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HomeMy WebLinkAboutBuilding Permit # 6/27/2016 BUILDING PERMIT 01 �o��� Sq LCD /ba �o TOWN OF NORTH ANDOVER b APPLICATION FOR PLAN EXAMINATION Perrin NO: p Date Received c H05��4 Date Issued: 1 t PO TANTe Applicant must complete all items on this page T LOCATION 6(A Z D°i/ Pri t PROPERTY OWNER 6® A) Al 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 P/wo or more family ❑ Industrial Alteration No. of units: J ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic`: ❑Well D Floodplain = Wetlands, , ❑ Watershed District O,Water/Seviier DESCRIPTION OF WORK TO BE PERFORMED: 13 u7c i2 e�-C c7�Q �'_ c z i c e' 12- e £T Identification- Please,Type or Print Clearly OWNER: Name: AfC) fir` Phone: S L( 0 -T Z 4 Address: , C)� S A 604 4 4"Ve-Wo C/ Contractor Name: �+� ��e�r' 14- `(/Phone: S S � �I!q V 2- Email: &A/ &C /,2,,v q, m 4 l,;,i Address: 0 J' o (( - M CLI Supervisor's Construction License: S V 7ff Exp. Date: 06"/ : / . 0 Home Improvement License: f Exp. Date: ARCHITECT/ENGINEER _ Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ - FEE: $ Check No.: No.: �11 N TE: Per s contracting with unregistere contra rs do not have,access to the guaranty fund t4®R'TH Town of Andover 2 t' ® ® 2 61 - `AKG ver, Mass, Taqc e27 261% coc.uc"awoc.c 1' L) BOARD OF HEALTH Food/Kitchen P E REENOL M IT T L D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .. ..... ....... .. ...... . .............. ................... .......... Foundation has permission to erect .......................... buildingson ..,... ..:............. *.Oln llrj�............... 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 Inspe n,Alter ti nd 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 CONST 10 Rough Service ..... . .. ..... .. ......... .,............ .... Final l B.UILDIN SPECT R GAS INSPECTOR Occupancy Permit Required to Occupy Buddtnz Rough Display in a Conspicuous 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. IKEA Home Planner Printout http://kitchenplanner.ikea.com/US/UI/Pages/Printouts/VPUISummary... > - -- 2 union st - Plan View All measurement in inches - iA 0000-9351-3120 130 259115 1 773/8 27 06 24 14 13/161 100 3/8 1—I --61 1 yTT j v IIS � 8 a v i _ 38 I/16 24 43 7/0 6/20/2016 11:02 PM 2 of 5 IKEA Home Planner Printout http://kitchenpIanner.ikea.com/US/UI/Pages/Printouts/VPUISummaiy... - 2 union st bathroom - Plan View All measurement in inches 0000-9351-3133 I C � O 1 i I 78 9/16 5 711 643/4 9 3!8 35 5116 30 18 11/16 2 union st bathroom - East Wall All measurement in inches _ 0000-9351-3133 321 ifi 31318 1 1311 1 l I r � s r i a ,1 i F r„ i 32 1/2 6/20/2016 11:00 PM 2 of 2 TOWN OF NORTH ANDOVER .mow®Q��QA OFFICE OF s 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOME0VVNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: La 942111ol JOB LOCATION: 15;? a 4 Number Street Address Map/Lot HOMEOWNER V4/0 7,z-3/ Ane Home Phone Work Phone PRESENT MAILING ADDRESS a2 ���` S 4A,-W©Vey /V* ®//�/sr City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dweifings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner" assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will co m with said procedures and requirements. i+ HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLAT NUG 688-9535 The Commonwealth of Massgchusetts ' F department ofIndlustr"ialAccidents 4 d X Congress Street,Suite 100 ' Boston,AM 02114-2017 www.Mass.gov/dia Workers'Compensation Insurance Affidavit:Funders/Contractors/E Xeetricians/Plumbers. TO BE MED WITH TMG PERMITTING AUTHORI Y, Applicant Information Please Print Legibly Name (Business/Organization&dividual): Q 7 < ye C, AU cf C-6, 6 - J©(t-C Address: Feap_ �C SS X ye— 4f` / City/State/Zip: A144-- V/ Y 02- Phono#: 3 3 1 _�i`�/C) =Y 2 3 Areyou an employer?Checkttie appi•oprlate box: 'Type of project()Vequired): I.❑l am a employerwith t employees(fall and/or part-time).* 7, ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remo delilig any capacity.[No workers'comp.insurance required.] 3..E]lam a homeowner doing all work myself,[No workers'comp..insurance required.]t 9. 0 Demolition 4.E]I am a homeowner andwill 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.❑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.insruance.r 6.rfWe are a corporation and ifs officers have exercised their right of exemption per MGL c. M.❑Other 152,§1(4),and we have na.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. .Homeowners who sn6mif#his 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 o£the sub-contractors and state whefher or not those entities have employees. If the sub-contractors have employees,&li must provide their woikcis'comp.policy number.' I-ain an employer that is p'iovMhg workers'compensation insurance for my employees.'Below is the policy andjoh site information. t Insurance Company Name: /�di �e l�2 y (� Policy#or Self-ins,Lic.#: / - Expiration Date: �3 J _ o� fob Site Address: v� ( r.,c`V S� City/State/Zip: A/Ole AJdO U� Attacha copy of the workers'compensation policy declaration page(showing the polley 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. X do Hereby certify under the pai s o_ penalties ofpeijury that the information provided above is true and correct. Signature: Date: 0 Phone#• 33, 9 Z( V Q Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health. 2.Building Department 3.CitylTown Clerk 4.Flectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE 1 DATE(M2012Q1 YYYI T RTIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: QUARANTELLO INS AGCY INC PHONE FAX 91 HUTCHINSON ST (A/C,No,Ext): (AIC,No): E-MAIL REVERE,MA 02151 ADDRESS: 75YPL INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA CREATIVE CONSTRUCTION SOLUTIONS INC INSURER B: INSURER C: INSURER D: 22 FEARLESS AVE APT 2 INSURER E: LYNN, MA 01902 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE F—]OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY D PROJECT ❑LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) y ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LAB F__] OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKER'S COMPENSATION ANDX wC STnTUTORY OTHER' EMPLOYER'S LIABILITY Y/N UB-2E81723A-16 03/31/2016 03/31/2017 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE NIA E,L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes,describe underE.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS[VEHICLES/RESTRICTIONS/SPECIAL ITEMS ']'HIS REPLACES ANY PRIOR CE3R'TIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP('OVERAGE. CERTIFICATE HOLDER CANCELLATION BOGDAN ANDRF,Y KIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 2 UNION ST. IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTfflIVE `- ) NORTH ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.