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HomeMy WebLinkAboutBuilding Permit # 6/22/2016- I BUILDING PERMIT y�osary416, TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N®#: { —X1,6 Date Received �R'�Rar�o Pei"�5 ��S•�cHuS�R 9 Date Issued:® IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER ke-V .;me rie, - Print 100 Year Structure yes no MAP ' PARCEL: C ZONING DISTRICT:�1� Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other y ❑ Food lain ❑Wetlantls ;❑ WatershedgDistrict SeptrcpaWell p x ry ' J- %�`r ,' �.. .`." 'ti�� rr r :%i�x'� d✓2 {j><�"�� bi ,�:''v., '�, r,�� �,.c.:7`r� ._ti��/�'�ia+z5i ;- l!�f,.f.�,� "�..�..'�P-";.;� fid,1. �,�:,.. ,�r',c.��..��'�/,'+l,,.i��,�� ,s' r :`4,;; DESC IPTI N OF WORK TO DEP RFORMED: r�+fll��S t- W r�� �)� a�4'Z'"t • po-s-11 .L s too lber2 C"ts • p woe (b4-C L& ,LUulzP .01 Identification- Please Type or Print Clearly OWNER: Name: �e�� e - `Gsrc. Phone: Address: /a YO.441:4 Jje. N® pg ®!11 V Contractor Name:�V14 1b Phone: -!;; S `4U Email: J<eL?me ave LdeaS mcd-s f tie-L- Address: Co D4 e /_#wef1® dlez Supervisor's Construction License:0 S 07530 Exp. Date: 1J- �� (�®!t, Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ /e OV0r FEE: $ 1 Check No.: µ Receipt No.: NOTE: Persons coma ' g with � e �tered contractors do not have tic tot runty fza�zd OORTH Town of Andover ® , . 0 . 2.61 -Z_Z- 0 Z- ° Y D LAKH ` ♦ � q I.Y9 6.r' COCNICMl WICK ADRATED S U BOARD OF HEALTH Food/Kitchen PERMI LD Septic System THIS CERTIFIES THAT u%� '`�d .,. BUILDING INSPECTOR ...... ............. ... .....�v.................... ... ...................................... ....... ........ .. �- 4 has permission to erect ........................... g � Al . Foundation .............. . buildin son .... .......... ..... ....4......... .................... Rough to be occupied as : s��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 Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST 10 S Rough Service ...... .......... ............... Final DING IN PECTOR ti GAS INSPECTOR Occupancy Permit Required to Occupy PuRough 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 Approved by the Building Inspector. Burner Street No. Smoke Det. , -- -- : _ -------------- ---------- ---------- I --------------------------- ----------- ley -{I 1 it top or bcrn'er I I I U ' - --------------------- ----------- - fIto V Lall WO M r ' zt . ri 1 f / - _ t7 �� _ '�- -_ _ j 4{Y '�-•, MOLE O. .,,to C-rc ^. .. I e � — I I I I: - I i rte., TT I • y,{ fir` I : -- -` --— li -------------------------------------- ------------------------------ r - f .,f fro�t h,:a-Azov ..,. ------ m r. sea Ox 1, ------ ----- Fciinolctian Ploi Illiarch 14, 2016 v �, The Commonwealth of Massachusetts z . f Department oflndustrialAccidents L d I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov1dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name (Business/Organizationffn/dividual): t EM Address: k � City/State/Zip: d vl A©-e Phone#: 17c�' - &H Are you an employer?Check the apliropriate box: Type of project()required): 1.❑1 am a employer with employees(full and/or part-time).* 7. 0 New construction 2Q 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.] 3.FJ I am a homeowner doing all work myself,.[No workers'comp..insurance required.]t 9. El Demolition 10 F-1 Building addition 4.F]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 ZIam 'fetors with no employees. 12:[]Plumbing repairs or additions 5. 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) 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. T1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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-con6ctors have employees,itiey must provide their workers'comp.policy number. I am an employer Mat is providing workers'compensation insurancefor my employees.'Below is the policy acid job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifV under thepainsan ;enalties o erjuiy that the information providee�d a ove is true and correct. e• Date: L�7 Sign .���...1�-' Phone#• Official use only. Do not write in this area,to be completed by city or town offrciaZ City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MM/DD/YYYY) ACCORH CERTIFICATE F LIABILITY INSURANCE ��26/20 s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: Ifthe certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME' .'T s )r O?' F_ . CyL� yF�tlPHONE "�Pv }I� FAX `�78} 683-3147 l8) i 1000 00cL ra, 3.god r l s.oat E-MAIL pa-,3_. 6 ADDRESS:- NoKt T;ldov_ ra 'T �i - INSURER(S) AFFORDING COVERAGE NAIC# I SURER A: ' �i ET:�I. _$ i c lT .`..�•C+E CO. INSURED IUT77 .'i...,_[,y,?;,}�, `s'_ T(�'. INSURERS: r=r {) o l: SU E C: INSURER D' tib..' INSUEER 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 BYPAID CLAIMS. '.. rSl� POLICY EF PO/plpY Y LIMITS TYPE OF INSURANCE SD D LI BE COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S1 ,000 ,000 RE SES Ea occurrence S a `��' CLAIMS-MADE 1771 OCCUR MED EXP An one person) S C Tom`--'1ED uF F�� a , o�,/��1 -� tai; r� PERSONAL&ADV INJURY S r L�I GENERAL AGGREGATE 5 `}+ � � +000 N'OTHER: L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S ePRO- LOC -B^ �T n(JPOLICY❑JECT DIaL.�tJtl`s E I L,;: r�COMBINED SINGLELIMIT AUTOMOBILE UABILITY E S '.. BODILY INJURY(Per person) S ANYAUTO BODILY INJURY(Per accident) $ .® ALL OWNED SCHEDULED AUTOS AUTOS OOWNED PROPER DAMAGE $ Per accident HIREDAUTOS AUTOS $ ''.. UA ACH OCCURRENCE $ UMBRELLA LIAB OCCUR GGREGATE S EXCESS LIAB CLAIMS-MADE 5 DED RETENTIONS STA T OERH- WORKERS COMPENSATION AND EMPLOYERS'UABILITY YIN .L.EACH ACCIDENT S ANY PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICERIMEMBER EXCLUDED? L.DISEASE-EA EMPLOYEE S (Mandatory in NH) '... Ifyes,des-beunder L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS belay vt'.it�.` DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if :e -. BUILDERS more spa is required) , if IO +1_ {DO I lqi ?ROS _ne� iOCn—OiO1�f .T5 1--. t H_t r _C_ DIR _cc a?p Ldp^,:<, ll_!.1S. TRUST 01845 NOTE: $400,000 LP-CI TaOUSE TQ '.r_T. I_U,, „J y11 LIOI. L..{ __ HOUSE, -c -jS LOSS P_"s7;rr P.DDTTTOTZ.f: CERTI IC TE HOLDER ``- '� CELLATION _jLL t ; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN V /F� iJ05 ca' �.7 1.l)'` ACCORDANCE WITH THE POLICY PROVISIONS. I .:� 02061 AUTHORIZED REPRESENTATIVE ©1988-2 4 AC D CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �iassrlehuse, -!�eP� 1r11e:i t Pz!hlic Sa'if `� Ors u 5ds a 3ca,d c�Building 7£ 7Uinit 1.U1F1 t1 Ult1U 11 Jl11J F-1 f 11U3 License; GS-075302 ` BEN.IAMIN C®Sc-IDOD 69 old Village Lai a North Andover NFA 01345 01` �Xl�it EltlGil 12/04/2016 Commissioner