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HomeMy WebLinkAboutBuilding Permit # 5/3/2016 TOWN OF WORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: i Date Received Date Issued: �IMORTANT:Applicant must complete all items on this page LOCATION C ---=- �lPnnt: PROPERTY OWNER 100 Year Old Structure yes" no . Print MAP NO. �� . PARCEL: ZONING DISTRICT: `Historic District yes no Machine.Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family ❑Addition [I Two or more family ❑ Industrial Alteration No. of units: El Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Floodplain El Wetlands 11 Watershed District. ❑ Septic El Well p E!Water/Sewer DESCRIPTION OF WORK TO BE PERFORME[Q,: cle \ A 0/sc 5 i"A � 11 KC Identificatlo ]Please Type or]Print Clearly) Lo,2, 1 J L,�� l' OWNER: Name: F� Phone: Address:& I EHome CTOR Name: J ave . ,,, :Phone: �ti '"'o Ex Date: r's Construction License: �> p rovement License:— ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST! SED ON$925.00 PER S.F. Total Project C®sf: $ / ' FEE: Check No.: Receipt No.:_ d� � NOTE: Persons contracting with unregistered contractors do not have access to the en ranty fund/ Signature of Agentl0wner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ' y Date Received Date Issued: �? IMPORTANT:Applicant must complete all items on this page -LOCATION '"PROPERTY.OWNER • , Pant;, 100 Year Oltl Stru toe es c r y no MAPNO PARCEL ZONING DISTRICT N�storac Distract yes no Machine:Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition El Two or more family 11 Industrial p Alteration No. of units: ❑ Commercial El Repair, replacement ElAssessory Bldg ❑ Others: ❑ Demolition ❑ Other tic:, D Well ❑ Floodplain;; �; ,�1Netlands ❑r Watershed District, Ei Water/Sewer r,. s y DESCRIPTION OF WO K TO BE PRF RM v /T aC. Au ( :X, kt CJ kr��Z I ntilication Please Type or Print Clearly) ` OWNER: Name: Phone: ��~ ' Address: CONTRACTOR Narne ` . ` hone: 1—� 9 Address: �- 3� = � r < '3 Supervisor's Construction License: Exp. Date Home Improvement License: Exp. Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ Z 0 r Q L) FEE: $ Check No.: Receipt No.: NOTE: Persons contracting wi h unre istered contractors do not have access to the gacarainty fund Signature of contractor �Signature'`of Agent/Ow _. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I tkORTH Town ' offAndover �,. 0 WIN- — Clk LAhVer, ass, cocNicHew�c.e �1• _ U BOARD OF HEALTH Food/Kitchen PERMI-T LD Septic System THIS CERTIFIES THAT ..................... .. .. .... ........... .... .......................................................... BUILDING INSPECTOR has permlS n 0 tact g Foundation .......................... buildings on .. ... ..... .... ... . ...�...........::. Ro g to be occupied .. .. . . ..... .. ... .. ...... .. . . . . .. .. .. .. .,. Chimney Rough provided that the person accepting this permit shall in every res ct 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 UNLESS CONSTV�11,ONX Rough Service ...... Final BUILDI INS CT®R GAS INSPECTOR Occupancy Permit Required to Occupy Buildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. w . ._ . P € f . of pages ., ....... .. .w. John Morrissey Remodeling 57 ComxA St. No, Andover, MA 01845l II' PROPOSAL SUBMITTED TO: JQB NAMI JUr3;d Aeeftl ESS __ _.__.___ � � dan LOCATION .._m m i .a W...._.. .. ... .. --J...._ wv.. DATE I)AT6;t7F PI ANS .......,", ._ ___._...�...,.m.. _. -__.........................._..... ......... _ .. ......_.....................___...____...... ......_ PklONf FAX N AFiCIIur :.w mmmm_m. .: _ __.,_ .. _ ::.:u .... — - _ . ehtreby submit specifications and estimates for: � '9m.,r`' ", ,u�Y��� Nr'"',, ,., ,d"." ^' u�'Q .., .,., ,. „.,, ...... ..... .... .. f � ... ................ ., w"w. _. am k � � of .............. " .. ................... .. ......... .... as .... ............ r a ....... .................. r " ,w 1 _..... ...... . . w�6w ,,� ," .., ...... _.. _ 3 e propose hereby to furnish f a�t�erial and labor -complete in accordance with the above specifications for tire~;jurat of: J � a r €.. ___. W..k... Dollars i f _ _._.... .. with payments to b¢,ntac�lc gas frallows. :.::.. . �... t t.t . `, . ... t° I Any alteration or deviation from above,specificatione,involving extra coasts Respectfully will be executed only upon wr0Gten ordor,and will become an extra chYarge submitted rave i arid above Me estimate All arae ernents contingent upon stake ware c1r nfti nr delays ay beyond Baur conuaL Note this proposal may be withdrawn by us if not accepted within days 'the above prices,specifications and conditions are satisfactory and are y hereby accepted You are authorized to do the work as specified, �a F'tayrnerats aulll he made asoutlined above. irfraatttre _ M F � _ t - ���K .._....� �., .._._. ' "".. 1 Date ofAcceptance m.....:..... . "� �'.:.._m �... � �..r ........... .. .. _.._..._ tic{nihil°e _.......� :� .. .�.... ........... . A•9J4S6HIfb/'1'-7(#Cip Ga�1a I i The Commonwealth of tilassachusetts .Department of IndustriglAccidents Office ofInvestigations 600 Washington Street Boston,MA 02111 wwlv.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Leglbly Name(Business/organization/Individual): E� c�' iA ' a Address: �7 <A- - � � - City/State/Zip: Phone#: `7 9 Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/orpart-time)x havehiredthe sub-contractors 2.[ I 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. workers'comp.insurance. 9• [,Building addition [No workers'comp.insurance 5. [] We are a corporation and its 10.F1 Electrical repairs or additions required.) officers have exercised their 3.0 I am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.Q Roof repairs insurance .re uiredemployees.[No workers' required.]� 13.n Other comp,insurance required.] 'Any applicant that checks box#1 mustalso fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they tfre doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the,policy and job site information. Insurance Company Name: /%' SS J Policy#or S elf-ins.Lic.#: 76 Expiration D ate: �U� Job Site Address: A de- J L City/State/Zip: AJ. Attach a copy of the workers'compensation-p olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenadties ofperjury that the information provided alcove is true and correct. - Signature• L/� I bate r/? Phone#• 61 7e t7 F? L/ 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): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - A �® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 5/3/2016 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 CONTACTPaul MacDonald NAME: MTM Insurance Associates AIC NN Ext): {978)681-5700 ac No:(978)681-5777 1320 Osgood Street ADDRess,certificates@mtminsure.com INSURER(S)AFFORDING COVERAGE MAIC# North Andover MA 01845 INSURERA:Travelers Casualty Ins Co of 19046 INSURED INSURER B: John Morrissey INSURER C: 57 Concord St INSURER D., INSURER E: North Andover MA 01845 INSURERF: COVERAGES CERTIFICATE NUMBER:15-16 Master 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD POLICY NUMBER MMIDD MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO NTED A CLAIMS-MADE [XIOCCUR PREMISES a occurrence $ 300,000 6802DS957331542 6/18/2015 6/18/2016 MED EXP(Any one person) $ 5,000 -PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X F C LOC PRODUCTS-COMP/OP AGG $ POLICY❑P2,000,000 OTHER: A101 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS I AUTOS Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ PER OTH- $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ ',.. OFFICERIMEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. Bldg. 20 Suite 2-36 N Andover, MA 01845 AUTHORIZED REPRESENTATIVE P MacDonald CPCU, CIC XJ(/!17(►�y'� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025/2m4nn r%1f ( 'OY/r//IOXlOf'IK(f�r C AKljJfr'�ClJef/J Office of Consumer Affairs&Business Regulation -terOMEIMPROVEMENT CONTRACTOR Registration: 189543 Type: Expiration: 715/2017 DBA JOHN MORRISSEY REMODELING JOHN MORRISSEY , 57 CONCORD ST NORTH ANDOVER,MA 01845 Undersecretary k 7 Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-105236 Construction Supervisor JOHN MORRISSEY 67 CONCORD STREET NORTH ANDOVER MA 01846 +�/►�""'� v�-- Expiration: Commissioner 1112612017