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Home My WebLink AboutBuilding Permit # 6/7/2016 BUILDING0.PERMIT t,oRrH qq- TILED TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION � o N Permit No#: ®l Date Received �RADR4TED Ppy�9 gSSwcHUSE� Date Issued: �6 I PORTANT: Applicant must complete all items on this page LOCATION oZ` - ►omdl I`�- �`��-U Print PROPERTY OWNER 9� Print, 100 Year Structure yes no MAP PARCEL:ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Mtrne family ❑ Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ' �11 DESCRIPTION OF WORK TO BE PERFORMED: t c( Id tifica 'on- Please Type or Print Clearly �� U OWNER: Name: tir Z GI Phone:'77 -,2 30-q` 2q Address: �2 —rkDM U1 14 '(�04 Contractor Name: AAA ��{iDrti��C Phone: -1` Email: Address; ( t1' Supervisor's Construction License: Exp. Date. it 7 Horne Improvement License: 10.2gS 7 Exp. Date: ARCHITECT/ENGINEER 10 Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMAJIFIQD COST BASED ON$125.00 PER S.F. Total Project Cost: $ T^- Check No.: �6 7 Receipt No.: — 10 NOTE: Persons contracting with unregistered contractors do not have),access e g ran ty nd p t%O R TH Town of Andover 0 0 / r . - ® ao �AKE h ver, Mass., COCHICMEWICN y1. AoRATE0 S V BOARD OF HEALTH Food/Kitchen r ERMIT T %j LD Septic System � THIS CERTIFIES THAT ��' Z C BUILDING INSPECTOR ................................................ ....... ................................................ .................. a Foundation has permission to erect .......................... buildings on ........�.... ... < tr................................ Rough tobe occupied as .......... ........ ............................................................................................................. 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 MONTHS Final PERMIT I IN 6 ELECTRICAL INSPECTOR UNLESS Rough /� .......... Service ............ ..... ..r.! '-"------"--..................... Final BUILDING INSPECTOR GAS INSPECTOR ccuj2a cy Permit Required t® Occupy Bu Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r Dry Wall TO Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. 1B � lA sr ?. a RACT# 0061140 ' CONT INSTALLED SA SPECIALI T NUMBER' CUSTOMER ; STORE NO. STREETADVRESS STREETADDRESS 3 n CITY STATE ZIP CITY STATE ZIP TELEPHONE �� TELEPHONE �U3 -6 /�t �? r3v gzzs u C DATE LOWE'S CONTRACTOR LICENSE NUMBER" ASH CBANK ARD LCC cHA GE ff' N- Y a? Y x STREETADDRESS CITY STATE ZIP Additional Specifications: The Environmental Protection Agency (EPA) has requested that Mat'Is f T„ Lowe's notify installation customers that a lead based paint hazard may exist in dwellings built 'Tax prior to 1978. See pamphlet EPA 747-K-99.001 for details. y Labor j4d'3rt,, d,N 6 �v.c. dU.,�pv�.� e(.- !to J.f C� *Tax Ll Total C7! Work is to commence upon reasonable.availqbility of Contractor which is anticipated to be [fill in date]. Estimated completion date is �` /�/f [fill in date]. NOTICE TO CUSTOMER All items listed in this contract and specification sheet(s)are to be installed under conditions agreed upon at time of purchase and at the price appearing on this contract form. This assumes sound existing substructures,superstructure and points of attachments. Extra labor or material incident to installation necessitated by defective substructures,superstructure,points of attachment,or the moving of fixtures or appliances to be billed at extra cost to customer. DO NOT SIGN THIS CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OP THIS CONTRACT. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNaER- STAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH.ON THE REVERSE SIDE OF THIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. WITNESS OUR.HAND(S)AND SEAL(S)BELOW THIS 31 DAY OF A 1H ! Seal ( ) Owner (Seal) (Seat) Specialist or Above Spouse _ r _ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite IOU Boston, MA 02114-2017 www.mass.gov/diu Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIMrrTING AUTHORITY. Ailmlicant Information 9 Please Print Legibly Name (Business/Organization/Individual): tj Q Pw Addt•ess: I D kl)� Dtl(le City/State/Zip: led 46J M jq 021-�5 Phone 5f.2-11136q Are you an employer?Check the appropriate box: Type of project(required): l�I am a employer with employees(full and/or part-time).* 7. F1 New construction 2 I am a sole proprietor iorpartnership and have no employees working for me in $. ❑ Remodeling any capacity.I No workers'comp.insurance required,) 9. F-1 Demolition 3-❑i am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 EJ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � 13.EJ Roof repairs t These sub-contractors have employees and have workers'comp,insurance.* 6 F-1Weare a corporation and its officers have exercised their right of exemption per MG1,e. i 4.[ Other f W� w 152,§l(4),and we have no employees.[No workers'comp.insurance required.] (,Cat Z(` *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 t llomeowmers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employeesif the sub-contractors have employees,they must provide their workers'comp.policy number. I ant air employer that is providing workers'compensation insurance for my eniplo}tees. Below is the policy and job site information. Insurance Company Name:__�� m• 1 V4VA' —J�05V$`WC4 00. Policy#or Self-ins.Lic.#:_ AGOG» y00-�7OA551 -,UfvIS Expiration Date: tfj Job Site Address: .2-1 jA" I &-- - City/State/Zip: 4�&d I rLhY Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi ation 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. I do hereby c the pants and penalties of perjr�r1,that tire information provided above is true and correct. Siena ire: Date: Phone#! Official use only. Do trot 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#: Page 5 GREEINS-01 LCARUSO A� �O CERTIFICATE OF LIABILITY INSURANCE DATE(M 5/26/1201201YYY) 6 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 [ADDRESS: ONTACT AME: Salem Five Insurance Services,LLC HONE 781 933-3100 FAX 445 Main Street /c No Ext:( ) a/c No):(781)933-9048 Woburn,MA 01801 MAIL insurance.services@salemfive.com INSURERS)AFFORDING COVERAGE NAIC# SURERA:Safety Insurance Company 39454 INSURED INSURERB:Safety Indemnity Ins.Co. 33618 Greene Installation Co.Inc. INSURERC,AIM Mutual Insurance Co. 0913 Ron Greene 10 Rita Drive INSURER D: Medford,MA 02155 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ADDLISUBR MMIDD� POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN I EU CLAIMS-MADE OCCUR X BMA0008519 05/08/2016 05/08/2017 PREMISES Ea occurrence $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT F—] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 B ANY AUTO X 6208932 01/30/2016 01/30/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Peraccdent) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY STATUTE I ER _ C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X WC-400-7025594-2016A 03/04/2016 03/04/2017 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ® N/A -- - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Lowe's Companies Inc.any and all subsidiaries are named as additional insured as respects to the General Liability and Auto Liability policies per written contract or agreement. 30-Day cancellation clause CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies Inc.and any and all Subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IS Insurance ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 1111 North Wilkesboro,NC 28656 AUTHORIZED REPRESENTATIVE _4- @ ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD L 1-1:34 FAX 781 .391 0624 GREENE INSTALLATION 0 LOWES W INST maul 164- v e- x., ;LN Office of Consumer Affairs&Business Reguintion is M z IMPROVEMENT CONTRACTOR Ig .tratiOn. 102957 Tjlpo: x1piration: 7/3'120'16 Private Corporatio GREENE INSTALLATION Co,;,IKIO. Ronald Greene 10 RITA DRIVE MEDFORD,MA 02155 Undersetrcts—ry