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Home My WebLink AboutBuilding Permit # 7/1/2016 1 BUILDING PERMIT %aoRro-� TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION Permit No#: � ' � � Date Received ��°aaATC0 s�C s�� Date Issued: 16 IMPORTANT: Applicant must complete all items on this page LOCATION . .ta I e,:. ')�y t�_ Print PROPERTY OWNER t Print 100 Year Structure yes no MAP zv 1 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: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ON ....�rrar rmi r l r a ri II ,.11 Y Mill'rrrr� e, , " DESCRI �T O , OF WORK TOTE ERFORf 4 " m 7 I entificat' 7 Pleale Type or Print Clearly OWNER: Name: Phone: Address: e t � .. tit. d ( � Contractor Name:�,, ee�t :t- hone: Address: Supervisor's Construction License: ) 9Y Exp. Date: '1 Home improvement License: 7d I Exp. Dater ' p p ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. a Total Project Cost: $ 5? C FEE: $ 16 Check No.: !2 Receipt No.: J NOTE: Persons contract/ with unregistered contractors do not have access to the guaranty fund / WINK 7//„ / ,a/� /. ... , r✓/� � ////✓,/i,1/ �„ e�L7///�iirli✓,%/i///i r1„✓,. .irr/ii//rf, r//%///////i ;,//i /i ,/;i r/ //./i/ / f ,� // ,< :yo. /7�%%� ,/„✓r / iii r + % tko Th dover Town of '2' E - ® . • y. An 1 r 06 26 ® ® T _ J Y% O �.-. Very `G�15Sy coc Nlc N@WICK �AoRAa�V '19,9 re® �? � U BOARD OF HEALTH Food/Kitchen P M, LUSeptic System THIS CERTIFIES THAT BUILDING INSPECTOR ........... . .. . .. .. .......... /.... .. .... ........................................ has permission to erect .......................... buildings on .....6.49..... Ato ., Foundation .: Rough to be occupied as ........ ..t. ® 40Ochimney .... ...... ..... ........ .................... provided that the person accepting this permit s all 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-Lawsr latin to the Inspectio , teration 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 ELECTRICAL INSPECTOR UNLESS CONS I Rough Service .. .... . .. ...... ..... Final 4 BUILDING SPEC OR GAS INSPECTOR Occupancy Permit Required t® Occupy Budldln Rough Display in a Conspicuous Place on the Premises — ®o Not Remove Final NoLathingor T Wall 1 o Be ®one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. JSA COMPANIES INC 55 Chase St. Methuen, MA 01844 Date 1/28/2016 Estimate # 93 Name / Address Lindsey Riordan 26 Brett Circle Pelham, NH 03076 P.O. # Terms Due Date 1/28/2016 Other Description Qty Rate Total 1-The following estimate is for address 20 Edgelawn 0.00 0.00 Ave. N. Andover, Ma. 01845 2- Fee for all necessary permits and inspections 250.00 250.00 3- Provide necessary demolition to kitchen area as 750.00 750.00 needed as well as bathroom demo and back room area with wall repairs also needed. No mold found at time of visual inspection. 4- Purchase and install new cabinets, counterto s 4,200.00 4,200.00 perplan in kitchen and bath areas. atenals $3200.00 Labor $1000.00 5- Purchase and install new appliances for kitchen as 3,000.00 3,000.00 per plan. Appliances $2500.00 Labor $500.00 6- Purchase and install new flooring as needed to 1,800.00 1,800.00 kitchen, bath, bed and living rooms as per plan. Materials $1000.00 Labor $800.00 Signature Total JSA COMPANIES INC jsacoinc@comcast.net 1-978-375-8041 1-603-471-1091 Pagel JSA COMPANIES INC 55 Chase St. Methuen, MA 01844 Date 1/28/2016 Estimate # 93 Name / Address Lindsey Riordan 26 Brett Circle Pelham, NH 03076 P.O. # Terms Due Date 1/28/2016 Other Description Qty Rate Total 7- Purchase and install all necessary paint and primer 1,000.00 1,000.00 as needed for a complete installation. Paint and materials $250.00 Labor $750.00 8- Purchase and install new wallboard with finish, as 1,500.00 1,500.00 well as baseboard, window, door trim, etc. as needed for a complete installation. Materials $750.00 Labor $750.00 9- Purchase and install new electrical materials for 650.00 650.00 new lights as well as updating kitchen wiring. Materials $400.00 Labor $250.00 10- Purchase and install new toilet with valve, seal, as 1,000.00 1,000.00 well as lav piping, kitchen piping as per plan brought to complete installation. Materials $400.00 Labor $600.00 /v gnature Total $14,150.00 JSA COMPANIES INC jsacoinc@comcast.net 1-978-375-8041 1-603-471-1091 Page 2 The Commonwealth of Massochusetts F Department of Xndastrial.Aceldents X Congress Street,Suite 100 Boston,M4 02114-2017 www.mass.gov/dia Worl(ers'Compensation Insurance Affidavit:Builder's/Contractoxs/Eikctricians/Plumbe7rs. TO BE I+ILED WITH THE PEBMITTING AUTHOPJTY. Applicant Information Please Print Le 'bl Mame (Business/Organization/Individual): .Address: � f � . m .._ )V .'- Wo / City/Mate/Zip: It 0661" i t4� tq ` ' Phone#: ! Are you an employer?Check Elie app'iopriate box: Type of project(R'equir'ed): 1.[J 1 am a employer with : employees(full and/or part-time).` 1, New con§truction -I am a sole proprietor or partnership and have no employees working for me in $, `Remodelifg ,, any capacity.[Noworkers'comp,insurance required.] 9. Demolition In I am a homeowner doing all work myself[No workers'connp..insurance required.]t 10 F]Building addition 4•❑lam a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions propiietors with no employees. 12.F1 Plumbing repairs or additions 5.[]I arua general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors bade employees and have workers'comp.insurance.t 13.F1 Roof repairs 6.Q We area corporation and its officers have exercised their right of'exomption per MGL c. l4. Other 152,§1(4),andwe hayo na.employees.[No workers'comp.insurance required.] r: 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who subniif 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-c6ulrac{ors have employees,they must provide their worke'rs'comp.policy number. X arse an employer that is pr'a'viding workerscompensation insurance for my en ployees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lic.#: Expiration Date: �X fob Site Address: �' '"' City/State/Zip: .,w Attach a copy of the worker's' ompensation 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 WORD 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 cert! and ai eraatiles ofper jury tliat tlee infor'mcttlora provided .bo e is true and correet. Si nature• Date: Phone#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 Department 3,City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MMIDDIYYYY) CERTIFICATE LIABILITY INSURANCE 06/30/2016 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 NAME: KEITH BEAUSOLEIL FORTIFIED INSURANCE AGENCY HONo Ext, 603-644-3700 a/c NO 603-644-0001 911 CANDIA ROAD E-MAIL ADDRESS: INFO FORTIFIEDINS.COM MANCHESTER NH 03109 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: MERCHANTS MUTUAL INSURANCE CO INSURED INSURER B JEFF AGNEW DBA JSA COMPANIES INSURERC: _ 11 ESTHER DR INSURER D: _ BEDFORD, NH 03110 -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 I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IND D POLICY NUMBER MMIDD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY BOP1084614 04/09/2016 4/09/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR DAMAGE TO RENTED 500,000 PREMISES Ea.occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY® JEC 1-1 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident LANY AUTO BODILY INJURY(Per person) S SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTYDAMAGES AUTOS Per accidentLIAB OCCUR EACH OCCURRENCE S B CLAIMS-MADE AGGREGATE S RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A INLAND MARINE BOPI084614 14/0912016T-4 LIMIT OF INSURANCE:$50,000 DEDUCTIBLE:$500 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RESIDENTIAL PLUMBING AND CARPENTRY REMODELING CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD ST. N.ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE JSACOINC COMCAST.NET G`1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Wei cu m -S e, CS-065690 a F ' SAGNEW55 CHASE ST \ NM THUEN 014 - _ 07i3iii 116 : Of ice of Consumer Affairs&Business Regulation $OME IMPROVEMENT CONTRACTOR ec istration: 172928 Type: ,expiration: 8/1412016 Individual JEFF S.AGNEW JEFF AGNEW 11 ESTHER DR. 4 � � BEDFORD,IVH 03110 Undersecretary i ME v� [ f @�g� �6BERS,� �GASFlTERS ` ISS43 >'�H�'FOLLp�t�NG�ICEt�SE � ' 9CEh4 D AS A MA ER$?l 1�6 BER E .,S AGE s 6.1 ESTHER;€3R , ,f BEDFOR, ,:INS x}31 i tD— 22 ca ,M 53444 12060 w gi. ,. e