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HomeMy WebLinkAboutBuilding Permit # 11/8/2016 BUILDING PERMIT of t0 Dr►r z TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ' Kermit N©#: _" ;-o 1 7 Date Received I I Fd. .. M � acHus� Date Issued: IMPORTANT: Applicant mast complete all items on this page P LOCATION Print PROPERTY OWINER,,,,,",,,,,,,,,,,;,�,�,�,,,�k,,,c,-",:''()-,-, Pnni ! -lob Year Structure yes„, no MAP PARCEL: ZONING DISTRICT:, Histdri6 Districtno Machine Shop Village .,. no 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 Cl Septic 0 Well ❑ Floodplain D Wetlands ❑ Watershed District Water/Sewer ®ESCRIP"TION OF WORK TQ BE PEPF`ORMED° ( � U— S r k Identification- Please Type or Pit C"learl - w OWNER: Name: ,, Phone: Address: P ,,. - Contractor Name: Phone: Address: Supervisor's Construction License: M_. / . Lt ut, Exp. Date: wM Horne Improvement License: � � � � Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No.. FEE SCHEDULE.BULDING PERMIT.-$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PP S.F. i - rota.l Project Gest: $ ��� b � � FEE: $ � � Check No.: 0 F FE-7 Receipt No.: i el NOTE: Persons contracting with unregistered contractors do not have:access to the gaacarcanty fund 5�gnature of Agent/Owner Signafiure cf canfractor. - . t10 R Tky own of V _ : T ndover O No. Y _ 17 h , ver, Mass, / +� coc«Ic.aew.cK �• � 7 Rqr�o � 5 L) BOARD OF HEALTH Food/Kitchen PERMIT .T LD Septic System THIS CERTIFIES THAT .......16.0*.Q.. .1r ........... . 0� � BUILDING INSPECTOR has permission to erect......... .............. buildings on .......Y& A*.ee.......�.. ..., _............ Foundation .. .�. ® ..4 � Rough t0 be OCCUpled as ....,. ..., .. ..... .... . ... . ... ............... ChimneyIr 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 C®NSTRUCTI RTS Rough .. .............................. Service ........ ..... .. ... ..... Final BUILDING INSPECTOR GAS INSPECTOR OccupancV .hermit Required to Occupy Buildinz 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. 'w"I r�pun tar..l}uoa aulpuiq r s;Lm r�cl n€aunt cult sl[p�culubls U001 I 00,050 U$ 1 I T J /SOL Z3 �� �� cio(�_cr unit�duro; aocln zn t tuatu:Clni r: > �[€ttniula sut,l'DIJO.0€o[€Fnt.l v;u0dn onp rile€u.GedJQ1l,O£ I 00'050`6L inns ,€It.n)J tsa[i sl.€�nogeyn\°Fnlsix� €titislq.uil a.10 cuutJp M-111 Iltr it?p:t d€.€p Krdd01 u101311a Ill:s�PnlieFl Clur.l.nan\sJo.nt}nl>lntmur J,{07.1ArFI liin\_100?1 'J"MO U0111"Illstil�s•pl l,1 n5au tiulllels 11 110t1l put:NO:)N t la\5 XW! -u011t:111su€pl0,u€sncisa lnaa J0.€�gcin.l di.its III:N�'AI tfi[I IkI El,•tQl of€;unls�1 lalo.1 uoildi.tos@Ci l3afoid 1H 60 Kln:)IP.1-11ui L€ aF.lO�taaSteltJ�t.rd DDU ssaIPPV/@LURA 1F10:t'!`�Ll€.f OO.[F'.l56LIY.l.tOd'r1\ASeN mo�•�ulloa.lenotret.rod{i)�_lul S06L-939-19L HIM VI `FllnottF C rr11 OA Nr atII?j flI I 95h;l 91 W/f,I?0I �kOR7k m Town of North Andover A orhood Conservation Dishzct Commission Machine Shop Village Neighb y gyp •..r M�d�Ar1n nrf"�� 1600 Osgood Street North Andover, 1�1A{)1845 �SsacKuS�� A licat o For EXCLUSION From Certificate to Alter For Items 9,10 or 11,pxovide the following documentation: Photos/drawings of existing doors, windows or siding, as applicable Description/Catalog Cuts of proposed materials to be used for doors, windows or siding Plan and elevation of reconstructionfor Item 11 Determination: This project is determined to be exempt ©not exenipt from review by the Machine Shop Village Neighborhood Conservation District Commission. Projects that are not exem t must complete the Application for Certlf irate to Alter, available from the Building Department and be reviewed by the Commission, i Determination made by: i Lizetta M Fennessy Signature , Neighborhood Conservation District Commission 4 November 2016 Date Current Chair:Liz Amnessy,77 Bim StrOct,liMettaretiness C�7 ah,Oo,CUEp, MSV NCDC Page 2 6 f E The Commonwealth of Massachusetts _ DeparttneSt of-TadustrialAceidents X Congress Street,Suite 100 Voston,MA.02114 2017 o�tu wwv.mass.go v/dra Wavkew Connpensatzon lnsuranc6 Affidavit:Buildoxs/Cou actc►xslEleetrXciax�s/ mbexs. TO BE FILED VM)aTHC PF-RMXT' C-AVTHti?�CJ"Y. • _.P=lease�x-tut Le 'bl A licant orm-atfon �GI✓?, tl Name(businesslOrgauization/ tdividual): Address: S ty stateCo �� G3 ]2i.I P= Type of project(xeoxed)_ tlreyauaneznployer?Checktlie pzopxiate•box, F x 1, am aemployer With empl0 ees Gull arrdlor part tune). 7. Q Neva cnnstrization g. Rexnadelvig 2.�I am a sole proprietor or parlue186iP and have no emp cyecs Vrorking"')M zae in 9 ❑Demolition olition any capacity.[Naworkers'comp,insurance required.i I am a hon owner doing ail work myself.Ci`Ta workers'comp.insurance required j j 10❑Building addition 4.01 ma ahomemxmer acrd will bB hiring contractors to conduct au work onnty property. X will l ❑EleejXirI aTepjaiS's or additi9P8 • ensuretbat all contractors eitherhave workers'nomper�satiozw insurance or are sole 1-2.i s;�� g repairs o7.additions P with no irnp�aye6s. .5.D I am a general contractor and'brava hiredthe sub-contcactcrs listed outhe attached sheet. 13'.[]Roofrepairs These sub-contractors kava employees and have workers'comp-insura€tce 14. other r, We are a corporation and its.officers have exeroisediheirright o£'exemption quird.1 eGl c. and vre have na employees.[N.workers'comp.insurance reed 7 pensation p rappiicautthatrhd"Bvxd rn statso olicy information'. ut e aredeinglall.warkaadthenhir0outsidecontractors moustsubmiita owa£fidavitindicat�xgsucb i Homeowners who submittlais affidavit ind£c g Y I tractors that chec" boI' rause attacfied'an additional sheet ae their w 1 e e'�omP sub-contractors lSe cY number. d state whether of notthose entities have Cin employees. Ifthe sub- bava employees,they must prove X axrt urs erssplayer taut is providzng�vorkers'coraspensation insurance for rrty e sployees Pel aw is tlae policy aasd)0b site cc SFS !` " 9 hisuTanoo Company Name: r y �O Q ' Expiration.Datw policy#or Self ivs. Lie.#'. CitylState/Zip: Sob Site Address: d t olic noun. er and expiration.date). Attach a copy of the vvoxloexs' cb pensation policy declaration.page{sho�vving hep �'punishable by a ffie UP to 50Q00 ecure coverage as reg7xi ed der MGL G. 152,§25A is a cxinain O ViolO OEDEX tend %e of uli to $250,0 0 a failure to s enatties in the,form of a ST l' andlor one-year RK as'Tell as civil p da against the violator.A Dopy ofthis statement may be forwarded to the Offxco of Snvestigations of elle D�fox lris�uanoo y coverage vexiftcation. S do liereliy cerin under MePalm am penalties af�peerrj®uYy�Haut Elie infarmatian provided atm e is tz u_e correct Si atuxe: one#: j official use only. _Dv not-write in this area,to be cornpletecl by city a; town offxeiar -permitlLicense# City or'xo'avn.: xssuiugAuthoxiLy(circle Due): ' ector 5.Plumbing inspector' 1.Board ofEfealtlr 2.En�ildingI)epartment 3.Citylloavn Clerk 4,Electxicallnsp 6.Other Phone#• contact Oct 2616 02:29p The Insurance Store Inc 6173257892 p.2 CERTIFICATE OF LIABILITY INSURANCE °"=E`w'°°'rr""' 01/14/2016 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 MOLDER. IMPORTANT. If the cerNFlcate holder is an ADDITIONAL INSURED, the polley(les) must be endorsed. If SUBROGATION IS WAIVED, subject to I We terms and conditions of the policy, certain policies LRay require an endorsement. A statement on this certificate does not confer rights to the certificate holder In 11eu of such endorsernent(s), PRODUCER HAM E THE INSURANCE STORE eRONE (617► 925 8952 {617) 325 — 7892 Arc,Nu,ext}: rA+c,No): 106 SPRING STREET EMAlL ADDREss:_ WEST RC*M TRY, LIR. 02132 mm INSURERLS I AFFORDI NO COVERAGE MAICr INSURERAWESTERN WORLD INSURANCE COM2ANY INSURNI) INsuRER a SAFETY INSURANCE EORTANOVA RODFIN0. INC ENSURER C I 50 Elm Street INSURSRa; G`ohastset: Ma 02025 ENSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFY TI-AT THE POLICIES OF JNSURANCE LISTED BELOW 1AVE BEEN ISSUED 70 THE INSURED NAMED ADOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICI- THIS CERTIFICATE MAY BE ISSUED OR MAY PMRTAIN. THE INSURANCE AFFORDED BY THE POLIGFS DESCRIBED HEREIN IS SUBJECT —0 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.L MITS SHo%N MAY HAVE BEEN REDUCED BY PAID CLAIMS. S TYPE OF INSURANCE "OR POLICY EPG EXP iJl+lITS LTR INSR ME) POLICY NU MBER IMhVDolYYYY} IM WRP/YY'rY1 OrNERALL1AMiLiTY EACH CCCURSENCE 5 1,000,000 >Staa�E'UN a REQ s 100,000 r..NL MERCIAL GENERAL UAEILI•TY PREMISES(Eeaxn,arce} CLAIMSAME �OCCUL NNPP8184354 11/04/15 1.1/04/15 rd EoEXP(Anyonepamori s 5,000 PERSONA:-a ASV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GREG4T@'_IMITAPPLIESPER: PRODUCTS-C]MP+Or^AUG 1 `,2,000,000 ICY j El LOG s AUTOMOBILE LIAR€UtY -(Ea am dent) S 1 r 000,D 00 ANY AUTO BODILY INJURY Leer Panum f ALLCN'NEDAUTOS LED AUTCS 5238330 05/06/16 05/06/17 BUDILY INJURY 4Per aaidon:) S WNI-O X FIRED AUTOS .1C AUTOS r N s 100 000 AV TOS (Feraccldent) s UMBRELLA LIAS OCCUR EACHOOCJRRI.RCE S BXCISS LLA9 CLAW&MADE AGGREGATE 5 DED RETENTION S 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY Y f u I TORY LIMITS ER ANY PRCPRIETOFWARTN9VEXECUTLVE ❑ NIA EL EACH ACCIDENTS OFFiCERAnE Orr eXCLUDEDT {Mandatory in NH) EL.DISEASE,EA EMPLOYEE S Rnda- DESCRIPTION O=DPER4TION56alma E.L.fJ1SEA9E-PDLI.".Y LIM-T b I I DESCRIPTION of OPERATIONS f LOCATIONS 1 VEHICLES(Attach ACORD 101,Addftianal Renurhs S-hoiMlm,a more space Ls rvgClmdl ROOFING CARPEN'MY" 0 CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVF,R, BUILDING DEPARTMENT 120 MAIN STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION PATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER 11A 01845 ACCORDANCE WITHYHEPOLICY PROVISIONS. , AUT rZE REPRESENTATIVE "I i Y C 12"110 rORD CO R3PTION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks I ACORD I' 2516 02;29p The Insurance Stare Inc 6173257892 - p.1 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDaIYYYY) 1012512016 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(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). PRODUCER CONTACT NAMEZ Ann Gallagher THE INSURANCE STORE INC. PHONE -ill (617)325-8952 we Ro: AP RlEssl alnSUr�a.DLCOm 106 SPRING ST. INSURERS AFFORDING COVERAGE NAICA WEST ROXBURY MA 02132 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25665 INSURED INSURERs PORTANOVA ROOFING INC INSURERC: INSURER D 50 ELM COURT INSURER E- COHASSET MA 02025 INSURER F: COVERAGES CERTIFICATE NUMBER; 96994 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 INHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. (NSRTYPE OF INSURANCE IN BR POLICY NUMBER WWI]POLi POLICY EXP i LIMITS LTR COMMERMALGENERALLIA1331-M EACHOCCURRENCE $ CLAIMS-MADE OCCUR PREM. S a 0caxrr)y1W S MED EXP(Anyone person) $ NIA PERSONAL&ADV INJURY S GEN'L.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICYF JE° [LOC PRODUCTS-COMPlCP AGG 5 OTHER: $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT S i Ea acddent A14YAUTO BODILY INJURI(Per person) S ALL OY,INED SCHEDULED NIA I BODILY INJURY(Pec acddent),$ AUTOS AUTOS }iIREDAUTOS NON-OWNED locdenDAV,AGEs AUTOS 5 UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE NIA `AGGREGATE S I DED RETENTIONS S WORKERS COMPENSATION ` s AND EMPLOYERV LIABILITY STATUTE= ER Yf N E.L.EACH ACCIDENT $ 500,000 A OFFICER/NIEMBEREXCLUDED7 NIA-NIA NIA 6HUB8D80784116 1{)/2612016 10/2612017 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE S 600,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S $00,400 NIA I D£SCRWTION OF OPERATIaNS I LOCATIONS I VEHICLES (ACORD 101,AddHEanal Remarks acheduta,may be adachnd If more space Is requlrod) 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 banefts to employees in states other than Massachusetts if the insured hires,or has hired those employees oulside 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 tivww.mass.govliwdiworkers-compensalionftnvestigationsl. CERTIFICATE HOLDER CANCELLATION! SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE: WILL BE DELIVERED IN town of North ,Andover ACCORDAN CE WITH THE POLICY PROVISIONS. 120 main street ADTHO R¢EO RE PR ESENTATI V£ C. north andaver MA 01845 �' "(M.G�,�. e Daniel ro� y,CPCU,VicePresiden:—Residual Market-4VCR18MA 01988-2014 ACORD CORPORATION, All rights reserved, ACORD 25(2014101) The ACORD name and logo are registered marks ofACORD