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Home My WebLink AboutBuilding Permit # 6/9/2016 t%OR,rn Of BUILDING PERMIT 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI Nr� y� Permit NO: Date Received Date Issued: �CMOU JIRTANT:A licant must complete all items on this page LOCATION /p ` Print PROPERTY OWNER Print MAP NO: PARCEL: 4 BONING 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: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: 2"Demolition ❑ Other ❑Septic p Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sever Identification Please Type or Print Clearly) OWNER: Name: �� - ... � " Phone: Address: CONTRACTOR Name: °µ° Phone: gym, Address: M Supervisor's Construction Lice se: Exp. Date: Home Improvementt License: Exp, Gate: ° `LZ Z , ARCHITECT/ENGINEER Phone: w °,a " Address: Reg. No. FEE SCHEDULE:EULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST EASED ON$125.0 ER S.F. Total Project Coat: $ � �.,a FEE: t—a " �. Check No.: 4 Receipt No.: �' g y rad 1`dO'I'>IJm I'es°sasas cosaPractfsz with unregistered contractors civ not have access t � ee o the aaaraszt to Signature of Agent/Owner Signature of contractor 4,°, � ":"� , Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Ll Stamped Plans El TYPE OF SEWERAGE DISPOSAL, Puf. ')ewer Tanning/Massage/hotly Aft ❑ SwEnming Pools 11 Well ❑ Tobacco Sales L1 Food Packaging/Sales 11 Private(septic tank, etc. ❑ Permanent Dempster on Site, ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL, SIGN OFF - U FORM I PLANNING & DEVELOPMENT Reviewed On (0MVA) Signature—E,� L/W—t COMMENTS- CONSERVATION Reviewed on Signature COMMENTS- HEALTH Reviewed on Signature COMMENTS----P�j ry) (39, Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/s Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date e.,zz MENTS 1Z, F V%®RTEyA nctuv ell Town of 0 ® 2,6 * � h ver, ass, ® �AKa 1. COCMICN&WICK °RAriED `� ll BOARD OF HEALTH Food/Kitchen PEKM ,IT L D Septic System AI BUILDING INSPECTOR THIS CERTIFIES THAT . .................................... . .... ................... ... ....................... ..........�.............. Foundation has permission$o erect b ildings on ... • • •'•J• ••• p .... ................... Rough Vi 1k A 4N 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final I RES I ELECTRICAL INSPECTOR PERMIT EXP6 MONTHS T Rough Service .... ..... ............................... Final B ILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy By Rough Displayin a Conspicuous Place on the Premises — Do Not Remove Final No Lathingr all To Be Done FIRE DEPARTMENT Until Inspectedan rove y the Building Inspector. Burner Street No. Smoke Det. r0►ty� � Page No. of Pages TALLAKSEN BUILDERS 179 Washington Street, T'opsfiefd, MA 01983 PROPOSAL SUBMITTED TO I'0 /T e PHONE aE -OAFG DATE STREET JOB NAME J f� 90 jda . CITY,STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE 2',57 1, we hereby submit specifications and estimates for; ___-___ __.._____.__ Addt /_.-�'/�1 -_.__" _.____.. �. U,/t�`. ��nr;-- ,571 ,1��" t�.��^a�o.✓ .fs�---�9 �.._.__._.._..____ __ -. ._._._-_.--_......_._...__. _ _..._.. 1.(�1/�tn/,1 ...,.-a_I�QIJ✓ 60[1 ............ 11'. .._a!r We ttropoge hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: �---�-"'� Payment to be de as follows: dollars � ,..,,((__ ,,( / A All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from above specifications Involving extra costs will be executed only upon written orders,and will become an extra Signature---- charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our Note: s proposal may be - workers are fully covered by Workmen's Compensation Insurance, withdrawn by us if not accepted within d a y s. 2frepti are of .VrOP035411 - The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to Signature_ do the work as specified.Payment will be made as outlined above. Date of Acceptance: _______ Signature -._ S-111\ The Commonwealth ofMassachusetts Department of Industrial A ccidents I Congress Street,Suite 100 Boston,MA 02114-2017 kvwww.mass.gov1dia Workers'compensation insurance Affidavit:Buflders/Contractors/E lectricians/Plumbers. AAUlicant Information TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print e aib�l Name(Business/Organization/hidividual): Address: 2 Phone M 0,61--L City/State/Zip: Are you an employer?Check the appropriate box.- Type of project(required): [] 1.Ell am a employer with employees(11.11 aml/orpart-time).* 7. Now construction 2. 1 am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.[D I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 ffh"uilding addition 4.[:]1 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 1 LE]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.®Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.[:]Other, 6Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(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, 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-contractors have employees,they must provide their workers'comp.policy number. =.......... Jam an employer that isproviding workers'conipensatiott insurance far my employees. Below is the policy and job site information. Insurance Company Name:_ Policy#or Self-ins.Lic. 24) Y Expiration Date: ' , — , City/State/Zip: Job Site Address: erxL..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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct 6 Sigpature: Date:- C` Phone#: J 6 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License V 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#: 0 DATE(MM/DD/YYYY) ACERTIFICATEF LIABILITY INSURANCE 2/25/2016 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(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 CONTACT Barbara McDonough ---AME: -------- ------- Gilbert Insurance Agency, Inc. PHONE Ext�l_(781)942-2225 FAX,-MANa:(781)942-2226 137 Main Street ADDRESS:bmcdonough@gilbertinsurance.com INSURERS)AFFORDING COVERAGE............ NAIC# --------------- Reading MA 01867-3922 INSURERANorfolk & Dedham Insurance 23965 ---------------- ------------------------------------- --------------------------------------- INSURED INSURER B-.Utica Mutual Ins. Co 25976 Gary Tallaksen, DBA: Tallaksen Builders INSURER C: 179 Washington Street INSURERD: INSURER E: Topsfield MA 01983 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 MASTER 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. INSRLTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MWDDmYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENED A CLAIMS-MADE I X I OCCUR PREM IS TO occu(Ea $ 50,000 ND-P-010148 12/20/2015 12/20/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 _GE_N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY FIPRO ❑LOC PRODUCTS $ - 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COEa accidMBINEDent SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS _------_ NON-OWNED PROPERTY DAMAGE $ '.. HIRED AUTOS AUTOS Peraccident ------ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE EERH _----- ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ _______100,000OFFICE '.. B (Mandatory In H)EXCLUDED? 4481667 12/21/2015 12/21/2016 E.L.DISEASE-EA EMPLOYE $_ 100,000 (Mandatary in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 '.. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDS --- CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CCORDANCE WITH THE POLICY PROVISIONS. AUTHO ]ZED REPRESENTATIVE M Gilbert, CIC/LINDSE U 1968-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD INS025/7(11401) Office of Consumer:Affairs&Business Regulation IMPROVEMENT CONTRACTOR brl, t egiatratian: 138879 Type: "Expiration: 5/27/2017 Individual GARY P.TALLAKSEN GARY TALLAKSEN 179 WASHINGTON STREET TOPSFIELD, MA 01983 Undersecretary i w, 2��c I arant� a ;j„6wnent of I�"� Yak , :� ,, fe a ., Board c.:f Buiid:naf Ri guf ation and Standards . �r11� fl'lsw$Vnnad °aGN�sa-„w PIM License: CS-099337 GARY P TALLA 0EN %1 w 179 Washington S1rae�F Ir ic�i, TOPSFIELD MA;019 Expraf,6on Corrar fr,s'foner 0111712017 'FisDRI ER' NUsA 0a END 40 NUMBER `g� 80i% NONE $1,58a7!' 6 18 1 NE ANN//""M e TOP9FIELD TON ST MA 01983.1632 ” DD 06.07.2013 Rev 07.15-2409 _..