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Home My WebLink AboutBuilding Permit # 6/7/2016 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ' -T # C" Permit No#: Date Received ��Ss�choS�R�� Date Issued: ze I iIP012T 9i Tc applicant must complete all items on this page LOCATION / P t ° I PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:__ Historic District yes no Machine Shop Village yes no I TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential o New Building ❑One family ❑Addition i C Two or more family ❑Industrial D Alteration No.of units: ❑Commercial -Repair,replacement 01Assessory Bldg Others: ❑Demolition E�Other D Septic, .r Well o Floodplain n Wetlands Ej Watershed District Q Water/Sewer DESCRIPTION OF WORK TO BE PERFOf MED: Identification-Please Type or Print Clearly OWNER: Name: Phone: Address: F Contractor Name: Phone: i Email: y bAddress: I I Supervisor's Construction License: Exp. Date: I� Home Improvement License: Exp, Date: ARCH ITECTtENGINEER Phone: I Address: Reg.No. FEE SCHEDULE:BULDINNO PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Gast:$ ` G FEE:$ Check No.: = Receipt No.: NOTE: Persons contracting with unregistered contractors do not have:access to the guaranty f and Sigrlat�of Ag�nt(Owner _. __ Sinnature of contractor_ � _ _ NORTH Town ofI 2 Andover No. � h ver,Mass, 79 A�RA7EOEPQo-�� 3 11 BOARD OF HEALTH PE�iRMII�l TO IL Food/Kitchen Septic System THIS CERTIFIES THAT.... .� ..•••... BUILDING INSPECTOR ® 'fir.t..... Foundation has permission to erect..........................buildings on...... .... T... ... Rough to be 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR LESS CONST ONS Rough Service . BUILDING INP TOO Fina �.. � GAS INSPECTOR ®ccupancT,Perndt Repuireci to Occupy Ruiidin Rough Display in a Conspicuous Place on the Premises—Do Not Remove Final No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. k 0S")"E & D 0 V E Artful and Affordable Gifts for Everyday Occasions I authorize 2111 Century to change out our root top HVAC system Quoted at$5000. Thank you, Kellee Twadelle Owner 565 Chickering Road,North Andover,MA 01845 Tel:978-689-4141 Fax:978-689-0707 www.roseanddove.com VERMONT MUTUAL GROUP BUSINESSOViINERS POLICY DECLARATIONS 89 State Street,PO Box 188 To report a claim call your Agent Montpelier,VT 05601-0188 or the Company at 800.435-0397 Policy Number: BP11022879 - RENEWAL POLICY Type of Billing:DIRECT BILL TO INSURED Named Insured f Address Agency/Address 21ST CENTURY HEATING AND AIR INFANTINE INSURANCE, INC. CONDITIONING LLC PO BOX 5125 7 GLENDALE DR MANCHESTER, NH 03108-5125 NASHUA, NH 03064-1635 (603) 669-0704 POLICYPERIOD From 06/16/2015 To 06/16/2016 at12:01A.M.' `Standard Time at your mailing address shown above. INSURANCE PROVIDED BY:VERMONT MUTUAL INS CO. TOTAL POLICY PREMIUM at inception is: $905 and at each anniversary. IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. BUSINESS DESCRIPTION -Form ofBusiness: LIMITED LIABILITY COMPANY DESCRIBED PREMISES Prem.No. Bldg.No. Location/Occupancy Location/OccupancyMorta eholder Name and Address 001 001 HEATING/AIR COND CONTRACTOR (See Schedule of Mortgageholder(s) - 7 GLENDALE DR BPDEC5-If Applicable) NASHUA, NH 03064 PROPERTY-Limits of Insurance for BUILDINGS $ . Actual Cash Value-Buildings Option(Y/N) . Automatic Increase-Building Limit(pct.) % BUSINESS PERSONAL PROPERTY $ 5,000 EARTHQUAKE DEDUCTIBLE(pct) % DEDUCTIBLE$ 250 OPTIONAL COVERAGE/EXTERIOR BUILDING GLASS DEDUCTIBLE$ 250 OPTIONAL COVERAGES-Applicable only if an"X"is shown in the boxes below: Limits of insurance 1.❑Outdoor Signs $ per occurrence 2.[]Tenant's Exterior Building Glass $ 3.Interior Glass ❑Basement/ground floor level ❑All Floors included 4.❑Employee Dishonesty $ per occurrence 5.❑Money&Securities(Special Form Only) $ Inside the Premises $ Outside the Premises COVERAGE EXTENSIONS 1. Optional Higher Limits-Accounts Receivable $ 2. Optional Higher Limits-Valuable Papers $ ADDITIONAL COVERAGES Optional Higher Limits-Forgery and Alteration $ LIABILITY AND MEDICAL PAYMENTS Except for fire Legal Liability,each paid claim for the follovdng coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Paragraph DA.of the Businessowners Liability Coverage Form. Limits of Insurance Liability and Medical Expenses $ 1,000,000 Medical Expenses $ 5,000 Per person Fire Legal Liability $ 50,000 AU oyk fire or exiosiorl FORMS/ENDORSEMENTS ATTACHED TO THIS POLICY(See Scp!�q,Votforms f2d Eqfdors -BPDEC4) COUNTERSIGNED lD FIs Be (DATE) ( THORIZEI REPRES NTATIVE) THESE DECLARATIONS TOGETHER WITH THE COVERAGE FORM(S),COMMON POLICY CONDITIONS,FORMS AND ENDORSEMENTS,IF ANY, ISSUED TO FORM A PART THEREFORE,COMPLETE THE ABOVE NUMBERED POLICY. Includes copyrighted material of the Insurance Services Office,Inc. Copyright,Insurance Services Office,Inc.,1997 INSURED COPY 05/05/2015 (SWOL) BPDEC1 01/10 The Commonwealth of Massachusetts Department oflndustrfalAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 wwmmass gov/dia Y Workers'Compensation Insurance Affidavit:Builders/Con tractorstElectrieians/Plumbers. TO BE FILED WITH THE PERNUTrING AUTHORITY. Applicant Information Please Print L 'bl Name(Business/Orgenbation/lud�ividuaal): Address: /X e/ City/State/Zip: &d,I a Phone Are you as empioyeR Check the appropriate ooze - Type of project(required): 1 am a employer with--tf�_cmpiayas(ml andtor pan-time).• 7. eNew construction tam a cote proprietor or partner'shtp and have en®ploy.cs working for me in 8.❑Remodeling any capacity.filo workers'comp.in,rrrmnae rewKd•) 9. ElDemolition 3.0 1 area bomcowea,doing all work myxtf.]No workers'romp.ianaaaa repdrod.)t10 E]Building addition 4.E] m mewa I aa hoeoand will be hiring auaaetoa to andua all work on my properry-I will ensure Were au co—too,either have workers compensation insnmoee or are sok 1 L❑Electrical repairs or additions Proprietors with no—ply—. 12.❑Plumbing repairs or additions 50 I an,a general 000taxtor and I bave hived the an b-wn—lora hated on the amcbed stet". 13.❑Roof repairs These sub- rrtraaorr bave cnptoyaa and have workers'comp.insinanne.t 14.❑Other 6,E]We We aa mrpomtiou and its otiieeo,have oreemd their right oraeoption per MGL c. .152,§1(4),and we have no employers 1N.workers'comp.inrmanct, q.ird.] *Any applicant that cLaks box#I a at also fill out the ration below sbowiog their workers'compensation Pettey info—tion t Homeowner who sahmit this ntfidavh indicating thry are doing all work and then hire...id.convaaors mrst submit a new a7Tidavit indicating such. tCoaoacrors tbaz chat nus hoz must aztachd=beet sheet showing the name of the svbcannactors.aed sate whether or not the==tities bave employers.If the sub-cootmctors have employers,Wry marc provide their worker'romp.poliry somber. !am an employer that is providing workers'compensation insurancefor my employees.Below is the policy and job site information. [insurance Company Name- Policy#or Self-ins.Lie.#: Expiration Date: lob.Site Address: CitylStateJZip: 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 ind/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 fay against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance :overage verification. r do h r)5'under the pains and penaldes ofperjury that the information provided above is true and correct irknature ��— Date d-11-1Z 'hone#' 0j)icial use only.Do not write in this area,to be completed by city or town ofjieiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrowu Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone N: COMMONWEALTH OF MASSACHUSETTS '- BOARDOF - � SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE AS A MASTER-UNRESTRICTED -, DENNIS P GALLIEN - "` _ 7 GLENDALE DR - e NASHUA,NH 03064-1635,, � 30110312812018 20519 r