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HomeMy WebLinkAboutBuilding Permit # 7/29/2016 II BUILDING PERMIT �otT Q E4TLEp jF6�4,Q TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ssgCHti`'�'C Date Issued: IMPORTANT: Apptzcant must complete.all items on this page LOCATION I _ Print PROPERTY OWNER P } '�� Print 100 Year Structure yesnn MAP PARCEL: z ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family ❑ Industrial ='Alteration No. of units: ❑ Commercial ❑ Repair, replacement- ❑Assessory Bldg ❑ Others- Demolition ❑ Other ❑ Septic o Well ❑ Floodplain ❑Wetlands ❑ Watershed District Cl Water/Sewer DESCRIPTION OF WORK TO BE PERF IVIED: Identification- lea e Type or Print Clearly OWNER: Name: Phone. Address: ��� Contractor Name: �a ��r� 9 Phone: �� - Email: 741, ;64,,/- 1Z �.�0-g-9 Address: Supervisor's Construction License:C -/,_2,2 Exp. Date: Home Improvement License: Exp. Date: ARCHITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $T FEE: $ o — Check No.: Receipt No.: NOTF,- s contr ctin with ware ed con, ac to o not hav acces guaranty fund �oRTH own of : :. - 0 No. -� �i z h , ver, Mass, COC.u[ktw.c. �. 4 � `r V BOARD OF HEALTH Food/Kitchen PERMIT_ LD Septic System `3 c �►c�.-E�i c Lc�� art THIS CERTIFIES THAT 4��4 ....,... , ._, BUILDING INSPECTOR has permission to erect .......................... buildings on . . .1. .. , `......... Foundation .C�� ...Z. 5cCjARough to be occupied as ....... .. ... ..'r............................... ., 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 TIO Rough Service ., ... ...,.. ..... .......... ... Final BUILDING I PECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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 Approved by the Building Inspector. Burner Street No. Smoke Det. -Cruikshank's Carpentry By signing this document you agree to the terms provided to you on the estimated proposal. Payment installments to be discussed off of the construction loan contract. During some construction projects other expenses can occur due to not knowing what can be hidden behind walls for exp.( improper framing,termite,lead or asbestos to name a few)A cost plus basis will then occur meaning cost of materials plus labor expenses by the hour at a rate of$130. For a two man crew Any products used in the project that may later have defects or malfunctions is to be processed with the manufacturer's and not the contractor. If there is any question's you have during or about the installation process please feel free to bring them to my attention. Any upgrades or extras will be discussed and agreed upon before the additional work is to be done and will be added to the contract as well as initialed signed and dated. That balance will be due before the installment process is set to begin. All estimated proposals are good for up to thirty days due to unknown market increases of material cost. 1 year labor warranty is in effect as of date of completion Materials warranty's based on manufacturers policy This contract is based on the estimate number 322 Total Renovation costs is$25,000 Plumbing costs provided by home owner Customers signature. C Service Provider. The Commonwealth ofHassaehusetts z Department ofrridustfialAecidents y0.w = d 1 Congress Street,Suite 100 Roston,HA O2114 2017 www mass.govldia Workers,Coznpensatiou insurance Affidavit:)3uiiderslContractors/FIi cq riciaus/.Piujmbers. TO BE BIIMD'WITS TBE PERMITTING AUTBEOPJTY- AppiLeant Information 1'lcase Print Le 'bl Name(Business/Oxganization'fndividual): /111q IA Address: Cityltata/tip: �?�' � 7'hone#: olo 3 Axe an employer? Cheer t]ie xup la '.t Type of project(required): 1 a emplcyervvitlh employees(fool]and/or part-time).* 7.. []New coxistruction i am'a sole propdetoror partnership and have no employees working for me in $, �Remodelitig any capacity.[No-workers'comp.insurance required.] 9, Deznolition 1E]I am ahomemner doing all work myself[No workers'comp.-insurance required.]t 10 ❑Building addition. <1 I am a homeowner arnd 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 I.1;❑Electrical repairs or additions F pr6Vrietors with no employees. 12 plumbing repairs or additions 5.FJ I am,a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roofrepairs These sub-contractors bade emploYees audhave workers'comp.insurance.t 14.El Other 6.E]We are a corporation wad its offf.gers have exercised their right of exemption per MGL c. andwetavena,eitiplayees.[Noworkers'comp.insuraucoiequired.] *Any applicant that checks box 41 roust also fill out the section below showing theirworkers'compensation policy information. t homeowners mho sulim it}bis aifdavit indicating they are doing all work and then hire outside contractors must submit a navw affidavit indicating such tCont€actors that ohecktbis boxmust,attacned an additional sheet showing the namo ofthe sub-contractors and state whether or notthose entities have employees. I£the sub-coni rac ors Have employees,hiey must providotheir workers'comp.policy number. I am an employer that is providirxgworhrs'compensation insurance fo:r mY employeeM'Belo)v is thepolicy and jell site information. Insurance Company Name: Policy#or S elf-ins.Lic.#: '��` ' Expiration Date: Sob Site Addy ess: 6"r r/t�f City/State/-Zip:._ Attach a copy'of:the w compeisation policy declaration page(showing the policy number and expiration date). Pallure to secure cov&age as required under MGL o. 152, §25A is a criminal violation punishable by a tine 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 ofup 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 verlfzoation. X do hereby cel tify uxidet tlae pains a d ttilti ijrciy that the information provided alcove is i'ue wird col reef. Si ature: Date: Phone#: Of use only. Do not ivi•ite in this area,to he completed by city or town official City or Town: Perwit/License# issuing Authority(circle one): i 1.Board of Health. 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Paychex, Inc , RF 6 7/29/2016 8 : 31 : 14 AM PAGE 3/003 Fax Server arx CERTIFICATE OF LIABILITY INSURANCE 07/29/20 60lVYYY) 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 an this certificate does not confer rights 10 the Certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY, INC. PH 150 SAWGRASS DRIVE (A -NO.EXT: 877-266-6850 FAcNo). 585-389-7426 ROCHESTER, NY 14620 E-MAI ESS:L GertsCapaychex.com AD R INSURER(S)AFPORDING COVERAGE NA1C# INSURED INSURER A: NorGUARD Insurance Company 31470 MATTHEW CRUIKSHANK INSURER B: 14 STICKNEY BROOK ROAD BROOKLINE, NH 03033 INSURER C: 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 TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRR TYPE"OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS NSR VD IMWDDIYYYY) (MMIDDIYYYY) GENERAL LIABILITY EACHOCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO HENTED $ Ea occurrence E=11-AIMSMADEE "CCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY =PROJECT=LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) BODILY INJURY ALL OWNED scHEbutFn (Per person} $ AUTOS AUTOS HIRED ArJTOs OVPWNED BODILY INJURY $ (Per accidenl) PROPERTY DAMAGE $ (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRE NCE $ EXCESS LIAB CLAIMS:MADE AGGREGATE $ OFD RETENTION$ $ WORKERS COMPENSATION AND X WC STpTif- OTH- A EMPLOYERT LIABILITY MAWC700838 03/07/2016 03/07/2017 E.L.EACH ACCIDENT $ 100,000.00 ANY P ROP REETOFVPARTNER/EXECUTI VE OFFICERWEMBER EXCLUDED? YIN.. E.L.DISEASE-EA EMPLOYEE $ 100,000.00 ;Mandatory In NN) NIA E.L.DISEASE-POLICY LIMIT $ 500,000.00 Ir yes,d—ibe under DESGRIPTDN OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(Allach ACORD 101,Add€tonal Remarks Schedule,I1 more space is required) 281 ANDOVER STREET CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION 600 OSTOODEN SUITE 2053 DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY NORTH ANDOVER,MA 01845 PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE ACORD 25(2010105) (0198&2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD :� r'f�e�a�rr>>rc:urierrl�/o ^'l�rr.;,nc�rrde(li Office of Qmsui:,-r A ffikirs&Business Regulation RQ C IIiIIP:;OVFfJtENT CONTRACTOR �M } r gists*iota: 158000 Type: k, ji=xpiration: :1!1,2018-.- ©BA 4�,f;; ^,i'LJIKSH,ANK'S CARPENTRY AhKi PHEW CRUIKSHANK 14 STiCKNEY BROOKRD — BROOKLINE,NH 03033 Undersecretary _ c 1. � x. L Pgnocuff Caulplic�r3 .: LSZZO VJS3 :OSUaajj � N i S3`';.v ,.,UC s,-,0-.,1Z?JP. 7r1 FSUfr)l. i..0 k SLC3�