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HomeMy WebLinkAboutBuilding Permit # 3/30/2016 ORTH BUILDING PERMIT %A TOWN OF NORTH ANDOVER 0 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ArED CHUS Date Issued: IM#ORTANT: Applicant must complete all items on this page f ( 6'��i�''+ ' I,. i r j� f I � � 1` � i °�l �r�l r, I � J,�// TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ane family 11 Addition Li Two or more family [I Industrial 11 Alteration No. of units: F1 Commercial ri Repair, replacement El Assessory Bldg 11 Others: El Demolition [I Other Nrr ON,/ mCIV DESCIRIPT ON OF W RK TO—,BE PERFORMED: 7777 , A)/'y'k I r Identific tion- fleaseType o 1�r Print Clearly OWNER: Name: Phone:" Address:- L'I'd A? IN -"n Nkfl V X W womai/ r„r rr 111011 gIgi ve 4 a 10r, 011 FROM, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. ,”' Total Project Cost: $ 5, 7' FEE: $ Check No.: 21Receipt No.: ,12- 162, 1:1 NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund -------------- 7777`77] Agent/Owner Signature of contractor NORTH Uj"%,wn of" Anuover 1,. AIL C, T h Ver, ass, 2 o LAKE ti COCKICNE WICK 5 S V AW BOARD OF HEALTH Food/Kitchen E R I L mummmft� Septic System JTHIS CERTIFIES THAT ........ .................. BUILDING INSPECTOR .. ......... ..... ....... ........... a,2........ .......... ... . IL �, � �.... Foundation has permission to erect ......... ..... ......... buildings on . ....... .. l..... �..... Rough to be occupied as . ... . . . . .... .... .. .. .. ... .. 'o"f" .... ... ... .� .. Chimney provided that the person accepting this permit shall in every respecconform to the terms of the app ication 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. 4 WerUA- PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMITEXPIRESIN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST S Rough .A........................... 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 Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. 6` f � e 1 RTE Sa&a ft a tm�Bteti Adlt�eaallTsEdxh b9 tRo&p.CttMtW IfAman CONTRACT PW I FAXED f.1Hbi�8 �a Damald to S mg)89 plm 021OM6 401273 Am Raw 105ffi11d&Rfsd 105HMft ;,oad NW&Andavw,MA 01843 NwMAsdvet.11AA 01845 SON �&OAFW.W, 19 p lada►aticeatmatpnaodaa��e dmBfianafir&ad 9BATJsaw I11� IirA �reama�smsmsoa�s��rTsasoa�Laaa�aatrla�ogge 7ht. vrmla �tamdfil eot:oattv�5 t5aaooaft�odelamiasaddie�ttoEQ6bmassoaadsatgomrfimaev4tifieteRar�tafiettffi�diead of ehaaaasd{rtdoorairAtmuEsletobotmOdtOcealgotQtroasaem� mn$i.fo�ead0@eeP pdmm9 anal Por tmd�fire��Oo ear.baeeeaaatR ttttedtoti aed�tv�tan not�aaeXy atiCa�eda'feFaa�l++e�kol8laro�$b�s.A at�odfiseobto@asparmiaumcoQ�afatrtaAtaedoaa�A!ooaa:baetfiea�s! �aiesa�sa��oe� Atmomatafthm 9, P,aFAdUmmtdaaraedfartmobusba aat�r tv�i6000ta�cteodgyatomaataedsoaett�yostlso tedanrahgim�y. s�aao ATAC3=LAT.Rovt�atabaracdao�fi1a�11a6�S°fi�raraf8r19es�ood8boegtetabatmtn¢09)�molaotofaCtoq�e, S44M Ai41CF1.AT.Pcavidaiaboraa0ia�mtas�iln9'byerotR,30ce��mg�stimttrtot64b)aq�e�etafatLtaepeaa 8A88ffiistetdotbrlhotsamvalaftftct�neditz�bladdaglfialot�ifi�OnaSvtlm aoulcfittfieas6a.Diamotralatmtooaarpdmrta@ceta�veadctsten . • Y'IiCA�:Piov�databoraadmetaiatttoiodstitl)�4� SwverSorthaett�ae�sAtl�agta�7�te ottverhasfotit�ssl tot�fatefrhal�ge. +r�aaa 'Q�kPaavt�e�areda SLmiaa�u d�Omstn 3jeofierbgyeooaade�adraw. 41 H11if C�II�i<kPtariQbOtAat�ataro (tl�ffiaemr�otalBrWtosBtoodbbot�setasonmtfiop�meta oima6a�totel9Ogatt3efiouto�l. • StOD.00 i OVEDUNM RoNdefitboeaadt lot"J r1<n37deat*Fc*dchm1Od�lam tet34)agttaeaA e! exErAaromttsggloenmdfietaa►aQanmdffisormea�lq+dtfi�gimim6tdroavmTmt+gftombet�f�Tadt�odw�l6eptag� �adA be teatt�v1�aeOt:Eorgade ts�tlo aad kft fit a t�tae�►aeaaIIt aea�O.it�b as�ag aad totsdrnp ratdboBseattama�Y� !l36Aa R wII1�pt5►a0ap tRdlg a&toadivestod�saoatruY.Y=wWc bebW dit tattm= -,-_-, dt�toaxaast+ts, ttetof6os7996tmtBtatooedt?,4Q0►ser5�en4aadeateomtNaeotlOR%l6tdea of �( ScetlagascrsaratupmtkeseaE680aadaeadr& i"140�ansdageamjtedlgrdmacaScar. ''T-7 ��,.J✓ L ',r f'. Rardm.at�raadhmUba!„onrfio� ab�,,aroa�lbeaogablaaaecdmrd�teettbeaatrflawv 1 .- -'�� ��� ronrrroamtmtfit�aoNeomsxkbbegisq,aad.daramae�arfia�eaaieitovm�wowMtaheeteRtl� ef r',; ! �:� f! MAR - 16 a ) , Pedot�t{DOeSQWbeZ� Adh#Eoaof7ptd�eb �Aetfofi08?'B aooasc�,�aeuomu CONTRACT PROGRAM pap 2 a1can 1Ts�ald Cie (978)8360079 012016 401272 Ogg 1051 Road t05 Road Nm&AndoMMA 01845 Nm&Audove;MAOl845 JOD DDSCREMON draoo a�►atya�* a aanm�ee��Imanaafoaol�Dm�baiaaaoattayoe.fwa0� ftwdobs3uia swao epiM,c,,, vee cW -1(1 trol[e Acm �kvke..,ard, n S -P(��t� ani n Wb hcLv,&- JnsAj6c (�,uu on &maevd �rr uhem tr 56a-L--ncededt -b r (u&J--,prlr * c*- WU5vr • Rpb,.e4 �qrl VeA Am RIS en rrwenn . 0 A6 cork or,,. Cummu aa0 rTout $0ZSA8 *�cEaa�aTt:t�rrn�aaanco 151,ININS ME 0 � Koo 30 The Commonwealth of Massachusetts I Print Form Department of Industrial Accidents Office of Mvestigations 1 r�'r• '-7-44 1,�' 1 Congress Street, Suite 100 . , Boston, MA 02114-2017 w w Nr.mass.go vAlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization,/Individual): Builders 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): 1. ✓❑ 1 am a employer with 100 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.F] 1 am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9• ❑ Building addition [No workers' comp. insurance comp, insurances . Weare are a corporation and its 10.❑ Electrical repairs or additions required.] ❑ 3 officers have exercised their 11.❑ Plumbing repairs or additions .❑ 1 am a homeowner doing al I work myself. [No workers' comp. right of exemption per MCL 12.❑ Roof repairs insurance required.] � c. 152, ��'1(4), and we have no Weatherization employees. [No workers' l,,'). ✓❑ Other comp, insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy in'Ibrmation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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. If the sub-contractors have employees.they must provide their workers'comp.policy number. I am an emplo ver that is providing workers'compensation insurance for rnV emplovees. Below is the policy and job site information. lnsuranee Company Name: ACE American Insurance Company Policy 4 or Self-ins. Lic. #:WLK 48151553 Expiration Date:6/30/2016 Job Site Address:-40), �.. r .. a` _ Cit}/State/Zip: • 1t � A )� ) 4 °w 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 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 herebV certify under the pains and penalties of pefjuay that the information provided above is true and correct. nature: Date: Si r m �F r � �' �.•--�--� Phone 4:603-324-1974 Qfrcial use only. Do not write in this area, to be completed by eitV or town of"cial. 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 4: s DATE(W1MIDDNYyY) CERTIFICATE OF LIABLITY INSURANCE I 0612420,6 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). JIN CT PRODUCER 'D Aon Risk services Central, Inc. (g66j 7b3-71?? FAX (800) 363-0105 m Southfield MI Office .Ezt) (AIC.No. 3000 Town Center o 5ui-ce 3000 SS: _ Southfield MI 48075 USA INSURER(S)AFFORDING COVERAGE NAIC INSURED P.A Old Republic Insurance Company 24147 TODBUild Co rD. INSURER B: ACE American Insurance Company 22667 '.. 260 Jimmy Ann Drive Daytona Beach FL 32114 USA kI'N1SU'REF C. ACE Fire Underwriters Insurance Co- 20702 D: E 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. N07WITHSTANDING 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 B1'PAID CLAIMS. Limits shown are as requested S TYPE OF INSURANCE S POLICY NUMBER O CY I O C Y. UFdITS LTR lNSD WUD M1i I. C YYYY (MM/ODJYWYI A X COMMERCIAL GENERAL LIABILITY r4WZY304834 06/3 _ 15 6j5 2 01bi EACH OCCURRENCE S?,000,000 CLAIMS-MADE X❑OCCUP. DAMAGE O R N ED 52,000,000 PREMISES Ez occurtence) MED EXP(Any one person) 525,ODO PERSONAL d ADV INJURY 52,000,000 roe GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S4,000,0001 m PRO- X POLICY ❑JECT ❑LOC PRODUCTS-COMPIOP AGG S4,000,000 � C THE R. o A AUTOM061LELIABILITY PIWFB 304835 06/30/2015 06/30/2016 COMBINED SINGLE LIMIT 55,000,000 (Ea--dem) ANY AUTO BODILY INJURY(Per person) Z ALL OWNEDSCHEDULED BODILY INJURY(Perawden7) N AUTOS AUTOS X HIRED AUTOS X NON-OWNEDPP.0 ERTYDAMAGE '.. AUTOS (Per acodem T' N Ur8HFEELLA LIAa OCCUP, EACH OCCURRENCE U EXCESS LIAB CLAIMS-MADE AGGREGATE '.. OED RETENTION '.. B WORKERS COMPENSATION ANDIIJLRC48251553 06130j201506/30/2026 PER OTH- EMPLOYERS'LIABILITY XSi PTUTE ER YIN All Other States ANY PP.OPF.IETOP./PAF.TNEP,/EXECUTIVE EL EACH ACCIDE Ni SS,()00,GDO C OFFICE PJMEMBER EXCLUDE0 N NJa SCFC4815190 06j30/7015 06/30/Z016 {Mandatory in NFT) WI Only E L DISEASE-EA EMPLOYEE S1,000,000 If yes,dcscnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT 51.000,000 '.. ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional P.cmarks Schedul,may be anached if mora space rs required) d vidence of Coverage RTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIP.ATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Builder ServicesGroup, Inc. AUTHORIZED REPRESENTATIVE A TOIDBUild Company 260 Jimmy Ann Drive Daytona Beach FL 32114 USA ©1988-2014 ACORD CORPORATION.All rights reserved. aCORD 25(2014101) The ACORD name and logo are registered marks of ACORD - _ i Ce O Conn iii e r ai,�Il U J less Reaalati on 10 Park 33iaza - Sine -5170 Boost0 M.`-,issa—chtlsetts 021116 Home 1mprove lent Contractor Registration Registration,: 179141 Type: Supplement Card Expiration 6/212016 BUILDER SERVICES GROUP, INC. RICHARD SCHWARTZ 110 PERIMETER RD NASHUA, NH 03063 I.t dMe Add Us and return card—'Hari.reason for-c wTt. Address Renes+'a; Er plojnlcm Lost£ and =s--_{>I'Jorr:f i'ts nsuncr Atfa r,d Lictnse f,r registration valid for indis'idul use a0- Bulls e zi ,n hcforr La te. If found return to: aG3E PJ ??VEMENTGONTPACTG% Office of£onsurter Afiairs and business Regu latirin '/0regsaio : 17941 Type 10 Park PlnzSuite 5s Expiration: 072/2015 Supplement Lard $ostor—NIA 02116 UILD=R SERVICES GROUP, INC, ICHA.RG SCH-TJARTZ �_ �✓ 30 JiMMY A1.1'QN1 DRIVE A.YTONA BEACH, EL 3_114 c'ncler+cir:; rt Not ti'.31iv_N'ithout sOnalum « C&SLg«««o! # �\ m C6g<a SCHWARTZ & \ !» mglR�s;��RErI all> /k riamm»A! 9!D «rzll2yw . <qtn dTmcSSLAC ua Isom awe%p «,mamm a«a m,QawxG e ae ! &g Qw beu2""MDU bna to Name,