HomeMy WebLinkAboutBuilding Permit # 10/11/2016 BUILDING PERMIT o� SioR7F� q
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TOWN OF NORTH ANDOVER o �KT4�Q 061 wQ
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APPLICATION FOR PLAN EXAMINATION
Permit No#: /7 Date ReceivedR,TFD•p ,
4t
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Date Issued: 10
IMPORTANT: Applicant must complete all items on this page
LOCATION v3o.,-V(J , YLUt_kk
Print
PROPERTY OWNER r\_LCLd) :I�� j
J T tint 9 00 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resi ntial Non- Residential
❑ New BuildingOne family
❑Addition ❑ Two or more family ❑ Industrial
Alteration No. of units., ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION qF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: to 4 r\ Phone:q - 0 i 3kc
Address: ` V LY
Contractor Name: Phone: , 3
Email: ;f JltLh cti
Addres � �1
Supervisor's Construction License: l t 2- Exp. Date: _
LHome Improvement License: V1 t Exp. Date: ' 4
ARCH ITECTIENGINEER 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: $ ® FEE: 3 0
Check No.:_. _ `Receipt No.: 3 f 1
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
.... ............................
tk®RTH
Town _ 6Andover
No.
h
h ver, Mass, 1 d • 1 0 �o
ATE
u
BOARD OF HEALTH
Food/Kitchen
PERMIT . T LD J_ Septic System
THIS CERTIFIES THAT Kv Q= ►1 BUILDING INSPECTOR
i
has permission to erect .......................... buildings on .....Y7.gy..W,o O k"`f�..... Foundation
1 .......... . ._
i' Rough
to be occupied as ............. �� 1 ..,..�,^!....... ?!t .!.v.�....... .�!..5......... 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 E iT EI ES IN 6 MONTHS ELECTRICAL INSPECTOR
LESS CONSTRUCTI T T Rough
... Service
...... ... ..... ................. Fina!
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occui2v Ruiidin 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.
F I Irl IC! (!5 El1(1a(7?� No
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(1711)
®INNER AUTHORIZATION FORM
Benjamin Campbell.
I,
(Owner's Name)
owner of the property located at
478 Waverly Road, North Andover, MA 01845
(Property Address)
47B Waverly Road, North Andover, MA 01845
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
pemnit and to perform work on my property.
0wripes Signature
Of4
Dat
1
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A6 Ra CERTIFICATE OF LIABILITY INSURANCE
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 ISSUENO INSURER(S),AUTHOR= I
REPRESENTATIVEOR PRODUCER,ANOTHE CERTIFICATE HOLDER.
IMPORTANT; R the certificate holder is an ADDITIONAL fNSt7RED,the poifcytlae)must be andorlNM. if SUBROGATION 16 WAIVED,stlbJeOl W
the terms irrd coadHlons of the Polley,cartMln Pol3daa nwy rsqutn an gndonement. A statementon this*"ficete doss not caller rights to the
effmcato holder in Neu of Duch endorsemr s.
rRooucvl 14710 pa sh
MARTIN J.CLAYTON INSURANCE AGENCY tNC ;IK.Amm
. 413 8360804
kda h i da n.com
1640 NORTHAMPTON ST„RTE 9 not ArFaR NacaveR+oE N my
HOLYOKE MA p1pN1 ACADIA INS CO 37325
MUMS
GAUTHIER INSULATION INC PO BOX 344
IPSWICHMA 01838 suasR P, r
COVERAGES CERTIFICATE NUMBER:76783 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
INOICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONI MQN OF ANY CONTRACT OR OTY': DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRISEO HEREIN IS SUBJECT TO ALL THE TERMS, j
L'•XCLUSICNSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS.
TYPi eF INWRANCE
mucy mg1pt 'Quey
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POLICY❑Wn LOC PRODUCTa.00MP10PAGG 7
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m0w1DNi� CLUOEOR' 07 wA Pru wA MAARP300327 10f3pf2pi3 10!3012016 --,I!AGrACCMOE T i 500.000
(wmdMPry Irs NXI E.L.OLSEASE.Eh EMPEOYE£IS 500000
D�'°sR deralLounyor !a.t,DISEASE.POLICY LIMIT I 1 500,000
cisarrmN PERAnoNe bNw
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eBIGRaTgN of eRERATpNaliCrdATN]Xaf VENICL W(ACORa 1e1,AedIrNAM r4m�,M�9cIMlWa,mfy I AWPMe II man�pn q npW-.0
Worker!'Compeneadon bene8ls wit be paid to Massachuseaa employees only Pursuant 10 Endorsement WC 20 03 OS S.no auft talion Is glvon to pay
dsims for bene is 10 anlP10yess In States Other than Ma57dChUSelt2 if the Insured hires,or has hired!hese efnpWyoes outside of MaGsecfrueen,
This eer0ikate of Insuranes shows the policy In force on the dela that this certificate was Issued(unless the woration data on the above policy praeedes tho !
issue dale of th[s cflrtittcala of Insurancej. The aftbA of this cmm%a can 4S moaitorad daky by mmasming Me PcWof Coverage.Coverage VeAflcoon E
SOofch 00101 www,mass.pavhwdlworken-campanaatbnlMveei{gaOonaJ,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TH4 ABOVE DESCRIBED POLICIES BE CANCEUX"EFORE
THE EXPIRATIONDATE THEREOF, NOTICE WILL BE OMATRED IN
Town of North Andover AtCORDANCBWrTH THEPOLICYAROVISMS.
12DO Osgood Street
A*TXOR1tE0 REPRESENTATIVE
North Andovar MA 016x5
DanlelM.t y,CPCU,VkePrssident–ReeidualMarkei–WCRI@Mq
®188840114 ACORD CORPORATION.All rights reserved.
ACORD25(2014!01) The ACORD name and logo we raglatared marks of ACORD
1
The t`,.'atttrtjonwea th rtf Ala.s.cachimctt.s
Department of Industrial Accidents
Nfrc•e rtf ItIve.stigations
t I Congress.Street,Suite 100
Bostent,MA 02114-2017
wv%," masa'.govlclict
NVorkers' Compensation Insurance Affidavit: Bitil(lersiContr:Acte►rs/Electricians/Plunil)c'rs
Applicant Information Please Print he ilali
Name iLir irtc:titir ,cctrirti3:i'in.Ei E'a1a:!!: f�3� is����1 �_�� ,A.L __
Address: LTJ_t3 g Y,
Citv,'State`7ip: 1 �. _ Inft Ott 3 � Plionc 9 T�
Are}oti an crnploier? ('heek the appropriate box- -k1lic of project ircquircd):
ant a _,c iml ceunr"ieior and [
�ti, 'L`i;-t5'4{3iltlCIISYTY
cmpluyccs€full sand Orr :ar;-tntac}:' It �c hirc.c§the yttlt c�*rtta�tctEirs
partner-.
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{No u«rktr,' comp in*.nr:uwo eca[tt(� tr ,trance
re.ltsirccl.J 5.
�'v oratioi,w ; 1).C) 1_lectttcal rq atrs or addition
� c•arc i�•£t�' t!aril
nJi :CL'I it`aa�i\crL <'d tln-. �: j I C) PlutttNm, repairs or lisMitkmi
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i unt an emplo-rer that is providittg workerti'cttnrpenwtitin hmurunce fnr rn,)•emploYcea. Ifeloex•is the policY and joh site
inf ortlnation,
c ii Site.yddres;t V Ci't� SI'l Ci �
v r 1`2 rJ-t
l N _ .0 et
tttaeb a cops of the workers'compensation policl declaration pagv(shom ins the po ic% number and expiration date).
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Orup to$W?)}_i-10 a day;tin,Ijmt Tho rinialoT. R'c 331%kcd th'it t:C£)t7V- Ut thiS>t dtaitCttt Mdhe iof k m—ded Io th -Off-Tcc of
liaF` sti ations o`th.e )31A for ctsrrr3<,c�cri"iCutiit'I
I dei hereby certify°under the paint and pe•traltie.c of perjury that the infonnarion pro!•i(led abt3t'r'is trot"and con•ect.
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Official rr.se onl4•_ Do roil write in this area,to be complered by city-ar molt°n official.
Cite or Town-_ Permit/License ---
ksuing,AuthoritY tcircle ono:
I.Board of health 2.Building Department 3.Cite'' m%ii Clerk 4.Electrical Inspector 5.Plumbing Inspe'dor
6,tlther
Contact Persrtlt: Phmkv #:
y
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Mass ac setts 02116
Home Improvement ctor Registration
Registration: 173410
Type: Individual
Expiration: 10!112018 Tr# 291320
KURT GAUTHIER
KURT GAUTHIER r
119 COUNTY ROAD
IPSWICH, NIA 01938
Update Address and return card.Mark reason for change.
" Address Renewal Employment Yost Gard
SCA i 0 2aM-o5/11
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: j
k ReglstrationQ ` 3410 'type: Office of Consumer Affairs and•Business Regulation
Expirad n'."' 8 individual 10 Park Plaza-Suite 5170
Boston,MA 02116
KWU GAUTHIER r ��
KURT GAUTHIER
119 COUNTY ROAD
otpIrtMent of PLc y j
ea w q o«
and Stn
/icense 0
ar � � |
KURT RGAuTjjtV . ` . {
O Box 344
IP-icb MA m \ \
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