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Home My WebLink AboutBLOWN CELLULOSE IN ATTIC TO R49, DENSE PACK KNEEWALL FLOOR t&ORTN � BUILDING PERMIT o�ZZLE O_.,6F'�� TOWN OF NORTH ANDOVER 32 y. APPLICATION FOR PLAN EXAMINATION o t Permit No#: Date Received AcFlus��y Date Issued: IMPORTANT: Applicant must com tete all items on this page r LOCATION PROPERTY OWNER (�`oma_JC_ int q�� Print 1 100 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 Buildinge family ❑ Addition ❑Two or more family ❑ Industrial �eration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other t�<! Yefl .'✓. k: ii '.ntii^ .ri /li Flan.`�'-� �, ti ".. .1^"`,sa- DESCRIPTION OF WORK TO BE PERFORMED: i 41 AWG. tet'1d1�. `r N i de tificatio - Please Type or Print Clearly OWNER: Name: Phone: Address:_/W/ 6;--ea,4" Contractor Email: �� Pal'�� .. ractor Name: Phone: ��fs•7�1�- ,,.._.... Address: Salem 1AA 1970 Supervisor's Construction License: F5 79 -7 7 Exp. Date: 6I/Z 31l Home Improvement License: III Z,05 y Exp. Date: 3/121 ARCHITECTIENGINEER 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: $ 02 6f7),- FEE: $ " Check No, -~ _2,6 6 7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th at knty faced F NORTH q Town s �* 6 ndover a "" R 0 No. �. 016 � "g. hver, Mass, Q COCMIC"4!W1Cn --- �•9 °RArFo s � BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..��. ..�...j!'�..�'../a. .......................... ....,... BUILDING INSPECTOR has permission to erect ........ buildings on �. .�.�..�il� .. .,!'!!!� f=oundation Rough tobe 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 CON§MM1 S Rough Service .. ....... . .......... ................ ......,.. ' Fina[ BUILDING PECT GAS INSPECTOR Occupancy Permit Required to ®ccupV Building 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. 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(C17PL -L„0'!Epr' r ATU 'YtlanaleanDfthisrit�.t, and�. a:r_wPs�tro:ddgarnrkmInn 'A J�PACER'rq Vt i7:co�pp3" dtr�rsb ,oc I3amen,:acr s Sigtsaturc Q Contra ctoPssiguatttte Olga O 31 �( The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.anass.gov/diva Workers' Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plurnbers ADDlicant Information Please Print Leizibi Name (Business/Organization/Individual): Adak LL€. 0M-rsw. Aveiiue- Address: SRlcFA \/i r, 111070 City/State/Zip: Phone #: 7k' 71iV" F/b/3 Are yo at employer? Check the appropriate box: Type of project(required): 1. m a employer with 4. ❑ I am a general contractor and I 6 C]New construction employees(full and/or part-titne).s` have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor the in an capacity. employees and have workers' Y p Y• t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. 7 We are a corporation and its 10.El Electrical repairs or additions 3I❑ [ am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof r pairs insurance required.]t c. 152, §1(4),and we have no employees_ [No workers' 13.0 "ther_ i/St->-�� r� comp. insurance required.] *Any applicant that cliccks box#1 must also fill out the section below showing their work-ers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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-contractors have employees,they must provide their workers'camp.policy nui nber. p arta an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site information. �7 J Insurance Company Name: �G[ ?-1 Gh Policy##or Self-ins. Lie.#: r,Z 7 D /Z / Expiration Date:_ �ZU�I -7 .lob Site Address., 1�lQ� �l'LEL_ pGvl of g(j City/State/Zip: AH,&tr-P Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Fai lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of I nvestigation,of tate DIA for insurance coverage verification. l do hereby cortify under the pains andfpenalties of perjury that the information provided above is true and correct. Sip nature: �, f'f} i', [ Date: Prone#: 2 Ly l/ 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 9.Plumbing Inspector 6. Other Contact Person.: Phone H: ••u+ �-�- 4l LJI 4�I.A.0 .7. JY GY "'VI L-slur, <,I VUG, r&A ot:L VG'l CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYYI TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 7THISCERTIFIGATE TIE DOES NOTAFFtRMATIVE1LY OR NEGATIVELY AMEND,EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, OF INSURANCE DOS NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVEC DTHECER C TE O D R. T: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, ertain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such end rsement s . PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 W CENTRAL STREET (AIC,No,Exq: (A1C,Nol: j E-MAIL NATICK,MA 01760 ADDRESS: 22MI W INSURER(S)AFFORDING COVERAGE MAIC# INSUREDINSURER A: AMERICAN ZURICH INSURANCE COMPANY ! ATLANTIC WEATHERIZATION LLC INSURER 8: INSURER C: 51 REAR JEFFERSON AVE INSURERD: E: SALEM,MA 01470 i INSUREftF: COVERAGES C♦WRT)FICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE ENSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDUIOH OF ANYICONTRACT Oft OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 15SUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN SUBJECT TO ALL THE rERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I INSR I ADO SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE i L R POLICY NUMBER IM,RPDIYYYY) IMNAODIYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY W DAMAGE TO RENTED $ CLAIMS MADE OCCUR, REMISES JEaoccunence) I I MED EXP(Any one person) $ FRSONAL&ADV INJURY $ GENT.AGGREGATE LIMIT APPLIES PER:! POLICY [:D PROJECT LOC ENERAL AGGREGATE $ I RODUGTS-COMPIOP AGG $ AUTOK40BILE LIABILITY i COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS I (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADL AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X we srATUTaRY OTHER EMPLOYER'S LIABILITY YIN UB5B27U121-16 03120/2016 03/20/2017 LIMITS ANY PRDFERITORIPARTNERIExECUTIVE OFFICERIMEMPER EXCLUDE07 NIA F.L.EACH ACCIDENT �. $ 500 000 I Mandatory in NHI I E.L.DISEASE-EA EMPLOYEE $ 500 000 byes,describe under DESCRIPTION OF OPERATIONSterow i E.LDISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIDNSIVEHICLESIRESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTMCATE ISSUFb TO THE C6RMHCATE HOLDER At=FEC-Mr,WORMS COMP COVERAGE. e I CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPIR TA VE N.ANDOVER,MA 01845 ACORD 25(2090105) The ACORD name and logo are registered marks of ACORD 1008-2010 ACORD CORPORATION. All rights reserved. i I 7ilk� CERTIFICATE OF LIABILITY( INSURANCE D/ /ODIYYYI) I 3/9/29/2 016 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 PDlicy(ieS) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the Policy,ci rtain 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 j £ONTAC7 NAME: construction Eastern Insurance Group LLC PHONE. , (800)333-7234 FAx 233 West Central St E-MAIL Alc No: -ADDRESS: INSURERS AFFORDING COVERAGE MAIC N Natick NA 01760 INSURER A:Arbella Protection Ins. Co. 41360 INSURED INSURER B Nautilus Insurance Co Atlantic Weatherization INSURER C: 61 Rear t1afferson Avenue INSURER D: INSURER E, Salem MA 019-70 INSURER F: COVERAGES CERTIFICATE NUMBERNa$ter 2016 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 PtRTAIN, 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. 1NSR AO B POLfCY EFF POLICY EXP L TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED PREMISES Ea occune $ 50,000 A CLAIMS MADE a OCCUR 500042815 /20/2016 /20/2017 MED EXP(Any one person) $ 5,00() X CONTRACTUAL, LIABILITY PERSONAL&AOV INJURY S 1,000,000 X CG000l 10/01 FORM GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 POLICYX PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT aaccideni 1,000,000 A ANY AUTO j BODILY INJURY(Per person) S ALL OWNED SCHEDULEq /20/201fi /20/2017 BODILY INJURY(Per accident $ AUTOS X AUTOS j 1020015871 ) X HIRED AUTOS NON-OWNED X AUTOS PROPERTY DAMAGE $ Peraccidenl X UMBRELLA LlAB X PIP-Basic $ OCCUR EACH OCCURRENCE S 1,000,000' ,000,000 A EXCESS LIAS CLAIMS-MADE I AGGREGATE S 1,000,000 DEI] RETENTIONS 10.00 ! 600058654 /20/2016 /20/2017 S WORKERS COMPENSATION i WC$TATO- _71 FR OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTNE YIN OFFICERIMEMBER EXCLUDED? ElNIA E.L.EACH ACCIDENT $ (Mandatory In 14H) if yos,describe under E.L.DISEASE-EA EMPLOYE $ DIS,Is PYLON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S i3 POLLUTION PL200378614 0/1/2015 0/1/2016 EA POLLUTION CONDITION $1,000,000 GENERAL AGGREGATE $1,0()0,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES'(Attach ACORD 101,Addltlonal Remarks Schedule,If more Space Is required) i i I I I 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 STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE i r 1 John Koegel/SME � = ACORD 26(2010/05) icp 9988-2010 ACORD CORPORATION. All rights reserved. INS025(9ninn5l M Thn Ar npn raamn Anrl Inns 7rn raniQfnrorl morlee of AC%nRn I Massachusetts Department of Public Safety Construction Supervisor Board of Building Regulations and Standards Restricted to: License: CS-087977 Unrestridted-Buildings of any use group which corktain less than 35,000 cubic feet(991 cubic meters)of qi enclosed space. ERIC W PALM 3 HILTON ST SALEM MA 01970 Expiration: Failure to possess a current edition,ofthe Massachusetts State Building Code Is cause for revocation of9fir.license. Commissioner 04123/2018 DPS Licensing information visit:VRM.MASS-GOWI)PS License or registration valid for individul use only Office of Consumer Affairs&Business Regular= before the expiration date. Yffound return to: ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation 091stratIOW 142089 Type: -Suite 5170 10 Park Plaza Q, XpIration: 311212018- Ltd Liabifily Corpor Boston,MA 02116 ATLANTIC VVEATHE'RIZATION-LL.C. ERIC PALM 61RJEFFERSONAVE SALEM,MA 01970 iindersecretary Not valid without signature