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HomeMy WebLinkAboutBuilding Permit # 8/31/2016 tkORTH BUILDING PERMIT "t-Eo TOWN OF NORTH ANDbv.,'-iR APPLICATION FOR PLAN EXAMINATION Permit NO#' � �V i Date Received "4SSACNl7`-"�� Date Issued: ��l Applicant must complete all items on this page LOCATION PROPERTY OWNER a 9_ ,.' e LLe print 100 Year Structure yes C MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration Na. of units: i4<ommercial "epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Se trc .,❑Well Flaatlpla�r fl 1Netlan,s', ❑ Watershed Dtstnct `f r� , ,� a {" i . . ti c r' / c F;r ,�` ✓ `"` •'r, -f ,`� N� F�' .h"y��,,aL e ✓ i. ❑1Naterl�ewer � `� ��` .k.,, �..; �. �.,- z�r . x � �� � �, �� �, �� ,� , � � ,,:� DESCRIPTION OF WORK TO BE PERFORMED: eis �l 11 n� Identification- Please Type or Print Clearly OWNER: Name: er i L_ Phone:7 `73 -2 3 Address: ',4e�/, l ST Wv�104-rj Contractor Name: Lov,% Phone:-7 E3 1 e~ i o y Email: Qw,3 e- at.._ ; rv) Address: ti!p 1 tve® Supervisor's Construction License: s Exp. Date: 1 10- 'Z o i S Home Improvement License: fol 4 Exp. Date: ARCH ITECTIENGINEER— (,//,q _ 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. as Total Project Cost: $ O o FEE: $ _ Check No.: 13 5s. Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guars fund 4 0% RTj own of T _ ,� Q over No. 24h �.K. h ver, Klass 3 �� LOLH.C+4E wlc�[ 4�' 4�RATED S V BOARD OF HEALTH Food/Kitchen PERM Septic System THIS CERTIFIES THAT .........�J . ....... CSN ... . . .�r, �,,.... . . . ...... . BUILDING INSPECTOR has permission to erect ........................ . buildings on �. .. 1.1'rk ............... Foundation .�. Rough tobe occupied as ,........ .... .... ......................................................................... Chimney provided that the person accepting t is 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. T L D Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONS TION Rough Service .. .. ..... .... ........ ... Final BUILDIN I PECT R GAS INSPECTOR Occupancy Permit Rf uired t® Occupy Buildira 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- WELLS ROOFING COMPANY ...... ............._------- 112 Academy Mcnoe Weymouth, Massachusetts 02189 August 30, 2016 t: 78t-331-3104 f: 78 1-33 1-5666 Ninety-Nine Restaurants 14 A Gill Street Woburn, MA 01801 Re: 267 Chickering Rd. North Andover, MA -reroof proposal Gentlemen: Wells Roofing Co. proposes to furnish all materials and labor necessary to perform the following work, on the property indi- cated above, for the sum of $29, 000. : 1 ) obtain building permit. 2) Strip off all existing asphalt shingle roofing. 3) Install 6 ' of ice & water shield membrane along eaves. 4 ) Cover remainder of roof with underlayment. 5) Install aluminum drip edging along all roof edges. 6) Reroof with GAF Timberline 30-year architectural style roof shingles, color Charcoal. 7) Install a Cobra ridge vent with shingle cap. 8) Clean out gutters. 9) Promptly remove all debris. R,,e ,,pectfp,)lly submitted, Accepted by: I'A?16141d' 6160. .. Date: `Louis Wells Residemial Comiiiet-cial hidttwi-iol The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,tet Please Print Legibly Name (Business/Organization/Indivi(tual): ) Address: f PI te'' wt Y Vp­ City/State/Zip: Ko =.... Phone #: 781 - S 1-`�16 Are you an employer?Check the appropriate box: Type of project(required): 1.[&.I am a employer with 4. ® I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors New construction 2.© I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees "These sub-contractors have 8. ❑Demolition working an T for me in capacity. employees and have workers' Y p ty� 9. ❑ Building addition [No workers' camp. insurance comp. insurance.$ required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.R Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.7 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'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. 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 scab-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance far my employees. .Below is the policy and job site information. m Insurance Company Name: « I" �o 2 Policy#or Self ins.Lic.#:� -- Expiration Date: Job Site Address: CAI 1C-K(!r'oJC City/State/Zip:-9- J " � d►> _�?I_t� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure 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 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 Investigations of the DIA for insurance coverage verification.. I do hereby certify under the pains and penal les of perjury that the information provided above is true crud correct. Signature: VW Date: +J Phone#_..... 3,.7 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{MMl1YACC) CERTIFICATE ®F LIABILITY INSURANCE 8/30/2016 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 Select Department Eastern Insurance Group LLC PHONE (800)333-7234 X66807 FAC Na:(781)586-8244 233 West Central Street E-MAIL-ADDRESS:selectwork@easterninsurance.com INSURER(S)AFFORDING COVERAGE - NAIC q Natick MA 01760 lNsuRERAAdmiral Insurance Com an 4856 INSURED INSURER8MAPFRE Commerce Insurance 34754 Wells Roofing Company INSURERC:Star Insurance Co 18023 112 Academy Avenue INSURER D.National Union Fire Ins Cc 19445 INSURER E: Weymouth MA 02188 INSURER F: COVERAGES CERTIFICATE NUMBER:CGL 15-16 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. IN5R TYPE OF INSURANCE ADO POLICY EFF POLICY EXP LTR V POLICY NUMBER MMIDO/YYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RURTED 50 004 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ i A CLAIMS-MADE 1XI OCCUR CAD0001222609 2/8/2015 12/8/2016 MED EXP(Any one person} $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 G£NERAIAGGREGAATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PRO LOG $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT (Ea accident) l 000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BDTXKN 12/8/2015 2/8/2016 BODILY INJURY(Per accident) $ AUTOX H REDSAUTOS AUTOS X NON- U OOWNED Peoac d n1 RTY DAMAGE $$ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 D EXCESS LIAR GLAIMS-MADE 80023013724 6/23/2016 2/8/2016 AGGREGATE $ 5,000,000 DED X RETENTION$ $ C WORKERS COMPENSATION X I-TWO'R STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORtPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? [KY] NIA 00590401 2/31/2015 12/31/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ._.I.,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Roofing Contractor. Lou Wells is excluded on the Workers Compensation policy. CERTIFICATE HOLDER CANCELLATION (978)688-9542 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. BUILDING DEPARTMENT 1600 OSGOOD ST, STE 2035 AUTHORI2EDREPRESENTATlVE NORTH ANDOVER, MA 01845 John Koegel/CMH2 ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. I NS025 oninn5l ni Tha Ar_f)PF1 nnma-1 Innn nra raniafar-11 mar4a of Ar.nPr\ - Massachusetts Department of Public Safety I'. Board of Building Regulations and Standards License: CS-037338 j Construction Supervisor I I i LOUIS M WELLS 112 ACADEMY AVE WEYMOUTH MA 02188 i Expiration: Commissioner 01/10/2018 1 9 0 1 I'