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HomeMy WebLinkAboutBuilding Permit # 4/19/2016 (4) _ ... -1 OORTH BUILDING PERMIT p��KLI--o TOWN OF NORTH ANDOVER 0 Y APPLICATION FOR PLAN EXAMINATION d1S L�4N1l NlW H W� Permit No#: � � � �� � ��� Date Received � uS���� Date Issued:_ 9 1 IMPORTANT: Applicant must complete all items on tiv s page LOCATION , '. ° 4; Print PROPERTY OWNER ,'=a C Print 100 Year Structure yes no MAP d 0 _PARCEL: _ZONING DISTRICT:__ Historic District Machine Shop Village yes. no . TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑Two or more family El Industrial [I Alteration No. of units: ❑ Commercial o°Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other /� 'r ",?meor;, /moi/r lr(0;%F�'m/i�r,l "✓':'9jr'li/y,`.0 (�'^ol Nur r��(�'�`IA7f4JY,rYiGR�"///,'�((P11N�T"'✓a�/1/�%�'r/%�.V//T',,f�iji/I///�%/,/j 8 �� ,n ,��+ " ���� � /,�/ .�/ �j�6' ,�' �rY ei�r d� l 1 ❑ �e'�+J'`P.d'DI'Str G"'� r /% DESCRIPTION OF WORK TO DE PERFORMED". �,) Identification- Please Type air Print Clearly OWNER: Name: Phone: Address: — --- Pho ,m ,. .... ..� 2,u Contractor Name .. . k . Email. . L�-e''' d cab 6"') G'�^�"�� W Address: " "' ;. .... Supervisor's Construction License: (aL Exp. Date: 0 Horne Improvement License: �" Exp Date: ` A�21 " ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDIMG PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST;BASED ON$925.00 PER S.F. � N . �� FEE: Total Project Cost: $ d Check No.: 65 1 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to,the uarlanty.fund __. —r <..o�„ ,,,,i /i / r///%% 1 ",,,,,,,,,i h `, ;v`//�✓/v,/>. ///a,.�//�' pl� ��f�/cif�// �"�° i�'. ,r r,� ,.k„rc,ii�a,o/i%/r1 ( ,o�ia�i7r I✓ri/�/i//G/rr�'�// I�, rr/I� .......______................ NORTh" Ift-_ Andover o ^ Town of 74 _ ® ® �( * C% , ver, Mass, o Co ,,..�� A. . µ 7qS RATED U BOARD OF HEALTH Food/Kitchen PERMIT. T LD Septic System � BUILDING INSPECTOR THIS CERTIFIES THAT ............ ............................................................ - Foundation haspermission to erect ................ buildings on .. �•.••• •® ,••••••�- •S4•••••• p .......... Rough ... Ej..c ....... .1.ca2).h.i.ni ...to be occupied as . . �..�.... ...................... ... ...... Chimney provided that the person accepting this permit shall in every respect conform ta 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION STARTS ' Rough Service ........................................ ............... .... ........ ...... Final BUILDING INSPECTOR , GAS INSPECTOR Occupancy Permit 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. B&MRESTORATIONAAD CONTRACTING,, INC: 218 PARIS STREET EAST BOSTON, MA. 02128 (617) 561-9998 (781) 342-5178 fax (617) 293-1722 cell PROPOSAL AIMCO 2 Greenwood Square 3331 Street Road, Ste 450 Bensalem, PA. 19020 JOB LOCATION: Royal Crest Estates, 19 Royal Crest Drive, N.Andover,MA. WE PROPOSE THE FOLLOWING: Work to be performed on Buildings: 27 Set up protection around the work area. Install safety fence around perimeter of work. Replace brick as needed. After flashing is completed,cut and point building 100%. Building 27: $50,000.00 We hereby propose to furnish all labor and material complete in accordance with the above specifications for the sums stated above. AUTHORIZED SIGNATURES ATE: 4-11-2016 Acceptance of Proposal: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do work as specified. AUTHORIZED SIGNATURE Gil' .DATE: Y The Commonwealth of Massa.chusefis Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston,M4.02114 2017 WWW mass.gov1dia Workers'Compensation insurance Affidavit:113uilders/Contractors/Li lec.tricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY- Please Print �eaibly Applicant.Information .- Name (Bilsiness/OrgaDizationffndividual): 615 1,4 Address: Alk" kl( e City/State/Zip:_/F Phone 1,V1­ on au employer?Cfie�k tbe appropriate box: Type of project()Vc I ed): Are y quir .1.[]I am.a.employer with �_ employees(full and/or part-time).* 7. E I]New construction 2.[J I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required,] Demolition 3.E]I am a homeowner doing all work myself[No workers'comp,insurance required.]t 10EJ Building addition 4.Q1 am a homeowner and will be hiring contractors to conduct all work on my property. lwill ensure that all contractors either have workers'compensation insuranceor are sole ILEI Electrical repairs or additions pr6pri I etors with no employees. 12.0 Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13-Fl Roof repaqs These sub-contractors hade employeesand have workers'comp.insurance.t /I 14.[JOtl 6.FJ We are a corporation and its, officers have exercised their right of'exemption per MGL c. 152,§I(4) and we bay- [No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submif'bis 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-cim6cio'rs have employees,They must provide their workers'comp.policy number. X am an employer that is pi woAcers'compensation insurance for my employees.'Below is the policy an(I)ob site information. Insurance Company Name: Policy#or S elf-ins,Lie.#.: 992 6 1-t Expiration Date: Job Site Address: J. id city/State/Zip: Attach a copy of the workers'66mpepsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required wider 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 fbivarded to the Office of Investigations of the DIA for insurance coverage verification. 7M I a 7 Y I do hereby cert un III e , ndpenattles ofpeijuiy that the information provided above is weandcorrect 711 Signature: Date: Phone#: �/2 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 Contact Person: Phone#: 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 r Jean Sullivan CIC AIS NAME: r Burgin, Platner, Hurley Insurance Agency, LLC PHONE , (617)472-3000 FAX (617)472-7248 14 Franklin St. la,,jas@bphins.com INSURERS AFFORDING COVERAGE NAIC# Quincy MA 02169 INSURERA:Hanover Insurance Company 2292 INSURED INSURER B.SafetyIndemnity Insurance Co 33618 B & M Restoration & Contracting, Inc. INSURERCAcadia Insurance Com an 218 Paris St INSURER 0: INSURER E East Boston MA 02128 INSURER F: COVERAGES CERTIFICATE NUMBEFIXaster Cert 2016-17 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. LTR TYPE OF INSURANCE D R POLICY EFF POLICY EXP LIMITS MWX M/DD GENERAL LIABILITY y N EACH OCCURRENCE $ 2,000,000 DAMAVE TO RENTED R COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 500,000 A CLAIMS-MADE NO OCCUR ZEiN8997647 /17/2016 /17/2017 MED EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY PRO- 0JECT LOC $ AUTOMOBILE LIABILITYy y EOMadeD SINGLE LIMIT 1 000 000 ANY AUTO BODILY INJURY(Per penton) $ B ALL OWNED SCHEDULED 208157 11/6/2015 11/6/2016 AUTOS x AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS N -ONONWNEDPeOPERide tDAMAGE $ AUTOS PIP-Basic $ 8,00 AUMBRELLA LIABpq OCCUR y N EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I RETENTION$ URN9055121 /17/2016 /17/2017 $ CWORKERS COMPENSATION N % WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVE E.LEACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? FRI N/A (Mandatory in NH) C-20-20-003740-03 /10/2015 6/10/2016 E.L.DISEASE-EA EMPLOYE $ 1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Contract # 18122-422094-CPe-00002; Property Name- Royal Crest Estates(North Andover); AIMCO North Andover LLC is additional insured 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 AIMCO North Andover LLC ACCORDANCE WITH THE POLICY PROVISIONS. 50 Royal Crest Drive North Andover, MA 01845 AUTHORIZED REPRESENTATIVE R Besse, CIC CISR CPI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. r1trem:9d with pdfFactory trial'ViSrslt3Ri t7yT:MMIUrM °