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Home My WebLink AboutBuilding Permit # 4/25/2016 �nvnmmwrrn.. f �nrm�,.. oRTT'I BUILDING PERMIT 0Z. TOWN F NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION AV Permit NO: _ C 1"° °� �� k Date Received a � Aca u Date Issued: ' IMPORTANT:Applicant must co m Tete all items on this 2a, e L777777777777 OOAT NPI a PR,OP'ERT Y ( NES MArF F t Y 1N l;`TT IOT, [�stor ;lp,01pot VolO'S Ppl 0910, Y r iid TYPE OF IMPROVEMENT PROPOSED USE Residential Non® Residential ❑ New Building El One family 0 Addition ❑ Two or more family 0 Industrial °'"Alteration No. of units: [3 ommercial i P,epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic /"'Cf"Well, : ❑�'Io6d N lr1T1", -'W'' tN nds ❑ 1 J er hed,District ttr� e�uer CA, cccXa �l` �"d"'gat�w OP-1kcic ,a "& "w N.A.+,amu Identification Please Type or Print Clearly) OWNER: Name: (v\v,,' � , �lw . ; Rhone: , Address: Address: i. t S,,U �l�i r� C�Jns,tr 11 tion �.,l 6 �/ � ,Hk I a e �e t L dere � t ARCHITECT/ENGINEER Phone: Address: Reg. No. IEEE SCHEDULE:BULDING;PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASEL?ON$925.00 PER S.F Total Project Cost: ; ,. .......... FEE: Check No.: 2,t, 1 Receipt No.: rxtractors do not have access to t7 e � NOTE: Persons contracting withwith �gst�r�e�contractors N° czrtzrrty_fzrzcl ,. igneturSe of Agent/Owner gnetBre of contracto,r �°.�- t%ORTH Town of Andover ®� .1,. � No. Wow 26 t _ V PA 26, 2oblk O LAKE ♦ ��' �.L�S' 'DA COC MICNE WICK Ll BOARD OF HEALTH PErxMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ... .................. BUILDING INSPECTOR . .. .......... ... . ..... IVIA....... .. .......... .... :: .. ........... . has permission to erect ........... ... Foundation .......................... buildings on ....160........ ... ....... .. ........... u Ro g to be occupied as . .. . .. . .. .... . ., . .. ... . .. .... .. ... ...... ... .. .. .. .. i ........... Chimney e provided that the person accepting this permit shall in every respect co or m t e terms of the a plication 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-EXRIRES IN 6 MONTHS ELECTRICAL INSPECTOR STARTSUNLESS Rough Service ......... .. .. ... ......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buzldzn Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingr Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Pr® ®sal Shingles EF Fogarty RoofingEd Fogarty Rubber P.0 BOX 177 (978)777-7337 Siding (978) 815-6758 c Billerica, MA 01821 Proposal submitted to Phone Date 100 Main street Realty Trust 978-835-6630 4-17-16 Street Job name 100 Main Street D. Mermelstein City, State Zip Job location N. Andover, Ma N Andover Architect Date of plans Job Phone We hereby submit specifications and estimates for: Roofing Work 1. Remove shingles from two sides of apron areas of building. 2. Install ice and water shield to roof deck surface. 3. Supply and install 8" dripedge,step flashings and roll flashings as needed. 4. Supply and Install GAF (IK0) Timberline shingles as per manufacturers specifications. 5. Install new metal trim to two areas on left side of building. Clean and remove debris from premises. Workmanship carries a 5 year warranty. Shingles carry manufacturers warranty. Mass Home Improvement Contractors Member Lic.# 111772 - 617-727-8598 National Roofing Contractors Member Lic. # 136814 Mass Builders Lic#062349 We Propose hereby to furnish material and labor-complete in accordance with above specifications, for the sum of: One thousand three hundred fifty dollars ( $1,350.00 ) Payment to be as follows All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according to specifications submitted,per standard Authorized ` practices. Any alteration or deviation from above specifications involving extra costs Signature will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Ownerto carry fire,tornado and other necessary insurance. Title owner/operator Our workers are fully covered by workmen's Compensation Insurance. Note: This proposal may be withdrawn by us if not accepted within days Acceptance of Proposal-The above prices,specifications and conditions are satisfactory and are hereby a pted. You are authorized to do the work ass c�fed. ymentit b made as tlined above. Signature: Buyer: -- Signature: Signature: Date of Acceptance: The Commonwealth ofMassachuselts Department oflndust'ialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 iviviunrass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 2.9-,> (`SIA Ri5k -(� c✓ kk City/State/Zip: Vy1 J Cil( &, �, M41— Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. ' I am a employer with _employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in $• 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3J_J I am a homeowner doing all work myself.[No workers'comp.insurance required.]► 10 F1 Building addition 4.0 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.E]Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.0 We are a corporation and its officers have exercised their right of exemption per MGL C. 14.0 Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this 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 whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I art:an etrlployer that is pf'ovidiug worlrers'eompet:satioit irtsui•ance for my employees. Below is thepolicy andjob site hiforinatlon. Insurance Company Name: Co C � Policy#or Self-ins.Lie.#: �� "" S cu'L� 'l S Expiration Date: A Job Site Address: ((0 IM(X(V\ �' City/State/Zip: H. Le Attach a copy of the workers'compensation policy declaration page(showing 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 WORK 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. Ido hereby certify r ndei the pai s and peuallies of petju)y that the information provided above is true and correct. Si nature: Date: 2 �� 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#: �� ® CERTIFICATE ' LIABILITY ' INSURANCE DATE(MM/DD1YYYY) 4/19/16 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 thi s certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER NANTACT ME: DEBORAH GRIMSHAW Beacon Insurance Agency, Inc. PHONE(AM No 978 251-2882 FAX N (978) 251-3185 22 Middlesex Street E-MAIL N. CHELMSFORD, MA 01863 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC6` INSURER A:ATLANTIC CASUALTY INSURANCE INSURED INSURER B:TRAVELERS EF Fogarty Construction Co INSURER C: 28 Old Haswell Park Rd. INSURER D: Middleton, MA 01949 INSURER E: INSURER F: COVERAGES CERTIFICATE 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 MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE _INSR WVD POLICYNUM3FA M/DD/YYY MVMDrYYYY LIMITS A GENERAL LIABILITY L261000698 7/10/15 7/10/16 EACH OCCURRENCE $ 1,000,000 DAMAGX COMMERCIAL GENERAL LIABILITY PREMSE O ES(EaoNTED $ 100,000 CLAIMS-MADE [A]OCCUR MED EXP(Anyore person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-OOMP/OPAGG $ 2,000,000 POLICY PRO- LOC - $ AUTOMOBILELIABWTY COMBINED tSINGLELIMIT $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS eraccident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 6HUB—OG15184-0-15* 7/10/15 7/10/16g WCSTAT U- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIEfOR/PARTNERIEXECUTIVE �p ' EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? J N/A (Mandatory in NH) EL.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY L IM IT *EMPLOYEE ONLY POLICY DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renerks Schedule,if more space Is regui red) CARPENTRY/ROOFING CONTRACTOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 100 MAIN STREET REALTY TRUST ACCORDANCE WITH THE POLICY PROVISIONS. 100 MAIN ST ANDOVER MA 01810-3819 AUTHORIZED REPRESENTATIVE DEBORAH GRIMSHAW ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 356-6680 E-Mail: Massachusetts-Department of Public Safety Board of Building Regulations and Standards " VI//Hltl IJ ILIIIrI JIl 1ICl V 91t/1 License: GS-062349 EDMUND F FOG 28 oLD HASWEi'L MIDDLETON MA 01 Expiration Commissioner 07/2412017 � ��ieCpaarvrrwauaea;�C�o��aa�ucrte� ' ' Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:; '111772 Type: Office of Consumer Affairs and Business Regulation Expiration: 2/26/2018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 E.F. FOGARTY CONST----Cb EDMUND FOGARTY _ 28 OLD HASWELL PARK-RD: — MIDDLETON, MA 01949 Undersecretary I Plot vali wit out signature