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Home My WebLink AboutBuilding Permit # 10/5/2016 ---------------------_1 BUILDING PERMIT�yIT ! NdRTy of�4i[D 0", `OWN OF NORTH ANDOVER 0� �' *, O0. APPLICATION FOR PLAN EXAMINATIONLJ Permit NO: Date Received 'VA 11 a gSACNus�� Date Issued: I ORTA NT: Applicant must complete all items on this page DATION t 0 5"P'D 6,W ; ,PROPERTY"OW, NER ; P" t MSF"°llJ; AR :Et�: �, Zt4;NlC 'DlTR1tT. lirtarc'D strict no Machin Shop Village o TYPE OF IMPROVEMENT PROPOSED USE Residential _ Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other _ Septic We0 "'Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Plebe Type or Print Clearly) OWNER: Name: Phone: � n, Address: CONTRACTOR ,Nage: .. � �� Phone: � � � �� '5 Address; ' uperiri or's m tru tion License., � Exp. ,Date. 'f m ,Home mprovement:License: 6 Exp. "Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. EEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ v. Check No.: Receipt No. i NOTE: Persons contracting with unregistered contractors do not have access ffie a ra icnd r Signature of Agent/Own'er Signature of contractor V&oRT� Town o _ b ndover o h ver Mass D O LAME 1, 1 �1- [OfNiGfiCWICK T,q 4Rareo APp`,�'6�3 S U BOARD OF HEALTH Food/Kitchen PERIT .T LD Septic System THIS CERTIFIES THAT ....,....... ..... . . !1JS BUILDING INSPECTOR has permission to erect .......................... bu, dings on ..... n!� ........ Foundation .............. Rough mf. tobe occupied as .............. ..... �........ ... ....................,..............,..............,.............. 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 COSTU STAR Rough Service ..,., ...... .... ........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to OccupV 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 pet. Date: 101311(, 7-RALPH , BURKE A Family Business Since 1941 Roofing _. Gutters Rubber Roofing- DANIEL M. BURKE 781,249-7110C 617-640-1110 C RALPH J.BURKE,JR. TELEPHONE 781-245-1110 office FULLY INSURED - LICENSED 27 BYRON STREET,WAKEFIELD,MA 01880 Estimated price for labor and material to; Remove all roof shingles Replace rotted/broken roof boards up to 100.square feet Re-nail loose boards Install aluminum drip edge " 6 feet of ice and water barrier " CERTAINTEED Synthetic roof underlayment CERTAINTEED LANDMARK ARCHITECTURAL shingles, hand nailed Reflash all vent pipes and chimney Remoye.all roofing debris from the yard Total cost All workmanship guaranteed twenty years. Please remove or cover all items in attic,as dust and roof particles may settle on attic floor.. Thank you Af � ,U NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: he(�'(Z 19W9 (Location of Facility) Si 7 atuy,d of Permit Applicant o/-- Date The Commonwealth of Massachusetts PrintForm Department of Industrial Accidents ' Office of Investigations I Congress Street, Suite 100 Boston, MA 02.114-20.17 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ , Please Print Legibly Name (Business/Organization/Individual): r_l Address: Z7 ftoly 7nr~ City/State/Zip: 1A11 /fE r1,1d m`4 011,Fd Phone#: 7k d sl i 4 Are you an employer? Check the appropriate box: Type of project(required): 1.[3 I am a employ=-With 4. ❑ I am a general contractor and T employees full an r part-time).* have hired the sub-contractors 6. 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 g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp. insurance comp. insurance.l required.] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their i 1.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name: O ragZd co Policy#or Self-ins. Lic.#: 1�, a.. (d(2 'Z 9'Q�3I Expiration Date:. d 2,0 Job Site Address: o F w'u--c m t q oG'i0 Ya 0 City/State/Zip: �/ IYW 00vG4 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 a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify#qer4#e a d penallies!( Le rLug that the an ormatian provided above is true and correet Signa rei L Date Phone#: - My1 I Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 3i Contact Person: Phone#: Y =rom:Linda J Caruso FaxlD:SALEM03 Date:101312016 11:04:13 AM Paoe:2 of 2 RALPJBU-01 LCARUSO CERTIFICATE OF LIABILITY INSURANCE DATE(1MM1ODdYYYY)101312016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 1 CERTIFICATE: DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED 1 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Salem Five Insurance Services,LLC PHONE (781)93$•31flfl FAX Ho; (7$1?933.9048 445 Main Street AJc No.FX1 Woburn,MA 01801 E-MAIL ADDRESS:insurance.services@salemfive.com INSURER(S)AFFORDING COVERAGE NAIC P INSURER A,Penn America Insurance INSURED INSURERB:Amguartl insurance Co Ralph J Burke Roofing Company,Inc. INSURER C 27 Byron Street INSURER D: Wakefield,MA 01880 INSURER 1=: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TH6 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE POLICYEFF POLICYE%P LTR INSD WVD POLICY NUMBER MMltltlfYYV MMltltllYYYV LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 500,000 RENTED CLAIMS-MADE �OCCUR PAC7112031 05117/2016 051'1712017 PREM 5E5 Ea ceeerrenca s 100,000 MED EX?(Any one person) $ 5,000 PERSONAL&ADY INJURY S 500,1100 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1.000,000 X POLICY JECT ❑LOC PRODUCTS-COMPIOP AGG S 1,000,000 OTHER: $ AUTOMOBILE LIABILETY - COMBINED SINGLE LIMIT 5 Ea accident ANYAUTO BODILY INJURY(Per person) S ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Pcrauidenl) 5 NON-OWNED PROPERTY DAMAGE S HIREDAUTbS AUTOS Peracddml 's g UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAItvI5 MAGE AGGREGATE S DED RETENTPONS $ WORKERS COMPENSATIONX R i O H• AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETORIPARTNERIEXECUTIVE Yr'�1 NIA R2WC770313 57 06120/2016 0612012017 E.L.EACH ACCIDENT $ 100,000 OFFICERIMEPABER EXCLUDED? IL.Ly �I - IMandatory in NH) - E.L.DISEASE-EA EMPLOYE• S 100,000 if ai,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB S 5()0,000 S DESCRIPTION OF OPERATIONS f LOCATIONS!VEHICLES [ACORO 101,Additional Remarks Schedule,may be attached if moro space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL HE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept North Andover,MA 01845 AUTHORIZED REPRESENTATIVE 9 I� 01988-2014 ACORD CORPORATION. All rights reserved. ti ACORD 25(2014101) The ACORD dame and logo are registered marks of ACORD i Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Cvor Registration Registration: 107146 „ Type: DBA '6�' Expiration: 7/29/2018 Tr# 419291 RALPH J. BURKE ROOFING Ralph Burke 27 Byron St ~ ' Wakefield, MA 01 880 _.+ J, Update Address and return card.Mark reason for change. v SCA 1 % 20M•0511€ ❑ Address 0 Renewal ❑ Employment ❑ Lost Card �� 1t9�(1f.97777L691(l1CC!-/�1LO�C��(CI?:IC/CJL//JPLC Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration '---,-107146 Type: Office of Consumer Affairs and Business Regulation Expiration 7/29/2018 BBA 10 Park Plaza-Suite 5170 ,Vw" Boston,MA 02116 RALPH J.BURKE R001~ IG Ralph Burke _ 27 Byron St �. •. • Wakefield, MA 41880 Undersecretary Not valid without signature Massachusetts-Department of Public Safety Board of Bujid;ng Oleguiations and SLoiidardc; ' :.IliTil34.1LLIl1l1 auYi----iss-Sa _ .:.. License. CSSL-099814 54 PAIDIDOCK LANE ' ]DRAT IATA 01:926 J � arlit`` Expiration commissioner 07103/2017 I I