- EtAPLOYERS'LIAbILITY YIN All Other state, X STATUTE ER ANY PP.OPl.1--P./PARTNEP.I EXECUTIUc E L EACH ACCIDE N7 11,000,GOO C OFFICER✓MEMSEREX.CLUDED% � N/A SCFC4815190 06/30/2015 06/30/2016 (Mandatory in NHl) WI Only E L.DISEASE-EA EMPLOYEE S1,000,000 If yes,descnbe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT 11,000,000 FsW ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addrtionai P,emarks Schedul,may be attached if more sp...is required) vidence Of Coverage $ RTIFICATE 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. _ c, a Builder Servi Ce5 Group, Inc. [AUTHORIZED REPRESENTATIVE -+I A TopBuild Company 260 Timmy Ann Drive Daytona Beach FL 32114 USA �°,�' ©1988-2014 ACORD CORPORATION.All rights reserved. .CORD 25(2014101) The ACORD name and logo are registered marks of ACORD - r F 'tr�,'s �, .3�1�=r`�. E';.t'..rf `6? r - � ..ce Tr inci •v Business l�V:-tGa LS LIn 1 `i _ aza uite a Boston, Massachiusetzs 02116 Honnre fin- -oveinent Contractor Registration Registration: 179141 Type: Supplement Card Expiration 6/25/2D16 BUILDER SERVICES GROUP, INC. RICHARD SCHWARTZ 110 PERIMETER RD NASHUA, NH 03063 i S dMe Addow and return card,Mark reasan'10,chant,t'. Address RcneN�al t.ntlth)rnettt I wi Gard _-.- Office r>iL't;n5nncr Aiiai:,b Buy?nrss Str uiz:itin l,icelsr t,r reristratiUn ti'alid for individul List:t;nl't �iOt-E IMPROVEMENT CONTRAC T OR h iUrt f? e e pir.ttiur. iatt. If found ret rrt to: 0,iice Of£:oruunrEr Afiatrsand I usineSs Regula ion r.erDisiraiion: i7 :141 Typet, 3 s,.-:-:s,.-:-:51-10 Expiraticn: 6P-512016 Supplement Cara Bosom'1"iA 02 H 6 UILDER SEPVICES GROUP, INC. ICHA.RD SC:-'.IJARTZ P,'fTONn oEr.0 i, FL M14' 'ndcr;rcrc;a; Not validj ithout sinsturc taVI RIC€tAR0 SCliWARTZ 1 r35 i t(11q'I'{t Is_i:STR E,EY f IAOCIICtitet'Nil 04126/201(i �c Stri(ar cf T v. C:SSI:K; (nsutafi rn Corttrattnr ifllr fp p(7ssesti a c0fr'ent ed'tion of the Nfassachusertti ;Ic.(:[sttikdui CodC^is cauS(�for tl=,vocation()f th15 lion,€t. _.__...............