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HomeMy WebLinkAboutBuilding Permit # 4/19/2016 %AORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION a � Permit N�xo ,. Date Received 4LL °oa�T�o�Qa C061JS r Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION S f161 qrinLt,( PROPERTY OWNER ,ro rint 100 Year Structure yes no MAP PARCEL: ZONING DISTRIHistoric District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential _ ❑ New Building ❑ One family ❑Addition w4wo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ® epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other X, ... ,.,.,. zarN� ,,T.io...r�,� �riiini/�i�✓ir/ul/✓IIU.11J rr��:rr „aro. rfrl ir.�lal ,ll ..C,. y1 r. ,l 1 �. ✓ � :i,. o"i r , o,R f,. -I r / fffllf JII;L,Jr�� //ll �, / / , i lA,p /i/D/'/�'//�l !.//��:/ f„ ( G � ,�1!D. / / 6( I'� ,���/ ���i f r �� ` i �rtf � sed O,sr,,� ;e � � �; ��� �e � f�, r<,� � DESCRIPTION OF WORK TO BE PER ORMED° IV M4A I 1A Identification- Please'T pe or Print Clearly OWNER: Name: i ( / � � Phone: Address: C.` 01-ml Contractor Name: . th CAC_ Phone: �� Email: ,) Address: 19% MCU I Supervisor's Construction License: Exp. Date: Horne Improvement License: 1 Exp. Date: 0 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. '9d Total Project Cost: $ � 10001 FEE: $ 9 9 W Receipt No.: «" 0 2 Check No.: �_)_.a NOTE: Persons contracting w`th un is r^ d co r^actors do not have access to the gu r n fund F NORTH own of T /oh , ver, Mass, LA COCMICNEWICN y1' �d A�"SATED �PERMIT T LD S U BOARD OF HEALTH Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT ....� ...... ................:.......................................... �� /^ � l� � �/��l/� J� Foundation has permission to erect .......................... buildings on ... .................... .. ................................................ Rough to be occupied as ..... ... ,� .......��.`.... d .................................................................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION ST RT Rough Service .......... .. ........ ... . BUILDING INSPECTOR. Final 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 Approved by the Building Inspector. Burner Street No. Smoke Det. CONTRACT ROBERT BOHONDONEY CONSTRUCTION CO. 12 HALL STREET METHUEN, MA 01844 978-685-0970(office)/978-685-8262 (fax) Fully Insured Construction Supervisor License#979 Exp 4/21/2018 Home Improvement Contractor#114238 Exp 8/16/2017 bohondonewonstrurtionPvahoo.com Customer Name: Rack Realty LLC Property Address: 126-128 Main St, North Andover, MA 01845 Contract Type: Roof Date: April 19, 2016 Scope of Services: Repairs 1. Supply local building permit. 2. Supply workers compensation and liability insurance certificate. 3. Strip existing roof shingles to bare sheathing. 4. Supply and install 6ft of ice and water barrier on all lower roof edges and 3 ft in all valleys. 5. Supply and install synthetic shingle base on remaining roof areas. 6. Supply and install new aluminum drip edge at all roof edges. 7. Supply and install new limited lifetime architectural shingles entire roof—choice of stock color. 8. Supply and install new pipe flanges as necessary. 9. ,Provide job site clean-up and safe work zone. 10. Dispose of debris from site. TOTAL CONTRACT AMOUNT: $15,000.00 Customer Signature: ���%` L� Date: `Y 14 Contractor Signature: t Date: %`( l16 . _ Page 3 of 3 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISP®SAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: /ckl� ld c '' Cl114� is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: a (Location of Facility) Signature"Per� ant � l42 Date �z --Met 0442 4 reg The Commonwealth of Massachusetts Department oflndustrialAccidents 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 PERMITTING AUTHORITY. Avvlicant Information Please Print Legib Name(Business/Organization/Individual): e Address: la City/State/Zip: Mft i gPhone i#: Are you an employer?Check the appropriate box: Type of project(required): 1.[1(lam a employer with � employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. [_1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition In I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4. 1 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 11.0 Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[ Zoof 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 G. 14.Q Other 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. 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 Iain an employer that is providing workers' ompensation insurance for my employees. Beloip is the policy and job site information. Insurance Company Name: r Policy#or Self-ins.Lie.#:&V( `fooD9`12EaU( ! Expiration Date: 7 O- lag I�G�loV v lob Site Address: l& 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. f I do hereby certifyrtnder the pains 7nrizal ' s of perj y that the information provided above is true and correct. i�Signature: Date: "l Phone#: 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): i 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 0 CERTIFICATE OF LIABILITY INSURANCE °�'�`�"'°°4/119/9/ 16 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 CONTACT NAME: Bates Insurance Agency Inc. PHONE FAX 781) 395-9459 92 High Street, Suite Bl EMIL (781) 396-4985 N Medford, MA 02155 ADDRESS: Andrea@BatesIns.com INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A:RCA—ESsex Ins Co INSURED INSURER B:A.I.M. Mutual Ins. Co. Robert Bohondoney INSURER C: Bohondoney Construction INSURERD: 12 Hall St I NSU RER E Methuen, MA 01844 INSURERF: 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 ADDL SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE 1 SR POLICY NUMBER MIDDIY MM/DDIYYYY LIMITS A GENERALLIABILITY 2CV1242 2/3/16 2/3/17 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERALLIABILITY DAMAGE TO RENTED $ 100 000 CLAIMS-MADE [A]OCCUR MED EXP(Anyone person) $ 5 000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 1,000,000 POLICY PO- LOC $ AUTOMOBILE LIABILITY CONBIINED�SINGLELIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALLOWN=D SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NED PROPERTY DAMAGE $ HIRED AUTOS AUUTOSTOS cc Neraident _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION AWC40070243322015 8/9/15 8/9/16 WC STATU- 0IR EMPLOYERS'LIABILITY JIWI` YIN ANY PROPRIEfORIPARTNER/EXECUl1VE E.L.EACH ACCIDENT $ 1,000,000 OFFICERMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If YYes,d escribe under DESCRIPTIONOFOPERATIONS below E.L.DIS EASE-POLICY LIMIT $ 1,000,000 1 7 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 126-126 Main Street North Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Inspectional Services AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-000979 ROBERT A BOHONDONEY t' 12 HALL ST METHUEN MA 01844 ti.\ ✓t__ o�;.1ti0n mm�ussioner 04/21/2018 1 Office of ...... e"Affuirs& 13usll esc Reguiotion ✓/ 0 E IMPROVEM iiegistratioi�: ENT CONTRACTOR xpirafion: 114238 , 811612017 Type: . ROQtaRT QONONDONEY DBA CONS7-CO ROBERT QOHONDONEI, 12 HALL.ST MCTHUEN,MA 01844 Clndelseeretnry