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Home My WebLink AboutBuilding Permit # 8/3/2016 BUILDING PERMIT �or�rM �f,• Q�'�LEq '6Y0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ Permit No#- Date Received 'A�RArE9 9S��vcHu5�� Date Issued: IMPORTANT: Applicant must complete.all items on this page LOCATION P r)fit PROPERTY OWNER btq;ln Print 900 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 ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement- ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic. ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District.. Water/Sewer DESC IPTION OF WQRK BE/PERFORMEP. ME Identification- Please Type or Print Clearly OWNER: Name: a Phone: Address: Contractor Name: f l Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT. $92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project COSt: $y t� FEE: $ . Check No.. 31 v10, Receipt No., 2,4?,6- NOTE: Persons contracting with unregistered contractors do not have access to the g ty f d ¢ NORTki q Town of s �T, 6 ndover G ti - . `' 0 No. y oh ver, Mass, COCruCMlwKK y �� •9 ArED �pR� •t5 U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT 1000 104 BUILDING INSPECTOR has permission to er t ........................- buildings on .................................. ._C Foundation Rough to be occupied as � .Ti �er ... ; .. AIr ,..�t, ,....�,Rl� r� chimney provided that the person accepting mit shall in everytespect 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 CONS .. TION Rough .. ... . ..... ... ........... Final CTO BUILDI E GAS INSPECTOR Occupancr Permit Required to Occupy Ruildin Rough Display in a Conspicuous Place on the Premises - Do Not Remove Fine No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts „ .• Department oflndustrlalAccidents M w.� 1 Congress Street,Suite 100 02114-2017 Roston,MA • www mass govIdia Warkers'Comperes b BE FILED WYT.Hfidavit:TH�P��,�INGA�,�,gOR�T'YctricianslPlu�rnbers. A licantlnformation . Please Print Le 'krl amo(Business/oxganizationliudividu9): . City/State/Zip: phone#:,� 7�c�� Elreyou n employer?CheckWe apliroprinie box: Type of project(��quired): 1. a employerwith employms(full and/or part-time).* 7. Q NeW coristnxetlon 2.E]I am a sole proprietoror partnership and have no employees Working for me in $. ❑1Zemndeling any capacity.[No workers'comp.insurance required.] 9_ ❑Demolition. 3.❑I am a humeowner doing all work myself[No wozkers'comp..invsuramou required.]' ZQ Vlumbing addition 4.rJ lam a homeowner andwitt be hiring contractors to conduct all work on my property. I will 1 'cal repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors withnc employees. 1.2: repairs or additions 5.❑I am a general coptractor and I have hired the sub-contractors listed on the attached sheet. Ij.-D Roof fePairs These sub-contractorstave employees andhave workers'comp.iuslumcc.f' 4.❑Other 6.❑We are a corporation pnd ifs of ipers have exercised their right of exemption per MGL c. 152,§1(4),andwehavangemployees.[Noworkers'comp.insurancezequired.] hAny applicant that checks box 41 must also'�Zil out the section below showingtheirworkers'compensation poli information i Ilomeawners who snlizuit'tlis affidavitindicatingthey are doing all work and.then hire outside contractors must si}bmit anew affidavit indicating such tContractors_that checkthis box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities Dave employees. Iffhe sub-cnziracors Have empinyses,rIiey must provide their workers'comp.policy number. .I am an enc ployer that is providing workers'compensation insurance for my employees.'Below is the policy and job site � LnfarYrlatLD]'i. /� Insuj:anceCompany Nance: /�.J•- [� ' w 7 3 . Expiration Date- 't #or Self-ins.Lio. City/State/dip: � Sob Site Address: Attach a copy of t e workers' compensation p obey declaratioxz page(showing the policy laumb r an l expir atinn date). Failure to secure coverage as required under MGL a. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/ox one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER an l a fino of up to$25Q.Q Q a day against the violator.A cagy of this statement may be forwarded to the Office of Investigatlons of the DIA.for insurance coverage verlftcation. I da hereby certify urzer ce in enalties ofpeijury that the information provided ago Lsa true incl correct 3 Rafe: /Y Si nature: Phone Official use only. 1)0 not write in this area,to be com,�nletecl by city or town official City or dawn: Permi"icense# Tssuintg'AuthortW(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone Coutact]Person: : ---Ili KANN&PR-01 JONEILL �CORo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 6/6/2016 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. I 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). CONTACT PRODUCER NAME; Durso&Jankowski Insurance Agency PHONE978 FAX 11 Saunders Street (arc No,Ext);_(_._._�688-7000. (Arc,No): (978)688-7001 North Andover,MA 01845 E-MAIL ADDRESS: INSURER(SI AFFORDING COVERAGE NA€C# INSURERA:Conc Ord Group Insurance INSURED INSURERB;Safety Insurance Company 33618 Kannan&Pricone Plumbing& INSURER C:Mal rkel Insurance Co Heating,Inc. INSURERD:Guard Insurance Group 3 West Ayer Street Methuen,MA 01844 INSURER E: INSURER P: 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 RESPE=CT 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 ADOL-SUBR POLICY EFF POLICY EXP L'TR 7-ypE OF INSURANCE_ INSD WV] POLICY NUMBER W _W (M1y11DDNYYY) (MRJDDIYYYYJ LIMITS A X COMMERCIAL GENERAL UABIL€TY EACH OCCURRENCE S 1,000,000 X 20009105 04!011201 fi 0 410 112 0 1 7 DAMAGE TO RENTED ICLAIMS-MADE OCCUR PREMISES(Ea occurrence) S ! MED EXP(Anyone person) S 5,000 PERSONAL&ADV INJURY_ $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER: S COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 B ANY AUTO 6237590 04/0112016 04/01/2017 BODILYINJURY(Per person) $ ALL OWNED X SCHEDULED DOUILY INJURY(Per accident) S AUTOS AUTOS X HIRED AUTOS X AUTOSWNED (p PROPERTY DAMAGE S S UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 3,000,000 'C X EXCESS LIAB CLAIMS-MADE MKLV10LE107332 04101/2016 0410112017 AGGREGATE s DED RETENTION S S WORKERS COMPENSATION PER OTH- j AND EMPLOYERS'LIABILITYSTATUTE ER D ANY PROPRIETORrPARTNERIEXECUTIV. YIN KAWC739294 06103/2016 06103/2017 F L.EACH ACCIDENT s 1,000,000 OFFICERim EMBER EXCLUDED? N f A - i (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE_S 1,000,000 4f ye s,describe under DESCRfPTION OF OPERATIONS beiow _ E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS r VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE.HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover Bldg 20 Ste 2.36 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover,MA 01845 i AUTHORIZED REPRESENTATIVE i E O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts f Department of Public Safety License: SJ-005206 2 Sprinkler Journeyman WILLIAM M KANNAN { 10B GRANnvIEW RD METHUEN MA 01844 � jZZ CA— Expiration: ' 09l0512017 Commissioner �