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HomeMy WebLinkAboutBuilding Permit # 4/14/2016 VAORTH BUILDING PERMIT 0.1�t��° a��o TOWN OF NORTH ANDOVER 0 � APPLICATION FOR PLAN EXAMINATION � z _ate. Permit No#: /�> .��f -/�� Date Received ��°°RATE°PPP�RS cus� k Date Issued: � ��� /�_� s IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER -""Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition [I Two or more family ❑ In stria) CIAlteration No. of units: ommercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 777777777777-777777 ❑ Se tic ❑Well ❑ Floodplain ❑Wetlands p hed ❑,Waters DistnctG �. DESCRIPTION OF WORK TO DE PERFORMEVVxD. yy ]� / / ( ��® A f d lC eBm� �C �T� � �. dV�`ds � ��'_ �ra:c�t Identification- Please Type or PrineClearly : Phone: c.­ °6 OWNER: Name Address: [Home ractor Name: �SC �`�( �� Phone: l A" tele s � ess: rvisor's Construction License: � 0 4'b,'43 _Exp. Date: / 1 Improvement License; `" Exp. Date: 1 ARCHITECT/ENGINEER kd e, � �® sir' Phone: — . Address: ° mA Reg. No. `7 6L) FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ l041 OD FEE: $ Z° � Check No.: Receipt No.: NOTE:` Persons contractingwith nnr"egistered contractors do not have access to tlae gaaaraatty fund P FORTH Town of Andover ® *L Cl- �.K. h ver, Mass, COCNIC"t W" �j®S pRA rE O P ,�C7 UL BOARD OF HEALTH Food/Kitchen PERMIT 11111116miff Septic System THIS CERTIFIES THAT 16� �� ¢ � BUILDING INSPECTOR has permission to erect buildings on `�� G� f'l�© �� Foundation .......................... ...... .................................................................. Rough to be occupied as ........... .1�/�... :....... :.: .......... ...... Chimney ...................... ........................f..... 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough 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 Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts r F Department oflndustrialAccidents d X 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 A A �[.� .� Please Print Legibly Name (Business/Organization/Individual): l t- I � _�� -n- Address: YS- (--'/a S z ' City/State/Zip: Phone#: L728— —W `, Are you an employer?Check&e appropriate box: Type of project()required): 1. am a employer with .. , employees(full and/or part-time).* 7. Q New construction 2. I am a sole proprietor or partnership and have no employees working for me in $. emodeliag any capacity.No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4. 10�]Building addition 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.Q Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof 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 c. 14.Q Other 152,§1(4),and we have nc,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. Homeowners who snlimif 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 fiave employees,lliey must provide their workeis'comp.policy number. I am an employer that is pidvidiiig ivor•kers'compensation insurance for•my employees.'Belory is the policy and job site information. Insurance Company Name: A 1 Policy#or Self-ins.Lie.#: 5-0 t) 5' x5'5'''7 Expiration Date: /V Job Site Address: 35/ Willow 5 City/State/Zip: ��,/¢ Attach a copy of the workers'compensation policy declaration page(sholving 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 WORD 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. I do hereby certify under thepains and penalties of perjury that the information provided above is true and correct. Signature: Date: Ari Iz t e Phone# Official use only. Do not ivrite in this area,to be completed by city or town official.. City or Town: Permit/I,icense# 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#: OP ID:WC CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 04/07/2016 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 CONTACT Segreve&Hall InSUr.ASSOC.Inc NAME: RUSS MalIIOUX 305 North Main St. PHONE End: FAX No Andover,MA 01810 E-MAIL Michael L.Segreve ADDRESS: PRODUCER RUSSE-2 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Mailloux Brothers INSURER A:Arbella Protection Ins.Co. 41360 Construction Co,Inc. 55 Chase Street INsuRERe:A.I.M.Mutual Ins.Co. 33758 Methuen, MA 01844 INSURER C:Commerce Insurance Co. 34754 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. ILTR TYPE OF INSURANCE SR UBD POLICY NUMBER MRI M/DDY EFF MM/DD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 8500060007 07/13/2015 07/13/2016 DAMAGE TO RENTED 100 00 PREMISES Ea occurrence $ , CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,00 '.. PERSONAL&ADV INJURY $ 1,000,000 ''.. GENERAL AGGREGATE $ 2,000,000 - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ '.. (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,00 ALL OWNED AUTOS BODILY INJURY(Per accident) $ 300,000 C X SCHEDULED AUTOS BGGZCG 05/20/2015 05/20/2016 PROPERTY D X HIREDAUTOS (PER ACCIDENT) $ 100,00 X NON-OWNED AUTOS OBI $ 250/50 Med Pay $ 8,00 UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ ❑YN N/A 5005012557 10/02/2015 10/02/2016 E.L.EACH ACCIDENT $ 500,00 OFFICERWEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101 Additional Remarks Schedule if more s ace is re cared RUSSELL MAILLOUX&RONALD MAILLOUX ARE EXCLUDED FROM WORKERS COM CdVERAGE CERTIFICATE HOLDER CANCELLATION NORTHAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Bldg 20 Suire 2035 1600 Osgood St North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-048231 Construction :supervisor fr 4 RUSSELL MAILLOUX 55 CHASE ST METHUEN MA 01844 Expiration: Commissioner 02/11/2018 Z'A.J1oiIf"C"N' Office of consumer iffa►r5&Business 12egulation License or registration valid for individul use only T before the,expiration data.:-If found return to SOME IMPROV C,ONTRAi:iGk eg�stration 1P.C7; Office of Consumer Affarrs and Business Regulation Expiration YF~ (Tiv le Ccm c:)r..non 10 Park Plaza-Suite 5170 fes, .. MAILLOUX 3ROS CONST CC};ih�.: Boston,MA 02116 Russeli Maillriu ' 5h GFASE STREET, fnydetsee_etas. Not valid,wjthout.signatu113