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Building Permit # 8/15/2016
VXORTHI BUILDING PERMIT 0, TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ,Y) S LIS Date Issued.6' I PORTANT: Applicant must complete all items on this _4g_ LOCATION E"31-r_4 (1 Pint PROPERTY OWNER n Print 100 Year Structure yes no I MAP PARCEL� Ji y ZONING DISTRICT: Historic District es no I Machine Shop Village yes ,no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential [J_New Building ��6ne family El Addition [I Two or more family El Industrial [I Alteration No. of units: F1 Commercial �f Repair, replacement - F.5_Assessory Bldg F_1 Others: [I Demolition El Other 0 Septic 0 Well Ei Floodplain El Wetlands El Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 12„ .. t 2-J 0ove'r _FALC2_��CQ�C _4404 Identification- Please Type or Print Clearly OWNER: Name: �jcPhone: Add Contractor Name: 51L,,? i,,JE4A Phone: E rn ai 1: S -S P--e,r) ,4x+J .......... Address: 2i':; r ari ...... 1 :(L Supervisor's Construction License: Exp, Date: I f0 ARCH ITECT/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'. $ (' "z"T o v FEE: $ 1, Check No.: Receipt No.: 7 NOTE- Per5olis eonintac ing with unregistered contra not h, access to the guarantyftind ---------- U T .........._Skjnatu__e t/aWiief____ ... ......... ....... t%O R Tay '9 Town of f _ 6 ndover 0 No. * �ft i y � LAKE h ver, Mass, 17 [bC NIc"E"C. 1' s u BOARD OF HEALTH PER I T Food/Kitchen Septic System THIS CERTIFIES THAT .... �...... . � ... `........ BUILDING INSPECTOR has permission to erect .......................... buildings on .. .....C-6.44 ............... Foundation Rough to be occupied as .(CNOA .. .. ........ � 6 .. Chimney provided that the person accepting this permit shall in every respect confo .. .... Crn 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 Andov . ` - PLUMBING INSPECTOR i #W46" *.tan2L�!%AbVIOLATION of the Zonin or Buiidin Re ulations Voids this Pe Rough Zoning g g Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TIO T Rough Service ..... .BUILDIN INSPE TOR. Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Terms and Conditions • Contractor agrees to furnish all necessary labor, tools, equipment and materials to complete the work outlined in the scope of services. • Contractor shall provide copies of a valid builder's license and proof of liability and worker's compensation insurance prior to commencement of any work. • Contractor agrees to complete the Scope of Services in a timely and professional manner in accordance with the specifications set forth by the architect and engineers, and in compliance with state and local building regulations. • Contractor agrees to clean all debris from construction only and to keep the job site in a clean and workable condition at all times. • Any materials, products or labor not specifically mentioned in scope of services is not covered under contract and will be paid for out of allowance fund or billed to homeowner (monies denoted in bold next to categories are included in overall price and will be drawn from to pay for materials and installations) • Homeowner (not lender) is ultimately responsible for payment upon completion of services and receipt of invoices. • Anything not specifically mentioned in above scope of services will be billed at$65 per hour,plus materials. • All materials/labor supplied by Silk Renovation/Restoration are warrantee for I year from date of completion. Stephen Silk havid&K4ren Perry A' a , Stephen Silk Renovation & Restoration North Andover, MA 01845 MA License # CS-098533 HIC License # 176182 (978)886-0447 CONTRACT: To:David & Karen Perry Re:176 Chestnut St., N. Andover, Ma 01845 Date: July 29, 2016 SCOPE OF SERVICES: Mudroom: • Remove/ replace 4 existing windows • Install new entry door w/side lights • Install new french door unit • New trim to match existing • Insulation and drywall as needed Total: $6500.00 The Commonwealth of MaSSIRchusetts Department oflnclastrialAccident>s 1 Congress Street,Suite 100 Boston,MA 02114-2017 yV`y4�' www mass.gov/dza Workers,Comp ensationinsurance Affidavit:Builders/Contractors/E7ectrzcians/Plumbers, TO BE:PIL>✓D WITS(THE 7.'B12M[T7'Lt`�G A.UTI:IO:E2I'C"�', Applicant xnfozmatian Please Print Le2ibXy NaMe(Business/Organization/fndividual): j " i Address:_213-2-a a.Q City/State,/Zip: 9 t c °• / .,. Phone � Are you an employer?Checic6e appropriate box: Type of project(x 4ulred): .I 1.[]I am a employerwith • ! employees(full and/or part time)* 7.- p Now eoxistt action. 2,Xj I am a solo proprietor or partnership and have no employees working for me ill 8• Remo delirig any capacity.LN6 workers'comp.insurance required.] . ❑Demolition. 1E]I am a homeowner doing all work myself,[No workers'eornp..uasuranoe recluired.]t 10 F1 Building addition 4.[-11 am a homeowner and will be hiring contractors to conduct all work on my property. I'M ensure that all contractors either have workers'compensation insurance or are solo 11.Q Electrical repairs or.additions proprietors with no offipIoyees. 12:h Plumbing repairs or additions 5.El I ani ageneral contractor and I have hired the sub-contractors listed on the attached shoot. 1j.-F1 Ro6frepairs Those sub-contractors hada cinployees and have workers'comp,insrrran 0 14.( Other-. _ 6.F_1 u We are a corporation pod its officers have exercised their right of exemption perlblG'L C. 152,§1(4),and we bavo no.,eiriplayees.(N;o workers'comp,insurance required.] ' *Any applicant that checks box 41 must also fill out the section below showing theirworkers'compensation policy informaticn, T Homeowners who subiilifkbis affidavit indicating they are doing all work and then hire outside contractors must si;bmlt anew affidavit indicating such. tContractors bat check thi box mnst•al-tached an additional sheet showing the name of the sub-contractors and state whether or not those entities have , employees. Ifthe sub-coritrac'tors have employees,they must provide their workers'comp.policy number. fain an employer that is pr•ovzdingworlfers'compensation insurance for my employees'Below is'thepolic' an'd job site in .rmation. Insurance Company Name: :Policy#or Self-ills.Lia.#:_ � Expiration.Date: _.,, Job Site Address: z t r 1. _City/State/Zip: Attach a copy of trio walrl�ers' cbmpeltsation policy declaration page(showingthe policy number and expiration date). Failure to scctu•e coverage as required under MGL o. 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 veri:Ftoation. I do 11er elry certify under the pains and"penalties ofperjury Haat the in I! n provided above is true and correct 5'iatiuo: Date Phone#: Official use only. -iso riot-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.City/Town Clerk 4.1lectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: __. /03/2016 12:34PM FAX 7815817866 PANTANO VONKAHLF INSURAN 0001/0001 SILKSTR OP ID: RR CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYYYI 08102/2010 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 RY 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(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain pollcies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such andorsemant(s). PRODUCER NAME.' Pantano/VonKahle Inc Commonwealth Ins.Partners LLC PHONE gq7-847.0005 Arc No;617-847-0006 PAY- 25 Newport Ave.Ext, AIC lira art: N.Quincy,MA 02171 9-MAILS:wkrev aal.nonl Commonwealth Insurance INSURERS AFFORDING COVERAGE NAIL q INSURER AI TRAVELERS INS.SERVICE CENTER INSURED Stephen Silk DBA INSURER a Renovation&Restoration 33 Perley Road rNsuRER a North Andover,MA 01845 INSURER D: INSURER E; INSUREM 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. N07WTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIGH 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. LTR TYPEOF INSURANCE Ium POLICYNUMBER (MMIAMI (MM1b0IYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE _ $ 1,000,00 ❑X 8801 D513215 04/22/2016 04/2212017 ATEIT- 300 00 CLAIMS-MADE QCCLIR PREWBE8 Ea occurrence S r MEQ EXP(my one parson) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 i'1'EN'L AGOREOATE LIMIT APPLIES PER: G11NERAL AGGREGATE S 2,000,00 POLICY❑PRO- F-1LOO PRODUCTS-COMPIOPAGG S 2,000,00 OTHER: $ IINM AUTOMOBILE LIABILITY E even t CMI 8 ANY AUYO BODILY INJURY{Par paman)~ S AUTOS OVvN8D SCHEDULED BODILY INJURY iPerarsl(fent) S AUTOS NON-OWNED S HIREDAUTO5 AUTOS .lhe UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSLTAe CLAIMS-MADE AGGREGATE WW_. S DEC) RETENTIONS WORKERS COMPENSATION - AND EMPLOYPRB'LIABILITY STATUTE ER ANY PROFRIErOhrPAATNERX-XS0UTIVE YNIA E.L.EACH ACCIDENT S OPPSCERrMEMOER EXCLUDrD? El —� [Mandatory fn NM) E.L.DISEASE-EA EMPLOYEE 5 If yyds,daWbe under 1) IPTION OF OPERATIONS below 91,DISEASE-POLICY MMMT $ DE5GR1"ON OF OPEI3A'11ONS r LOCATIONS I VEHICLES (ACORD 101,Additional Remarn SCIIYdula,qmy bu att+ched N muse apace la nequlmd) This car't:i i.cato is hareby issued as QVidence of existing itsurance coverage. CERTIFICATE HOLIER CANCELLATION SHOULD ANY OF THE ABOVE Ar3CRIBE©POLICIES BE CANCELLED BEFORE THE EXPIRAT(ON DATE THEREOF, NOTICE WILL BE DELIVERED IN David&Karen Perry i` ACCORDANCE WITH THE POLICY PROVISIONS, r 176 Chestnut Street l North Andover,MA 01845 AUTHORIZED REPRESENTATIVE 0 1988-2014 ACORD CORPORATION. All rights reserved. ACORN 26(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-098533 Construction Supervisor F<+ { STEPHEN A SILK 33 PERLEY ROAD NORTH ANDOVER MA 01645 (-/JZ7CA, Expiration: Commissioner 11113/2017 _j\. Office of Consumer Affairs&Business Regulation -y ME IMPROVEMENT CONTRACTOR egistration: 176182 Type t5xpiration 7/25/2015 DBA STEPHEN SILK RENOVATION&.RESTORATION STEPHEN SILK 33 PERLEY RD NO.ANDOVER,MA 01845. Undersecretary N