HomeMy WebLinkAboutBuilding Permit # 4/19/2016 OORTrl
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BUILDING PER I I
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN(: EXAMINA
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Permit NO:_� 'D Date Received I
P US�RL
Date Issued: T`
MP RTANT: ))licant mast 'om Mete all items on this a e
n
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Fitarht1 l Dl�trit; ISTRICT:ON'
Mb6hihe Shop V10"
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building i.:! ne family
ition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement I Assessory Bldg WW _.W.. Others:
Demolition Other
C IVkl, !i Well ; CJ Floodplain, 1.3 Wetlands W tersk� di trldt
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- Identifi nit on Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
, g`�AOR ( hone:
odo iZAI
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an�Li r
. p. Date:
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777,77777
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Exp, ate:
ARCI-IITECT/ENGINEER_ „" _ _,.,.. Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1 00.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cos : $ (( / FEE: $ .
00
Check No.. ..—_.--Receipt No.: _
NOTE: Pei°sons contracting with Ilnreqistel•ed colatl,actors(Co not have access to the mIIaI°rinty f III(1
Si Mature of Agent/Owner---- ignatu _wont-r- t _ --�-
Mai RTHTown of over
_
Ilk
C,° h , ver, Mass,
COC NICMEWICK �•
41,9 °R�creo rep�,�5
S fJ
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT ........ .I..... .. ....8.Cf told.f .......................................................
.,® ®�'. . ..... . Cj.'rd.c
Foundation
haspermission to erect.......................... buildings on ..... . ..... i..c.®�/. ... .......
Rough
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to be occupied as .......... ... .. .. .. ............ .... .l.. r. ................... ................................................ 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 I 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCTION STA Rough
.... Service
...... .. .. .. ...... Final
BUIL NG INSPECTOR
GAS INSPECTOR
Occupancy Perinit 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
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RISE60 Shawrnn.rt Roa(t, Unit 2 ( Canton, MA 02021 1339.5o2-6335
wwwAISEengineering.com
AUTHORIZATION
pwr)r,r's N@rr'0
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MA ConlrnUor Rctiistrrlllon No 120979
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RISE I n�ntnt�rinFodorat 10#05.0405629
g RI Contractor Ropi5tr011011 No 0106
MA Contractor RoglstrAtIOn No J20979
rIRISE1 division of-1 k{n�iflcrrill„ CT Contractor Registration No
ENGINEERING 61)"lumnint t nit rig,('ancon.%I 1
(4111)784-37UU I'.1X(401)7A4•37IU CONTRACT
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PR(7(d ANI 1RfSCON IRACT15(NTT(t[OM10UET%9"k1t151
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SERVICE CIIY,IITATf.21" ❑(Lll'iG C:TY.57AT1:.r:P
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Total: $2,604.38
Program Incentive: $2,100.78
Customer Total: $503.60
WE AGREE HEREBY TO FURMSH SERVICES-COMPLETE IN ACCORDANCE tVnH ABOVE SPECIFICAT!Ov5 FOR THE SUM OF
I
'"Five Hundred Three&601100 Dollars $503.60
V I'D::Fi;inl tt:SF,:C 710:1 N!u AS`i'ROV,lL tlY N15C Ct:G:':LEftilf,i cUGTOFAER A,REES TU NE/.1:T A!.IOINlT CUC I'l F U:l,Ill i C.It E5�t:l'1:tiaiL 9E CMAfili!:)IA.sF,i rI.Y O!t A'lY
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HLV[RSE FOR:!Jt'OR M. Uli0"111,11DnOU GUARA}i1EE5.111311'r OF ttl Ct510'7,SCHEC:1:1':::.At:UCO!liFtAt:7,IR)trti:5:it7.t1C!i
00 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
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CATS Or ACCCPT1.:.e
ACCEPTAUCI.OF CONTRACT-7HC AaOVr MZES S>ECIr,C%.T 101:5 NIU CO!:U111OUt:AltL
=Ai15FACTORY-0 U5 A`rp ARE REREBY ACCEPTED 1'OC ARC AVTRDFit,EC-TO CU'nE.VX;RK
L -v- AS SPFc:F!EO PAVI.lF 1:i Yrt t.Ur AAE( JA!IUVf y--
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,A" 02111
wiviv.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors[Ei lPlease
tricians/Plumbers
Print
A plicant Information
Name (Business/Organization/Individual'): co-op Power
Address: 15A West Street
City/State/Zip: West Hatfield, MA 01088 Phone 9: (413)772-8898
Are you an employer?Check the appropriate box: Type of project(required):
4. 0 1 am a general contractor and 11 0
1. am a employer with 20 6. E]New construction
ors deling
have hired the sub-contractors
employees(full and/or part-time 7. 0 Remodeling
listed on the attached sheet. '+
21-1 1 am a sole proprietor or partner- r""',i itin
ship and have no employees These sub-contractors have 8. R Demolition
working for me in any capacity. workers' comp. insurance. 9. 0 Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its I0 ❑ Electrical repairs or additions
required.] officers have exercised then* I I.[] Plumbing repairs or additions
3.R I am a homeowner doing all work right of exemption per MGL
c. 152, §1(4),and we have no 12.R Roof repairs
myself. [No workers' comp. employees. [No workers' 13.2 Other
insurance required.]t comp. insurance required.] I
*Any applicant that checks box#11 must also fill out the section below showing their workers'compensation policy information.
"Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box most attached an additional sheet showing the name of the sub-contractors and then-workers'comp.policy information.
I ant(tit employer that is providing workers'compensation insurance for tit),employees. Below is the policy and job site
information.
Insurance Company Name:__ HDI Gerling America Insurance Company
Policy 4 or Self-ins. Lic.g: EWGCCO00187715 Expiration Date:—11/08/2016
City/State/Zip:---/
Job Site Address:
Self-ins.
expiration date).
Attach a copy of the workers',e mpensation policy declaration page(showing the policy number an
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 hereby certify it formation provided above is true and correct.
j)det-tiiep(iiiisaiidpenaftiesofpeijuiytli(ittiteiii
i nature: Date:
Official use only. Do not write in this area,to be completed by city or tolvii official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Elnspector5. Plumbing]Inspector
6. t ier
Contact Pet-son: Phone#:
AC"R!®C� DATE(MM/DD/YY-YY)
CERTIFICATE LIABILITY INSURANCE 11/12/2015
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 NAMEA TDebbie MacNeal
James J. Dowd & Sons IRs PHONE FAX
14 Bobala Road A/C No Ext: - - A/C No):
E-MAIL
Holyoke MA 01040 ADDRESS: dmacneal@dowd.com
PRODUCER
CUSTOMER ID#:COOP
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A:HDI-Gerling America Insurance Compa
Co-op Power, Inc. INSURERB:Torus National Insurance Company 25496
15A West Street
West Hatfield MA 01088 INsuRERc:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:254565888 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.
"— F:
ADDL SUBR POLICY EFF POLICY EXP LIMITS
SURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYYEGGCC000187715 11/8/2015 11/8/2016 EACH OCCURRENCE $1,000,000
DA AGE TORE TED100,000
ERAL LIABILITY PREMISES Ea occurrence $E �OCCUR MED EXP(Any one person). $5,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000
X POLICY PE LOC $
A AUTOMOBILE LIABILITY EAGCC000187715 11/8/2015 11/8/2016 COMBINED SINGLE LIMIT $1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $ '..
X SCHEDULED AUTOS PROPERTY DAMAGE $
X HIRED AUTOS (Per accident)
$
X NON-OWNED AUTOS
$
Comprehensiv
B X UMBRELLA LIAB OCCUR 70354Q150ALI 11/8/2015 11/8/2016 EACH OCCURRENCE $1,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000
$
DEDUCTIBLE
$
X RETENTION $10,000
WORKERS COMPENSATION EWGCC000187715 11/8/2015 11/8/2016 WC STAT U- ER
TH-
p TOR LIMI ER
AND EMPLOYERS'LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? ❑ NIA ,
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS below 117, 1
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Certificate Holder, Eversource, and National Grid are Additional Insureds on a primary and
non-contributory basis per written contract
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.
CLEAResult
Attn: Contractor Services Dept.
50 Washington St. AUTHORIZED REPRESENTATIVE
Westborough MA 01581
@ 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
� tit �_�t)(1S1i11"lt;i' !��isili`Sllt,�i ��iliSlnt'�S �rc�4;r11iL111ti11
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Boston, TvIassacilust-tts 02116
improvement Contractor Re�(istrat1011
Reqisfira�ic)'; i6.21
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Expi 1/2 /20
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:•:: Oi �JWER, INC.
/a VvE`.T ST
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i r,dete :lddres::uirl i
,turn earn, \1,111, r<�t3.«n for chanuc-
Address Rendv at I-,mplovillent Lust Card
.ti ISu•in�•, IZc;�ulai:��n Licensc or tegtetnttintt i<tlid for to+itvtdut uu onh
OMF IMPROVEMENT CONTRACTOR before the expiration date. If f+)und r ttw
()ffirc of { onuin r affairs and Business Regulation
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�_� R +1�strailon: _ 21?
Type: 70 Par;: Plaza-5uttc X171)
;_xpiration: 1 ?018 -id Boston, N'TA 021 16
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LEAH C"•,�
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WE ST lot valid without Sion:tturc
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CS-097409
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LEAH M DANIELS
12 MARCELLA ST
ROXBURY MA 02119
05%18!2017