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HomeMy WebLinkAboutBuilding Permit # 11/15/2016 FORTH BUILDING PERMIT Ot�T mea rb��p TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#• Date Received Zj pnRnr�a spa`�g S Date Issued: /1 - / S � sac�+us t IMPORTANT: Applicant must complete all items on this page LOCATION ,v cr + Print PROPERTY OWNER Ca r t1 -f Pr t 100 Year Structure yes n o MAP ?" PARCEL: O L 3 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 aeration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �4 ��"„ 'F 3 � � a� ,�^ ��. r. ✓' "CG,a" " E'rtiXr� C� 5e�''...!J�''.� - S N`r -: � �x/�� -� ua, �. � ,�� "'� ����� �:„,c� � ��.�:p��l��y �.I�� ze�a.��s� a'4'7.✓ ✓.:a���..,. ?�s wa: � �/ 4t'...�,aQ fr s,�';. DESCRIPTION OF WORK TO BE PERFORM D Identification- Please Type or Print Clearly OWNER. Name: r rlPhoneiq It Address: Contractor Name: Phone: C1 115 3SIC • 3T3 3 Email Address: IN 34 r V—"(� Supervisor's Construction License: Exp. Date: 1 _ Home Improvement License: Exp. Date: 1� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000-00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 'LO FEE: $ Check No.: 3 0:; _ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ............ ........................­­­­................................................................ ...... ....... ................................................... of 1"'own , ndover 0 No. ver, Mass, 0 -- ISO "Via LAS49 COC "Ic"awl ATED U BOARD OF HEALTH Food/Kitchen PERMIT .T LD Septic System THIS CERTIFIES THAT .. ....... -1........................ BUILDING INSPECTOR ......... has permission to erect.......................... buildings on .....at4.... Foundation ........... ........ Rough to be occupied as ........kutlt#� ...............PAA.. .0"A.0% Chimney provided that the person accepting this permit shalt 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 CONSTRUCTION TS Rough Service ................. ................................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancj7 Permit Required to Occupy 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. RISE60 Shawrnut Road, Unit 2 1 Canton,MA 020211339-502-6335 ENGINEE[MG' www.RISEengineering.com OWNER AUTHORIZATION FORM Carrie Leary (Owner's Name) owner of the property located at: 26 Andover Street (Property Address) North Andover, MA 01845 (Property Address) hereby authorize V�-A:t—u--krsvUhnj (Subcontractor) an authorized Subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. L Owner's Signature -gate . ............ FISE 3HMW4W$ FAxW403a" i � AS a � onto se �-- Mg)771.4781. .. 1012016 422529 � 00003 ConicLomy 26 Ard%W S1 t r � A tavec Sit -- . o enr aa►i�av Ww6 Andow,MA 01945 --' JOB DESCRWnON oars- ScAo pw=q �s par o�,r�elcags to actkar 6aaa �o�cr a a�{ aye naa .)TE�w�n (4) aa�ndweaw+�adfies �ads�al�a3af�rindme�#llaocar,�tsae1 afc�ln�� . Atll�eaor�se +�k.aaeisd�a �e�a a �FOro �q,e�ys��fit6aca �Y�� � snap Fpaw:PeaQida ane nn►in a� ° r���8d �soo{lifer e AE C iA'l••ptorieotabatand � a6'lap wR-41la1( aadcdtnit�3s�6eetof°p�+e�+s spa�oe. S3S7�O AT1't�AiOC'ES$: [�aaertamtrietsbe dnbaelc ad'p}sutatr�w�3h�'r�bdlx� °�'� YHA'X11.A'�Pf:F�vWet�s�alm�esia�st��ii(41�' toc+f }�o v �a�s�ms'itiar�t c®bs dia{ct�aaoGnr}6{aek t .8�'ara�lba� $moo �A'RO�i:�a.€�betabnracda �'►�l{!3 �w6d►ra+�aa �P�'�anr eai� $1 l&75 yF�T1l1,A'fit: fm5ar�da s�oir i n ia(�51ta�6 10 ►. $ oo ��p r�r a�a t�tali p?�►}lh��of lE•l9 anl� i en� oft5�e6eseaserda�iaBat4���. $Zi7.01! CRA'I�A�P�vriBo mor ane � (3� �.�6 r�p aver open is m�e sass ' • �• AIFr. 7 RISE 1ldiri�mat�� . WGINmNG d suomatUaitm MOM C CT �� �aa�aermamos� C1i+MA-MRim aawavRa Csrrt UWY (97 MI.4781 01 16 422MM^-OM - se sRaraimam 26 An wer ftWAsisEo�►er t A�o.�r,MA a184S tft&Au&w,MA 01845 . Jeri DON RL55 applYatl l int a►tldsao . You vd =lybe=dwwgdtWWOW , �r ,�Ciesa�oa7 iGiocmtirc.aottoeitaeediZ.0004etcdmsduymwA=im 0Ljp Gflg096iwft Air Seating WON=upwtbe>bstf6RDaadsRdddi 1340iY m by*c £astke taRAbealWtif�arhoaedsiadoRratrqu .vowO6co at dwdi tcotft *MOWtR ate= �� aof aa6ofymhmftrymmWd '� ��� � trtors3#ve is$3.1 M S90.i1i! CUBUMM Tout OM75 v� surrioa � s�ws .r�s�ssRasa� "° Hw Bred T"i 76"Co forts 7I No—M-0, so�ar�+muara�aaaoa�.wrs re�ac+�.esa ►RaReaxopa r ap ar ��Nsp�oyamae�a�am Togs �a.ooa�a�aAar�R,m,�aow�ar,rur�pwrwse� omea�Rner�nmm ---•����. .._�_� ,aaaoa� oars $b maw= moateo 30 The Commonwealth of Massachusetts Department of Industrial Accidents j Office of Investigations I Congress Street,Suite 100 Boston,,MA 02114-2017 www.rraaass.govl diva !Workers' Compensation Insurance.Affidavit; Builders/Contractors/Electricians/Plumbers A licaiit Informativi� Please Print bl Name (Business/Organization/individual): Address: Li /State/Zi I\.J ` LIN 1 1�, `� � Phone #: � ' �� l� �`� ► Are you an employeO Check the appropriate box: Type of project(required): 1. 1 am a employer with 4, 1 am a general contractor and I `�* have hired the sub-contractors 6. New construction employees (full and/or part-time). n r 7. Remodeling 2. 1 am a sole proprietor or partner- listed on the attached sheet f, ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp, insurance comp. insurance.$ required,] 5. We are a corporation and its 10. Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, t§'1(4),and we have no 13. Other employees. [No workers' camp.insurance required.] `Any applicant that checks box if I must also fill out the section below showing their workers'compensation policy information, f Hoincowners who submit this afridavit indicating they arc 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'comp.policy number. I tern an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site information. Insurance Company Name: CA l ` C\w�kau, Policy#or Self-ins, Lie. #:� P� Q� Ir 10 d 73 Z'17 Expiration Date: �C) 3z) t ap�k� City/State/Zip: Job Site Address: ° --of Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required ttnder 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 aivit penalties in the forth of a STOP"JJ4[tl{ ORDER and a fina 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. 1 do hereby certify under the pains and penalties of perjury that the inforanativn provided above is true and correct. Si*►latttT'e: Phone ' ` b cit or town official. Official case only. Do not write in this area,to be completed y y ff j' y f City or Town; Permit/License # LLU hority (circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: DATE(MWDD/VWY) A V CERTIFICATE OF LIABILITY INSURANCE 1011812016 THl5 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(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). CONTACT PRODUCER NAME: Meg Munroe MARTIN J. CLAYTON INSURANCE AGENCY INC PHONE TADDRESS:xri (413)536-0804 FAX lX,Ncl: mmunroe@@m olayton.com 1649 NORTHAMPTON ST., RTE 5 INSURER S AFFORDING COVERAGE NA€c a HOLYOKE MA 01041A: ACADIA INS CO 31325 INSURED 8: GAUTHIER INSULATION INC JNSURER C: INSURER D PO BOX 344 E INSURER IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 94521 REVISION NUMBER: UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISS INDICATED, OTITHSTANDING ANY CERTFICATENMAY BE ISSUED OR MAY P(ERITAIN, THE INSU ANCpAFFORDEREMENT, TERM OR CNDITION OD BY THE POLICIES F ANY CONTRACTD SCRIBEDR OTHER OHERE N S SUBJECT CUMENT WITH PTO ALL HE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5RADDL sUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBERMMIDDIYYYY MMMD1YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO ENTED $ CLAIMS-MADE 1-1 OCCUR PREMISES Ea occurrence MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-E L_i LOC PRODUCTS-COMP/Op AGG $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY Ea accldenl BOSSILY INJURY(Per person) $ ANY AUTO Al ONMED SCHEDULED �rA BODILY INJURY(Per accident) $ AUTOS AUTOSNON OWNED PROPERTY DAMAGE $ Per accident HIRED AuT05 AUTOS $ UMBRELLALIAB OCCUR :: EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE NIA AGGREGATE; GGREGATE $ DED RETENTION$ WORKERS COMPENSATION X STATUTE ERH ANDEMPLOYERS'LIABILITY YIN E.L.EACH ACCSDENT $ 500,000 ANYPROPRIETORIPARTNERIE"L.UTIV E A OFFICERIMEMBEREXCLUDED? WA WA NIA MAARP3D0327 1013012016 10/30/2017 EL DISEASE-EA EMPLOYEE $ 500,000 (Mandatory In NH) Ordescribe under E.i n€ r-ASE-POLICY LIMIT $ 540,000 OES�RIPTION OF OPERATIONS below NIA DESCRIPTION Of OPERATIONS!LOCATIONS IVEHICLES(ACORD 101,Addl1€oval Remarks Schedule,may be attached 11 more space Is raqu€ted) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees Outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensationlinvestigations/, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel v.M.Crasuley,CPCU,Vice President—Residual Market--WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/11) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, NWS=;or 02116 Home Improvement Registration Registration: 173410 Type: individual Tr# 291320 f Eviration: 10111208 KURT GAUTHIER ? ,s KURT GAUTHIER 1'I9 COUNTY ROAD IPSWICH, MA 01938 f y ` AwJ Update Address and return card.mark reason for change. ent i ❑ Address [� Renewal GI Employm Lost Card❑ SCA 1 15 20M-05111 1 Craantrta�ccuecrl c 'CSsauaeCts Registration veMd for individual use only before the ice of Consumer Affairs&Besiaw Regulation expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation Is 3410 Type' 10 Park P -Suite 5170 Reg 4y "J5 Expirationt8 Individual Boston,MA 02116 l - KURT GAUTFiIEft KURT GAUTHIER 5cada ami g !o« Sa% ;asses CSSL-102"2 P.0.BOX 344 IP19withIMA 01934 ������~ � r�2�, { 05125=17