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HomeMy WebLinkAboutBuilding Permit # 10/7/2016BUILDING PERMIT TOWN OF NORTH ANDOVER A PPLICATION FOR PLAN EXAMINATIONfi Permit NO: ;,�,:t 61 Date Received 1- . JY)A 1711_�Clodlno (S"/ Identification Please Type or Print Clearly) OWNER: Name: ork-'s, Phone: Q dvv-, ARCHITECT/ENGINEER AA?<,.Phone: "(4661 gAM Address: �Q qA, -14 "fm 7, In Req. Nc�- 173((E,12,(,,) FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000,00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ c, P)c'o: FEE. Receipt Na.' T Check Na.: 0,9' L90 NOTE: Persons contracting with unregistered contractors do not have access to, yie guaranty fund Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ COMENTS DATE APPROVED Ll •■ I E KEJEU I EU •■ I E ■---•r ■ CONSERVATION ■ ■ COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection signature & Date Driveway Permit Located at 384 Osgood Street 3 0 H Q tL cxi 0 © OC N b Ll N Q L/I a n z J N 0D LaL �' 41 E U LL c © pu' in C7 z 00 .t O CC LL o a v1 ¢ V J W 0 Li (Utio Ln s LL a V a z V] 0 a: it z LAJ Q o Wj O LU a LL L m Z (n a+ d (!L G f- 0 r� W O W p� 0 CL O w 0 CD O N •E Q O � 7 � ® O CL C � M CQ .CL O c W The Commonwealth of Massachusetts x Department of lndustrialAccidents d I Congress Street, Suite 100 �< Boston, MA 02114-2017 �y www.mass.gov/dia Y Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH') HE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (,Business/Organization/Individual): A&E Fire Protection Inc. Address: 25 North Street City/State/Zip: Canton, MA 02021 Phone #: 781-329-9799 Are you an employer? Check the appropriate box: 1, [D I am a employer with 70 employees (full and/or part-timc).* 2.❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. lNo workers' comp. insurance required.] 3.71 am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. S.❑ 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.) 6.R We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 1 l.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.❑Roof repairs 14.©OtherFire Sprinkler Install `Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy informa€ion. 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 sub -contractors have employees, they must provide their workers' camp. policy number. I am art employer that is providing workers' compensation insurancefor nay employees. Below is the policy and job site information. Insurance Company Name: ABC MASS WORKERS COMP. SELF-INSURANCE Policy # or Self -ins. Lie. #: ABCMA15000715 Expiration Date: 01/0112017 Job Site Address: 815 Chestnut Street City/State/Zip: N. Andover, MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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 verification. Ido hereby certify r tder the pains and penalties of perjury that the information provider) above is trate and correct. Suture-- -.._. __.. -- -- ._..__.._.. ------------- - -- —-Date.:...................4 'yL._ -- - -- --- __-- 781-329-9799 Official use only. Do not write in this area, to be completer) 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 #: Client#: 1261909 AEFIR ACORD.. CERTIFICATE OF LIABILITY INSURANCE YYY) =6 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 anADDITIONAL' — INSURED, --"" t he 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). PRODUCERCONTACT NAME: Kathy Wagner USI Insurance Solutions, LLC PHONE 85587 - — -­­ - 4-012��. FAX 610 537-9481 123 Interstate Drive E-MAIL Kathy.Wagner@usi.biz West Springfield, MA 01089-3600 .APPREss:. 855 874-0123 INSURERS ) AFFORDING COVERAGE NAIC # . ...... --------- . ........ ..... INSURER A: ABC Mass Work comp Self-Insu 99999 INSURED A & E Fire Protection Inc. - - - --------------- - ----- - INSURER -B-:--- 26 North Street INSURER -C:-- — — --------- --- - Canton, MA 02021 -INSURER D : - ------ - ----- ---------- ----- - INSURER E:----.. ..... . . . . ............ INSURER 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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, ... .......... !NSR AIDDLSUB POLICY EFF POLICY EXP LTR OF INSURANCE WVO­ POLICY NUMBER M/DDIY LIMITS (MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE 0 RENTED PREMISES EJ (Ea occurrence) YEP,EXP (Any one person) PERSONA!. X ADV INJURY GENT AGGREGATE LIMIT APPLIES PER: PGENERAL AGi JEC O GREGA E 1$ POLICY R �t­ -­- ­--­ - T F LOC PRODUCTS - COMP/OP A G ]_$ ....... ----- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT LEa accident! I ANY AUTO BODI LY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED PIR -0 57ff Rt Y DA M AG —E� HIRED AUTOS AUTOS(Peraccident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE. $ PED I [RETENTION $ A WORKERS COMPENSATION IPER AND EMPLOYERS' LIABILITY 6 0 STATUTE _10TH YIN ABCMA15000716 01/01/201 1/0112017 X TE ER ANY PROPRIETOR/PARTNER/EXECUTIVE- NI N E.L. EACHACCIDENT _$1,0001,000 OFFICERIMEMBER EXCLUDED? /A (Mandatory in NH) LN E.L. USEASE -_EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Proof of Massachusetts Worker's Compensation Coverage CERTIFICATE HODER :' CANCELLATION Evidence of Insurance )SHE OULD ANY OF THE ABOVE DESCRIBED ERPOLICIES BE CANCELLED IVBEFORE EXPIRATION DATE THEOF, NOTICE WILL BE DELERED IN ACCORDANCE CCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE O 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S19052281/M168132311 P KXWCD