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HomeMy WebLinkAboutBuilding Permit # 5/24/2016 gAORTH BUILDING PERMIT ®��4Eo -g��'o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINAT-101 [ : ® ' Permit No#: I Date Received: ���s,AArE ca�us���y Date Issued:__�41 IM6�P 1�T'ANT: Applicant must complete all item§:on-th s%page LOCATION ✓ k-c �� Print PROPERTY OWNER ��IC-61 yl11a1i'e- Pmt 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:_ Historic District yes no Machine Shap Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family ❑ Industrial [IAlteration No. of units: El Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other N istnct ' �+ f� ❑U1/ell � � ,,❑ Floodplai� q Wetlands ❑ Watershed D r ��:` �/aJ P..pt�C SIH ; 3 �r >•/ , 3 rr a;. f/.;.Gi"f ,a,,�;d� .r7 � '' .1 r;.;., u,:�, d'? rvy{r.^;»,�.f r P., / ti N ��r � a'r ,✓��, i ✓ / "`r.r"'sr. r � akP "�'/' r '�. Water/Sewer....,fel a z ,,:/.,%r�„� t4�:�`� ,f w✓ �,,fpG`�9 r"��7tx f y,lr. ✓ ri( 5 t ;, ,c.,, r DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please'Type or Print Clearly OWNER: Name: rests S oc-. Phone: Address: Contractor Name: 601viv) A no 0 ov, cic_ Phone: m 7 Email: uviipll Address: F rrn Supervisor's Construction License: C S —Exp. Date: 24`1') Home Improvement License: 0 3Q(o Exp.- Date*' ARCHITECT/ENGINEER Phone: Address: Reg..N FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED Coon-HASEFFON..$125.00 PER S.F. dol VI Total Project Cost: $ ry FEE: $ � � Receipt Ncl Check No.: 7 NOTE: Persons contracting with unregistered contractors do not have-access4o the guaran fund - o -— --- tj®RT� Town of Anduvvi ®No ® - o - �.�� 11 VeY°9 SSS' 2 �' COC HICHEWICK �• O R'`TPED 0' 2 U BOARD OF HEALTH Food/Kitchen PERMIT TU LD Septic System THIS CERTIFIES THAT ..... L.'�:S.C�" G�.�..����F � ,U� >................................................... BUILDING INSPECTOR .... ...... .... ........... . ........... ... Foundation has permission to erect .......................... buildings on ��.( ��.�.. ./.:...................................... f O��e .. Rough to be occupied as .......... fi�.�0.��:��"1.....fi�............(��F� .:................................................ 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 MONTHSPERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S ARTS Rough Service ................... ........... .. ............................. Final BUILDING INSPECTOR GAS INSPECTOR ccupancy 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts F Department of IndlustriadAccidents - _ 1 Congress Street,Suite 100 Boston,MA.02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le 'bl Name(Business/OrganizatioxOndividual): {7% ' 06 ' " 4 Address: S 4 /0, City/State/Zip: ll cddlenl 1W,6-Q CJ 1t5 Phone#: �7�" % Are you an employer?Checktlie appropriato box: Type .f project(required): 1.1 I am aemployerwithemployees(full and/or part-fime). 7, []New construction 2.[J I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.No workers'comp.insurance required.] 9, ElDemolition 3.Qm I aahomeowner doing all work myself[No workers'comp..insurance required.]f 10F]Building addition 4.❑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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repa'y's or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1.3. Roof repair's These sub-contractors have employees and have workers'comp.insruance.f 14. Other 6.❑We are a corporation and ifs officers have exercised their right of exemption per MGL C. . 152,§1(4),and we have na employees.[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 Nis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whefher or not those entities have employees. Iffne sub-tori}tactors have emPloyees,'ttiey must provide their workeis'comp.policy rurnber. I aid an employer•drat is pi dvidiiig workers'compensation insurance for my employees.' Below is thepolicy antijob site information. Insurance Company Name: Ti,r U.rA VIC� — Policy#or Self-ins,Lic.#:� We 0 3 2 J Expiration Date: 02 96 lob Site Address: pC !1 V't City/State/Zip: A 41d owe` l� Attach a copy of the workers'4ompensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o. 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 cer'tif underthepains and penalties of pei ury that the information provided above is Jtrue and correct. Si nature: Date: Phone# 7 ' 7 Official use only. Do not 1pr•ite 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#: ® DATE(MMIDDIYYYY) Acc>REP CERTIFICATE OF LIABILITY INSURANCE2/11/2016 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(los)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). CO TACT PRODUCER AME: McDonald McSweeney&Ricci Insurance Agency, Inc. PHONE _ Alc Noi:781-843-8807 420 Washington Street E-MAIL Braintree MA 02185 DD Ess INSURERS AFFORDING COVERAGE NAIC# INSURER A:Acadia Insurance._1 INSURED UNI-P-1 INSURERS;Star Uni-Ply Roofing Inc INSURERC: 3 Forms Way INSURER D: Middleton MA 01949 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:688057472 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. IL7R TYD R POLICY EFF POLICY EXP LIMITS PE OF INSURANCE NSR WVD POLICY NUMBER MM/DD/YYYY MMIDDIYYYY A GENERAL LIABILITY CPA0074506 2/15/2016 2/15/2017 EACH OCCURRENCE 51,000,000 X DA AGE O RENTED COMMERCIAL GENERAL LIABILITY PREMISES Me occurrence) $250,000 CLAIMS-MADE a OCCUR MED EXP An one arson) $5,000 PERSONAL&ADV INJURY $1,000.000 GENERAL AGGREGATE $2000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2 000 000 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY MAA0074476 2/15/2016 2/15/2017 Ea accidentS1,000,000 BODILY INJURY(Per person) $ ANY AUTO ALLOWNED1xx SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED Per accident $ Ix HIRED AUTOS AUTOS $ A UMBRELLA LIAR X OCCUR CUA0074507 2/15/2016 2/15/2017 EACH OCCURRENCE $1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 $ DED X RETENTIONSO B WORKERS COMPENSATION WC0719335 2126!2016 2!26/2017 X WC STATU- I ER 0TH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE NIA E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $500,000 (Mandatory in NH) if yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space Is required) CERTIFICATE_ HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1966-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Mas cc htcsett Department ent of icsaWic Safety Department of Public Safety Board Of i u.tuidt ng Reguiafionn and Standardss License: HP-076413 iJcen e- CS-064262 A., i.t Iw �'°�r 1 r;�'` ICED A CAJW0ftS KEVIN A CAMPONESCKI 3 NORMAN ROAD 3 Norman Road a 7. READING MA 01867 Reading MA 0186 r F 1 V1111 xk'h Ex"9uu action n , 02/04/2017 Expiration: Cornnfts6oner Commissioner 02/0412018 /`,AP/d" 4(VI/pA�/O Rf,Fl9lI!'P��i�l'A f• 'fi C���.F,(IrP�fFJ e�/A C' /,u , i� License or registration valid for individul use only ' Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: ' t 1-aHOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 140376 Type: 10 Park Plaza-Suite 5170 h� Expiration: 10/28/2017 Individual Boston,MA 02116 I ( KEVIN A CAMPONESCKI KEVIN CAMPONESCKI 3 NORMAN RD -- — - READING,MA 01867 Undersecretary Not valid without nature 51EDICAL EXORNERY CERTIFICATE_ —.. _ _.. .... 1 a idr n l r.tnf r L�. �;. Regulfll�I(P,1 CFR79141791A9)Ind vol�d Ifft diking dolid 1find lhP".. I q 111'd d If ppll bl<,only „ r- t qC a'�p'6 p wr {g udve icor.-� 17 drhing n hhln an III-PI intro Ily run (49 CFR 791.62) ..,S ..R. �, �y,��� .i +roman+hbbFala p Oaaom,dbydpy.,W.p49rmontt6rntuatian CerllRale(SSE) �r F y rvxiurnunl Icon tlgvaliR<d Ey nperalWn of A9 CFR 74I 64 L14ENa,7E �(),q Thelf P. Ih provid<d ttgudinglhll phy+lenitxaminallan l+IrnnInd rompltl<.Arompletetalmlrolinnform vrllh lnynllarMmenlrmbod nr'.y I I,M1 Rnding 11rld,and illy,Ind h on 11,In my Willn. _ rri 1v SI4NATURY OF FIEDIC.ALExAF11NE R TELEPHONE DATE 1J. ass HNEND- 419WhOER 4 ( ^- .._..._. NONE , 4 ' '�� ❑Chlro 1 {, .. _„ DICAL ExAMINER'6 NAME(PIDNT) WFIR� pror nr Ph — tlAd,11 P.filinn"onok,Nnna —— �, hE7p, 0 Dog", TIN P/em � �1l7If/Y�0 tleh>daamm�eam ❑amrrEmdllwnrr �r y� O ���1 FIE61(CAI.EXAAIINER SI.ICEN9E OR NATIONAL REG lST'Ry NO. 1 / CER FIFIC�,�T'E NDASSUINGSTATE M 4i' p :f1 a la - Ch✓' N v L - ta6E% sso s�11 `� 7 IS IGNATMEOFURIVEIi A,SFATE G,4 yg, pia INTR CU DRIVER'S LICENSE NO SLAT �4`l r,, .i �� ONG 10'4 No j o IJA .Nt�'7,' ,G�91 ADURX"OFDRl RMANRD F16DIcrs. ( /r1Arl, ��` ( � ���i (-fJlr% i READING,MA 01867.2714 �--CERTIFICATION exFIRnT1DnaATe – —{ ��Y _..c•(,�,� ��>� 5 ON 02-06-20 15 Ray 07d5-2669