Loading...
HomeMy WebLinkAboutBuilding Permit # 5/4/2016 FORTH BUILDING PERMIT °��=`ED TOWN OF NORTH ANDOVER to '. 0 APPLICATION FOR PLAN EXAMINATION _ i � SRA deifYllt No#;0 / f Date Received �y oRA rED Wj Pp c�5 SS�CHus� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 76 Ve 5 Prin PROPERTY OWNER_ ' eQ0�� KUSJ1YJi Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Reside I Non- Residential ❑ New Building ne family ❑ASldition ❑Two or more family ❑ Industrial P'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑:Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District Q:Water/,Sewer DESCRIPTION OF WORK TO BE PERFORMED: Ce/4,4-tee- 14ff I c - t- % 14- S Identific tion- Please Type or Print Clearly Name: Phone: 7S- OWNER: Address: I 1/e5;�- Contractor Name: ErieW Phone �79 7��1- 11q 3 . i Email: Address: Supervisor's Construction License: U7-7 -7-7 Exp. Date: t4k3//g Home Improvement License: y U$ Exp. Date: �f 7- ARCH ITECT/ENGI NEER ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT;$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F- Total Project Cost: $ o��� s FEE: $ Check No.: Receipt No.: DOTE: Persons contractink with unregistered contractors do not have access to the guaranty fund 1 %A®RTH Town of ndover llil'54AI ® ID LAXII V h ver Mass, �® COC NIC MHWIC of �0 TIE D BOARD OF HEALTH Food/Kitchen PER T Septic System THIS CERTIFIES THAT .......... ........................... BUILDING INSPECTOR ........ ............................................. ... .................... . has permission to erect ....... buildingsi?l Foundation ® Rough to be occupied as .. - i ... .. . ...... .. ............... .. .. ... . .. .. ......... .. ... ...................... Chimney provided that the person accepting this permit shall in every respect conform to the terms o he 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 w LD VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final EXPIRESPERMIT ELECTRICAL INSPECTOR UNLESS CONST 10 Rough Service .. .. .. ... .. .. ...... ..... Final BUILDING IN C OR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingr Dry Wall To Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. How This fb rm satisfies au basi Afassach tpp-t bo�ema ofthestato'sHomeImProvem¢ntCannactor p fC CoerAffirGuidetoHome a �t a �Y �yP�onplatminghome�im oy 142A).butdo�nots raudeat2ndard onsnmerAffai>s anaBttsiaessR agreoing to any work as eats Mould ttrst obtain a copy U_"Aonstanez Tn(o anAtii7973 g7g7oYl�g a COPY o cad�OD12OPdatgr 3757OranpybyC !Nacos L®D�$cgOg d81)[O on a CompanyName StrcetAddress(donotuseaP�tOlfic"Boxa �) 7� 1 Atlantic ealellLlilluli ConuLLi �tndSal q�� CityrPoart /l/ liiif'. State• ode t� /d At o B-4nessAddress(mustin DaytimePhone"' l_ -- 91timss EVeaIng n _` City fawnQ `/ StatezipCode(hdiGerwrtfrmr,above) !?a ). �//A BtrsinessPhane Pedwalt mP1oY�IDorS.S.Nrmrb� '; �n:9r1ra�lLEtCastt� � Ce�yyu7tg,Nc� �AbT '�' IQS1J'-tLfA J r( r d2G fltC -ontractor tsr drnEtnaaa eaat� I1�-7� tDasc, he%-astoco :a'"wiagworkfor r " �- oe in detail the wrod:to rnmpleted, the 1€oarcowner. �ccij inSthetyp;brand,andgadeof rnateriatc t/o�beused.ny 7d'rional sheec.f, RegtdTo menaits-7hLfollotvin 9uire1d 5 and will be secured gbOddmgPnitsare GG bYtheconttactorasthehomeovmecs ropmed SuandCom {��vDelsWhosecuretheiroe�at agent: beadh tounless PtoUomSZteI e-ThefoU escluded(roan gipe GuarauPerwils wild b, �stanocsb0 owulgschedule wr71 ty puad Yana the comtratdor's Control arise I�111 e13rlpterZ4eA,) ; £� risioms of Date when wntmctOr WM begin Contracted work Tota!ContractPrimand pa ate OD contracted work will bas tbsEantiall TheContractorn YmahtSLednle ally Completed !Pees to perform the work famish the'matcaal and labor Payments willbemade acconlin to sreciticdabovcforthetotalacornofi �� • g thefollawingschedale: M S --uooa signin Con �� or uponcij othetattticonirzmpn�"the CDstofspeaalmduitems,whichevcrisgrcater bl' Completion by ) ) or upon completion of l S �upon completion ofthe contact �� -e (Law forbids d The follcwin8material/equiPmeatm emaodingfrtUPa entnnhlcontmctis ordered before the conLaned�trotomstbespecial g �PletedtobothParty'ssatistactioo) to meet the complrtion schedule(+°)egins in enter �to i e 'd for Including all fi not exceed thegeateraf gcj{3c)Iawrequit�U�any dep�it ordoxn whichm ()'enrthirdofthetotaacon T'in`e' cgai�hythoconbactorbefure "�6°fiatorderedinadvancetomeet the ca lmcaar(b)the actual cost or any a°3sxial ti+orkheSinsmay EanrersLVnrrnn F etiwFmeatarcustommadematerial Snhwntractors-TTtecoatcactnrw r.nnt h o vaded thceontraGnr? Pari}/subeontmetorn.' aPetstcbosolei Pio Yrs allrumsofthewarrxn taterialsandlaba hh dbyWecontracter. YopoasribleforcompletionofUieworkdes mmtheatneh under hiss TheconhactorfmWera arI fare,ardleasofthe tmyffiired ntract ContractAcce Bement SizrsEolresole[YresPansrTrleforall actions of contract shall not. pll-Uponsigning this document be Paymentstoansub carefitllybefnresi PYthatanylianorOther s �mta beengcontmctundarl v. clots for going this contract. tyinterest been placed on the m U�e�o� �noted within this do residence.RevievrUlefoUotvin document;the a Don't bepr�uredinto signin the gcautiousandnotices ivlaice sort:the con[r g contact T��.-e fine Ea read _ subcontraetoastobere�hasavalidHame andYunderstandit Ask questions ifsometitin gistered with theDi f eatt.antractorR "strafion.3helaw gisunclear. n� tienbywritingtothem Home Does r?4niresinasthomei ° D-e a�e contmetorhate insurance?Ask� Con 1�ROOM 5170,Bostoq AM 2116 o by'lou may in m�`�ent contractors sad PY afa tractorfor gmreabout contactor ° Know•a �roofofinswance''doeumeat hisinsum occom g617973-8787or888- } turightsand Panyinformationsothat eraL 7. Guide to theZiome Irn�onstbilities.Read the jmpO t Infn Y°tr con6rtrt coverage,°task to provement ContmctorLaw m'an0n On the rave se side of Yeuma s form and get a copy ofthe Consumer 7 cancel this agrentreotI, ifithasbeensi Contra torinwridngathiVht" gnedaia I Wird business d mom office qr branch o P ace othm Wan Ute eoutmst Wsnomral piaxof ay following thesitPdngofthisa fllcebyo�dinarymail busmen' rovided greement Seetheattadtednop bYtelegremsentw-bydeliv YaunotifyWe C� cancellationfomafitran �'notlnterthanmidnightofthe Tnvidmtie;aeoPi °rU:eeoan 5a� �ptanatiomofthisrigbx ibe�9+ktrdaWagneA U-swpy At`t BLAWS.pApq--..�� iti u¢25e otirerca �ESM =EacldZx y co-tnxtac HomeovmeYs ignattrre � Contractor's signature Date The Commonwealth of Massachusetts 9Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): & 11 tllcllltuti,LLC l R jeftersoy- venue. Address: g91e"+ M AI 1970 City/State/Zip: Phone#: f 7 k- 7Gl/f- F/q 5 Are yo n employer?Check theZpropriate box: Type of project(required): 1. I atn a employer with 4. ® I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner'- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working for me in any capacity'. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. EJ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof r pairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13. then L/i/Si comp. insurance required.] *Any applicant that checks box#1 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. 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: Policy#or Self-ins. Lie.#: !:�6 2 7 0 12- Expiration Date: Z��l Job Site Address: 2 5 h1qy City/State/Zip:-/. 14,_a1"_,, Attach a copy of the workers' compensation policy de6aration 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 hereby certify under the pains and penalties of perjury that the information provided a775 is true and correct. Signature: i> �` li Date: 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): 1. Board of Health 2. Building Department 3. City/Town Cleric 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: i AC40REP® CERTIFICATE IF3/9/2016 DATE(MWDDfYYYY) 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(les) 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 COIIStrUCt1 On Eastern Insurance Group LLCI PHONE (800)333-7234 FAx 233 West Central St E-MAIL ac No ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURER A Arbella Protection Ins. Co. 41360 INSURED INSURER B NautilUS Insurance CO Atlantic Weatherization IN5URERC: 61 Rear Jefferson A,_enue INSURER D: i INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER aster 2016 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 LTR TYPE OF INSURANCE ADD R POLICY NUMBER POLIO EFF MMI pYLIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence S 50,000 A CLAIMS MADE a OCCUR 8500042816 /20/2016 /20/2017 MED EXP(Any one person) $ 5,000 X CONTRACTUAL LIABILITY f PERSONAL&ADV INJURY S 1,000,000 X CG0001 10/01 FORM GENERAL AGGREGATE $ 2,000,000 GEN 'LAGGREGATE LIMIT APPLIESPER: PRODUCTS-COMPfOPAGG 5 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY Ea ecBlcdeD SINGLE LIMIT S 1 000 000 A ANY AUTO BODILY INJURY(Per person) S ALL OWNED FX771 SCHEDULED AUTOS A 1020015871 /20/2016 /20/2017 BODILY INJURY(Peraccident) $ UTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ Per accident PIP-Basic $ X UMBRELLA LIAR X OCCUR EXCESS LIAR EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS 10,00 600058654 /20/2016 /20/2017 5 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITYANY Y f N OFFICER/MEMBEOREXCLUDED?ECUTIVE❑ N f A (Mandatory in NH) E.L.EACH ACCIDENT $ If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B POLLUTION CPL200378614 0/1/2015 0/1/2016 EA POLLUTION CONDITION $1,000,000 I GENERAL AGGREGATE $1,000,000 DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES'(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) i I 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. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE John Koegel/SME ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 r7ntnnFl M Tha Aflnp l name and Innn am rania*a—I marirc of Ar`r1Rr1 •'tea � <-�- � c.i �.ir c.viv .�....�'t GY t9t7 YL1VL. G/ VVG CdX �CL-VCL- i CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) rCERTn!]FICATE FICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,. FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE ER D THE CERTIFIC TE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policoes)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER j CONTACT NAME: EASTERN INS GROUP LLC 1 PHONE FAx 233 W CENTRAL STREET (A/C,No,Ext): (AIC,No): i EMAIL NATICK,MA 01760 ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: AMPRICANZURIC?TINSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: IINSURERD: 61 REAR JEFFERSON AVE INSURER E: SALEM,MA 01970 j INSURER R COVERAGES CERT)FICATE 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 MAYBE 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. I MSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MDDIYYYY) IwADDIYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE COMMERCIAL GENERAL LIABILITY $ CLAIMS MADE ®OCCUR.' DAMAGE TO RENTED $ REMISES(Ea occurrence) ED EXP(Any one person) $ ERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:j ENERAL AGGREGATE $ POLICY ®PROJECT®LOO RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS j BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) 71 UMBRELLA LIAR []OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE g DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND I We srATttroRY OTHER EMPLOYER'S LIABILITY YIN UB513270121-16 03/20/2016 03/20/2017 LIMITS ANY PROPERITOR 7(EGUTIVE N N/A16� E.L EACH ACCIDENT $ 50fl OOp OFFICER/MEME:ER EXCLUDEDEXCLUDED? (Manualory In NH) ! EL DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L DISEASE-POLICY LIMIT $ 500,000 '.. DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. i I CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 1 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR TA VE _�:: w N.ANDOVER,MA 01845 : Ail— .< ;�• *. : ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Is-'2010 ACORD CORPORATION. All rights reserved. - Massachusetts Department:of Public Safety Construction Supervisor Board of Building Regulations and Standards19, Restricted to: License -0117977 Unrestricted-Buildings of any use group which contain �- �.�€c" .7�ti � , less than 35,000 cubic feet(99`1 cubic meters)of . a enclosed space. ERIC W PALM 3 HILTON ST SALEM MRs 01970 ; CA, Failure to possess a eurrent edition of the Massachusetts Commissioner 04123/2078 State Building Code is cause for revocation ofti�is license. DPS Licensing information visit:WWW.MASS.G01f1DPS !" ,r.irnrrrrr,nrrrnrrrfd ref{^Pd�rc3 rrr rrWF u License or registration valid for individul use oralyr �`��Office of Consumer Affairs&Business Regulation before the expiration date. If found return to. mm l 1" ME IMPROVEMENT CONTRPACTOR (7ffico of Consumer A Whirs and Business Regulation registration: 142089 Type= 10 Parte Plaza-Suite 5170 xpiration, 31121209& Ltd Liability Corpor Boston,MA 02116 ATLANTIC WEATHERIZATION-L.L.C. ERIC PALM �y 61R JEFFERSON AVE r�J SALEM,MA 01970 Undersecretary Not valid Vithout signature Al - k I