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HomeMy WebLinkAboutBuilding Permit # 5/19/2016 BUILDING PERMIT TOWN OF NORTH ANDOVER � 2 73 f APPLICATION FOR PLAN EXAMINATION r Perm �o: wDate Received 9" M Date Issued: "� �CHU IMPORTANT: Applicant must cam lete all items on this page LOCATION print PROPERTY OWNER Print MAP NO: PAFCEL:' lOIING DISTRICT: Historic District yep no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition L] Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg 17 Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District 11 Water/Sewer w� �f o N„v.n, ,p ��,�u„y k.,:;...1 P �,"A�p""�a°' �” MY V' 4w✓��""� @', i'w."e6 N� I...�„AO( 4".�" �W'�� U�'M,:�' rA�'�du.„a R @'g � �0111� �@ F ^ ff Www 'C.�aq P d' �d''�„ Identification Please'Type or Print Clearly) OWNER: dame: ".j ,, �:5-i Phone: , .... .ba : .. Address: CONTRACTOR Name: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Gate: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULCINU PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST EASED ON$125'.00 PER S.F. ( Total Project Cost: �fi � d � ��` FEE: $ t Check No.: k Receipt No.: SL2 0C) CITE: Persons contracts with urge ister contractors do not have access to the guaranty fund Signature of Agent/Own � Signature of contractor � �� w F FORTH Town ofndover •� .� - L ® 0 11 ver Mass SSy 19 26114 C% ' ICKI 1 / COC NIC NF wICN A \V °RATE® S U BOARD OF HEALTH Food/Kitchen PER Iff LD Septic System THIS CERTIFIES THAT ................................................ BUILDING INSPECTOR has permission to erect.......................... buildings on .......... ... ... r 6 . .., ... .U.IIJ.... . ................ Foundation Rough to be occupied as .........k*. .AMA.......rf ......................................................... 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough Service ............... ... . � ................................ Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® Occupy Building Rough Displayin a Conspicuous Place on the Premises — Do Not Remove Final Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. KIBC CONSTRUCTION Ir=- III 'COIR (781) 367.5142 OR ITC-( I-ASTPUCTI N@ c-j MAIL. ' �NiI 407 PARK ST, NoR` H RMAOING ISA. 01864 PROPOSAL,SUBMITTED To PHONE ®ATE Natalie Howard 978-685-7669 3/7/2016 417 Johnson St North Andover Ma 01845 Bathroom Remodel Demo: Remove plumbing and electrical fixtures and remove drywall down to studs. Framing: Repair minor framing issues and firestop. Insulation: Install R-15 insulation on exterior wall. Plumbing: Install new fixture stops on toilet and vanity; install tub with 1 shower valve 1 regular shower head. Fixtures to be supplied by homeowner. Electrical: Install new 20 amp circuit, 1 recessed light in shower, 1 bath fan/light combo, 1 vanity light, and 1 outlet at vanity. Fixtures to be supplied by homeowner. Plaster: Blueboard and plaster bathroom. Tile: Install cement board and tile in shower area and on floor in a basic pattern.Tile and grout to be supplied by homeowner. Trim: Install vanity, bath accessories, and trim as needed. Cabinets to be supplied by homeowner. Painting: Prime 1 coat and paint 2 coats walls trim and ceiling. KBC will supply all permits,and remove all trash. This is an estimate, and prices are subject to change due to unforeseen circumstances. License Numbers: MA CS 99247, MA HIC registration 168517 Contractor shall not be responsible for damage or delay resulting from act of God,civil disorders,strikes,fire,accidents,storms, delays or default by carriers or suppliers,inherent defects in subject premises,or any other case beyond its reasonable control. We propose to furnish labor and materials, complete in accordance with the above specifications for the sum of: '170.1"rat $1-'3,500.00 CE RMS OFk'FsE`V2f.4 "Y': .,l f l f I , 'I 3 � [y,d'laF PW.'t`�1GH [!'�t.Sr! 1--ClIt�3N1, .1/,33 1:)€`W-i This proposal will be withdrawn by KBC if not accepted within 30 days. Date of Acceptance: 3 �- Acceptance of proposal The above prices,specifications,and conditions, are hereby accepted. Customer Signatur ': Aawd'--� KBC is authorized to do the work as specified. Payment will be made as outlined by terms of payment. Authorized Signature: The Commonwealth o,f Massachusetts z W Department oflndustriad Accidents Ay,w ant t> 1 Congress,Street,,Suite 100 FK a .Foston,MA 02114-2017 �.K www mass.gov/d1a ,ym Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE MED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization&dividual): 6 e�CK,4 1" t"" Address: (_/C".L ,c „. m City/State/Zip: '" ,14•1..�� � � •^tr'c°i�aF� ..,� ���.�_ Phone#: 7 ��� ,�6, Areyo f-'employer?01eclr.tfie appropriate box: Type Of project(1°equired), LFJ 1 am.a.employer with L•.,. employees(full and/or part-time).* 7. Q New construction 2.[J I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.Q I am a homeowner doing all work myself,[No workers'comp.-insurance required.]t ❑ 10 Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repair's or additions propizetors with no employees. 12.F1 Plumbing repairs or additions 5.❑lam a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.n Roof repairs These stib-contractors have employces and have workers'comp,insurance. 6.❑We are a corporation and its,officers have exercised their right of'exemption per MGL c. 14.F]Other 152,§1(4),and we have no,employeer s.[No workers'comp.insurance required.] , _ *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit`this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors fhat check this box must�attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Wthe sub-coriiractors have employees,they,must provirlo their worlrers'comp.policy number. lain an employer that is p�avidiizg ivorrcers'compensation insurance for'nay enipldyees.'Below is the pollcy and job site information. Insuranco Company Name: t — �a Policy#or Self ins.Lic.#: V WL" -( - ' Expiration late: u / Job Site Address: � CAri; �ut.. CitylState/Zip` '�t../ra. rrtr;,¢r� . �.. r;.,r • . Attach a copy of the workers'compensation policy declaration page(slxoNving 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. X do hereby certify under tlae pains andpenadtdes ofperYury that the information provided above is tate and correct. Signature. Date: w 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 0 DATE(MMIDDIYYYY) CERTIFICATE OLIABILITY INSURANCE 04/26/2016 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(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 NAME: Nicole Qrlanzo ------- --------- - ------ BYETTE INSURANCE AGENCY INC. PHHONN Ext): (978)851-6678 _Fac Np); E-MAIL ADDRESS: nicole@akfowlerins.com 200 Park St. INSURERS)AFFORDING COVERAGE NAIC ff ------ --- --- North Reading -MA 0.1864 INSURER A: AIM MUTUAL INS CQ 33758 ---------- --- ---- ---------- INSURED INSURERS: KBC CONSTRUCTION INC INSURERC: INSURER D: ------ ------------- 407 PARK STREET INSURER E: - ---------- ---------- ---- ----- NORTH READING MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER: 47783 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. - --- -------- -------- - --- --- -—— ADb INSR TYPE OF INSURANCE IVSD W D POLICYNUMBER POLICY EXP LTR MMIDD/YYYY MWDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGET—017 ----- CLAIMS-MADE 1:1 OCCUR PREMISES Ea occurrence $ MED-EXP(Anyone person) $ --- --- - ----- ---- ---- N/A PERSONAL&AD_V INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ------ POLICY POLICY PRO EILOC PRODUCTS-COMP/OP AGG $ JECT -___— -- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ —_ AUTOS AUTOS -- NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS fPeraccident) —_.- ----- $ --$ UMBRELLA UAB OCCUR EACH OCCURRENCE $ _— EXCESSLIAB -CLAIMS-MADE N/A AGGREGATE DED RETENTION$ I PER�/ $ WORKERS COMPENSATION / STATUTE EOR AND EMPLOYERS'LIABILITY -"--- ANYPROPRIETORIPARTNER/EXECUTIVE Y/H E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A VVVC10060205712015A 12122/2015 12/22/2016 - -"""--"- ----- ---- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. 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. 120 Main St. AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M Clo4'ey,CPCU,Vice President-Residual Market-WCRI BMA O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 0 DATE(MM/DDIYYYY) CERTIFICATE LIABILITY INSURANCE016 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 NAME: --------------------------- -- A & K Fowler Insurance PHONEG ala Et (978)66 - �J �-_-_--- AIC No:(978)664-2209 200 Park St E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# North Reading MA 01864 INSURER Main Street America ---------------------------------------------- INSURED INSURER B: -------------------------------------------- KBC Construction Inc. INSURERC: 407 Park St. INSURERD: INSURER E: — ------------------------------ ------- North Reading MA 01864-2106 INSURER F: COVERAGES CERTIFICATE NUMBER:CL161711189 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. MSR ADDL UBR POLICY EFF POLICY EXP ----------------- - -- - -- - LTR TYPE OF INSURANCE INO&ZUD POLICY NUMBER MMIDDIYYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 -- A CLAIMS-MADE X OCCUR DAMAGE TO RENTED 500,000 __._- PREMISES Ea occurrence $ + MBT2239M 12/17/2015 12/17/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 - ----------------- GENI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 NPOLICY❑PRO [ I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT u OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS _ AUTOS _--_- _ NON-OWNED HIRED AUTOS PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION H- AND EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNEWEXECUTIVE -1 Workers Compensation cert E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? u N I A --------------------------------------- (Mandatory in NH) to follow separately. E.L.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) Insurance verification - Please refer to actual policy for all other terms, conditions and exclusions. 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 120 Main St. ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 1 Nicole Orlanzo/NMO ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 on1401i t, Massachusetts -Department of Public Safety Board of Building Regulations and Standards ^un---uui t---- lTi 'i- � uouuci vi56i t License: CS-099247 "A"T i s NO- KEVIN `KEVIN B COIRO - 407 PARK ST NORTH READING ✓.�..�J1 ���titi Expiration Commissioner 08/18/2017 Office of Consumer Affairs&Busidess Regulation �f ��OME IMPROVEMENT CONTRACTOR egistration: 168517 Type: \ xpiration: 3/1/2017 Private Corporati; KBC ONSTRUCTION,INC. KEVIN COIRO dz 407 PARK ST NORTH READING, MA 01864 Undersecretary