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HomeMy WebLinkAboutBuilding Permit # 6/9/2016 BUILDING PERMIT �� � D F. �q TOWN OF NORTH ANDOVER y,.,..'` a APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received bD�A TED PPp�a(y C 0 US Date Date Issued: �— IMPORTANT: Applicant must complete all items on this page LOCATION & t M I S0. Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ATwo or more family ❑ Industrial ❑ Alteration No. of units: 198 ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ricr , .,/i r r, r �,/„ /r r /r ,rr, r/i/i / ,o./ /, � e✓ ri/ r r,, // r ,r r i/// ,r r, ,, / , / /r �/ /i dFlooc� lai //, ❑.Wetland // / C1 / / r r, r r r rr r DESCRIPTION OF WORK TO DE PERFORMED: :�)C-Mt� �-rS as V(DV,aa bvial. NTi Ts ��I a l°'I10116 -I- L®) M,10/ � 1� r +' K j?aP'L.AC� 'rO 0oyi.A Y'*OX-r PQ19V)6USAy USE>. R MAA-L6A eovEA2 1. Identification- Please Type or Print Clearly OWNER: Name: c, 10 !m-D J%N SSbO. Phone: Address: ,V oft, ,.Uohl A Contractor Name: i r° w n Phone: Email: Q M a POw I-Itj& m `&a Y,-u vrg 1, 6P 0 MA-iL. .&)141 Address: Oz. (: a C:s r u r T Supervisor's Construction License: QS ) Exp, Date: ' 0141 Home Improvement License: I '0582-- Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cast: $ q000 FEE: $ Check No.: Receipt No.: NOTE: Persons co trlacting with unregist recd eontractors do not have ecce o t1 e gua]al f r r, � r Flans Submitted ❑ Flans Waived ❑ Certified Plot Man ❑ Stamped Flans TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swilmning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dwnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF ® I=U FORM PLANNING & DEVELOPMENT Reviewed On �1 i�rr Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS �❑ HEALTH Reviewed on �G Signature COMMENTS d Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Vater & Server Connection/Sic�nataare Gate Driveway Kermit DPW Town Engineer: Signature: Lo aced 384 Osgood Street FI ,�RT E ,T Temp"Dumpser onsite yes na Located at 124 Mam Street Ei� Deparo�nt sAnatasre% t� COMMENTS , . oORTH Town ofeAndover ? ,. dAK� ver, Mass, COC NIC"a WICK Ll 1J BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..J.-15 BUILDING INSPECTOR .. r.5..... .. ............... ....................................................................... has permission to erect buildings on h� &AFoundation ��•• Rough to be occupied a ... .... . .. .. . ...... .. . . 1.4.6: %..... .. l.� ... 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!bids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS Rough ON Service . . .. ...... ... ... ..... ....... ............ Final BUIL G INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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. T'he Commonwealth ofMassochusetts Department ofIndustrialAccidents d X Congress Street,Suite 100 Boston,MA 02114-2017 ^M.:: yVb�wt www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/I;lectxicians/Plumbers. TO BE FILED WITH TIE PERNI[TTING AUTHORITY. Applicant Information Please Paint Legibly NaMe(Business/Organization&dividual): .Address: City/state/zip: Phone#: Are you an employer?Check&C appiiopriaie box- 'Type Of project(requred): 1.❑I am a employerwith employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees worldag for me in S. ❑Remo daiig any capacity.[No workers'comp.insurance required.] 3.E]lam a homeowner doing all work myself[Ho workers'comp..insurance required.]i 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10F]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[1 Electrical repairs or additions proprietors with no employees. 12., Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we havenempl aoyees.[No workers'comp.insurance required.] a - *Any applicant that checks 156x#1 must also fill out the section below showing theirworkers'compensationpolicy information. i Homeowners who submit tWs affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-coniractors Piave employees,they must provide their workei.s'camp.policy number. fain an employer that is pi'ovid1hg ivorlcers'compensation insurance for my employees.'..Below is the policy and jolt site information. Insurance Company Name: '`�` INS C� Policy#or Self-ins,Lic. 'J)%b a' Expiration Date: (° Z1, 6 YT fob Site Address: Q� «8 /Am tj ST City/State/Zip: K n"- a.l e, o' Vt� /1'A Of 6 Y1 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited 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 verific tion. X do Hereby ceVt^_" nder the pains an enal"e ofperjury that the information provided above is true and correct. Signature Date: 6 Ct Phone#• 11� 6d9 $b + Official use only. Do not write in this area,to he completed by city or toren official City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Flectrical Inspector 5.Plumbing inspector 6.Other Contact Person: Phone#: DENNI-5 OP ID:JG T I I I I I TY ' DATE 06/107/201607/2016 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(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 this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Segreve&Hall Insur.ASSOC.Inc NAME: 305 North Main St. aHc No Ext): a/c No): Andover,MA 01810 E-MAIL Eric Page ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Co. 34754 INSURED Dennis V.Molla INSURER B:A LM. Mutual Ins.Co. 33758 dba DM Painting&Carpentry 132 Chestnut St. INSURER C: No. Reading, MA 01864 INSURER D: 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, INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY D PREMISESS AGE ( E TED 100 0O a occurrence � $ CLAIMS-MADE 1-1 OCCUR MED EXP(Any one person) $ 5,000 BGKVSV 10/18/2015 10/18/2016 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED a accident SINGLE LIMIT _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS _ HIRED AUTOS NON-OWNED PROPERTYDAMAGE $ AUTOS PER ACCIDEN UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TOLI TS I I ER B ANY PROPRIETORIPARTNER/EXECUTIVE Y/N CC-500-5013988-2014A 10/28/2015 10/28/2016 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Project address: Sutton Pond Condominiums, 148 Main Street, North Andover, MA 01845. CERTIFICATE HOLDER CANCELLATION NORTHAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 4 Massachusetts _D Board of BuildingPar'trnent Of Pubiic Construciotj ,Stt safe �uiatiO ,s a;�d eta tsar tts` Lice �e1t icor �� , nse: GS-105898 CJs DENNIS V MpL . # 132 Chestnut St " r Northw Reading ATA018" i �/1 S vj�l commissioner Expiration 09/02/2016 " P��e�071UJJ7C91 rue<rllll L+��lr<rJJrrc�ctde�l I' Office of Consumer Affairs&Business Regulation F HOME IMPROVEMENT CONTRACTOR Registration: 170582 Type: - 7 Expiration: 11/10/2017 DBA f DM PAINTING&CARPENTRY f DENNIS MOLLA 132 CHESTNUT ST >_ti NORTH READING, MA 01864 Undersecretary 1 r r , "' Ili�ll �r t: 'I , o, �u r�1 j � I ria of k � 1 1 'v-'�omw e Ja ON a 1 x3 '3 MIN I S Jt 4 Sf [s 1F. � LLy1� y A d � rc y: t' g, W ® p a 1 f S-LS i Qr le '�� ►E13�.t.. 3164fS.9a',4 Id CaLVA;.02V . eel i r , r ,S o11-t ��1IUU�/1