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Home My WebLink AboutBuilding Permit # 6/8/2016 (2) BUS LDING PERMIT 0��iLrD TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION � � pro Permit Neu#: � � Date Received �� `rco S�CHUS� Date Issued: _ I PORTANT: Applicant must complete all items on this page -� LOCATION Print PROPERTY OWNER �'�I 0 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 ❑ One family -- -- ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration _ -No. of units: _ ommercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic �❑ Well El Floodplain ❑Wetlands ❑ Wafiershed District, E Water/Sewer DESCRIPTION PERFORMED: ., P°TIOh1�OF W' R9°G TO BE� � Ientification- Please Type or Print Clearly OWNER: Name: ,. Phone: �., M .... 'S C. w w..wtl'Mu.,�r „, ua' ., ✓ rl" .ww.w iwiiq,� ,J' (..:may um.✓ � YWm"➢..,m, 9 mw Address: (�a 6 �, .° . � Contractor Na �o-° , Phone: Email: M , v ._ _ Address .. Supervisor's Construction License; , Exp. Date: Home Improvement License; ° '" Exp. Date: 6 �✓' � ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Oast: $ Z°° <_ 0O � FEE: $ Check No.: 6 ..�a � Receipt No.: NOTE: persons contracting with unregistered contractors do not have/access to the guarantyfund — Signature of an r;�cr FORTH Town of Andover 0 ® = LTOver, ass, 40 to -ego 04cocwIcwewrca RATED U BOARD OF HEALTH MM LD Food/Kitchen PER I T Septic System THIS CERTIFIES THAT BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .CW.".0$0j.... ... .. .. .. ... ...... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS . T.ION Rough Service .. .. .. ..... ... . ........ .... ..... Fina BUILDING 1 ECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough Display in aons icous 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. Floe Commonwealth ofmassachusetts ' Department ofXnd=astr/arAcczarents 1 Congress Street, Suite 100 KH :�R tl "t4 Poston,MA.021.14.2017 F www.mass.gov/dza Workers,compensation insurance Affidavit:Builders/Contractors/Electyleians/Piumbers. TO BE yff tD WITH THE PERMITTING AUTHORITY, A licant Information Please Print Legibly Name (Business/Organization/fridividual): Cztyltate/Zip: V1\ Phone#: Are you an employer?Check the appxoprlafe hox: 'Type of project(requir2d): 1.HI am a employer with !employees(full and/or part time). 7. E]New coxistzuction 2.Q I am a sole proprietor or partnership and have no employees Working for me in 8. [1 Remo delirig any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.FJ I am a homeowner doing all work myself.[No workers'comp.3usurance required.]t 10E]Building addition <1 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.Fj Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Robf repairs These sub-contractorshave employees andhaveworkers'comp.insruance.T ' 6.FJ We are a corporation and ifs officers have exereisedtheir right of'exemption perMGL c. 152,§1(4),andwehave 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. Y homeowners who submit 1l is afAdavit indicating they are doing all work and then hire outside contractors must s4bmit a new affidavit indicating such. TCorfractors 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. I£the sub-con`tract'ors fiave employees,tliep must provide their worlc&s'camp.po4cy number. I caro cin employer=that ispravidiiig wor•Iters9 compensation insurance for my employees.'Below * the policy and jolt site information. //�� Insurance Company Name: /a C Gr Policy#or Self-ins,Lic.#: A l� !N ' U ( � l 2 Expiration Date: Xr✓v fob Site Address: / l G 0 City/State/Zip: Attach a copy of the World&compernsation 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 punisliable 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 frao 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 cert' Vndeiliepai, s -ndpenalties ofperjary Mat the informationprovided above is true and correct. Si nature: GDate• CkPhone L� 7 "`z t /# 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): 1.Board of Health 2.Building)0epartment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-065281 Construction*Supervisor PAUL BRUNO 109 CHESTNUT ST RET� � ' LYNNFIELD MA 01940" OFCommissioner, Expiration: - 09/28/2017 i4CoR" CERTIFICATE OF LIABILITY INSURANCE 4i4i o�) 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 BELOYV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPR ENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPO TANT. 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 certififate holder in lieu of such endorsement(s). PRODUCER NAME: Jean Sullivan, CIC, AIS Burgip, Platner, Hurley Insurance Agency, LLC PHONE (617)472-3000 Fax No).(617)472-7248 14 Franklin St. E"SIL oRr=ss:ias@bphins.com INSURERS AFFORDING COVERAGE NAIC i Quincy MA 02169 INSURERA:Hanover Insurance Company 2292 INSURED INSURER B.-Safety Indemnity Insurance Co 33618 B & M Restoration & Contracting, Inc. INSURERCAcadia Insurance Company i 218 Paris St INSURER D: INSURER E: ,East Boston MA 02128 INSURER F: COVERAGES CERTIFICATE NUMBERklaster Cert 2016-17 REVISION NUMBER: THIS I 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 CERTIffICATE 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MM/DD uMns GENERAL LIABILITY Y N EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTEL) R COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 5— 00,000 A CLAIMS-MADE ®OCCUR ZHN8997647 /17/2016 /17/2017 MED EXP one person $ 10,000j PERSONAL 8 ADV INJURY $ 2,000,0001 GENERAL AGGREGATE $ 4,000,0 0 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,090 X I POLICY JECT PRO- LOC $ AUTOMOBILE LIABILITY y Y E,BINED SINGLE LIMB 1 000 000 BODILY INJURY(Per person) $ B ANY AUTO ALL OWNED X SCHEDULED 6208157 1/6/2015 11/6/2016 BODILY INJURY(Per accident) $ AUTOAUTOS X H R DSAUTOS X AUTOSNON-OWNED Parr. entDAMAGE $ PIP-Basic $ 8,000 X UMBRELLA LI AB X OCCUR y N EACH OCCURRENCE $ 5,000,000 AEXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X RETENTION$ C URN9055121 /17/2016 /17/2017 $ (,` W01KERS COMPENSATION N X WC STATU-T. 0TH- AND EMPLOYERS'LIABILITY �jY Lll ANY PROPRIETORIPARTNERIEXECUTIVE — E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) C-20-20-003740-03 /10/2015 /10/2016 E.LDISEASE-EAEMPLOYE $ 1000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Contract # 18122-422094-CPe-00002; Property Name- Royal Crest Estates(North Andover); AIMCO North Andover LLC is additional insured per written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AIMCO North Andover LLC ACCORDANCE WITH THE POLICY PROVISIONS. 50 Royal Crest Drive North Andover, MA 01845 AUTHORIZED REPRESENTATIVE