HomeMy WebLinkAboutBuilding Permit # 11/14/2016 0OR T11
BUILDING PERMIT �ob�Tt�o .6 ~o
TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATION
Permit NO: +
Date Received o
Date Issued:
�9ssacyus��y
ORTANT:A licant must com fete all items on this a e
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building L One family
❑Addition L9 Two or more family D Industrial
Alteration No, of units; Commercial
❑ Repair, replacement 0 Assessory Bldg ❑ Others:
11 Demolition ❑ Other� �.
REPLACEMENT OF 2 DOORS-NO STRUCTURAL WORK TO BE PERFORMED
Identification Please Type or Print Clearly)
OWNER: Name: WAYNE CHANG Phone: 617-967-6619
Address: 44 KARA DRIVE NORTH ANDOVER, MA 01845
100"
l `x
5 3
xf
ARCH ITECTIENGINEER
Address; Phone:
Reg. No.
FEB SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost. $ 2654.00 FEE: $�
Check No.: c
Receipt No.:_ 91
NOTE: Persons ontracting with unregistered contractors do not have access to the guarantyfund
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Town of aAndover
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U BOARD OF HEALTH
Food/Kitchen
PER IT . D 0,41.10.4...
Septic System
THIS CERTIFIES THAT ..... .. „ ` „ ,,,,, ,I>�„=,, 9UILDING INSPECTOR
Foundation
has permission to erect .......................... buildings on ... ........ ........................
. . . . + Rough
t0 be occupied as ... � .... ...... ........................................... Chimney
provided that the person accepting t is per6 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 CONSTRUCT, Rough
(0 i
Service
......... . ................. ............................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
y - a ccupy Buildin Rough
ccu anc Permit Required to
Display in a Conspicuous Place on,� Bethe Premises — Do Not Remove Final
No Lathing or Dry Wall To Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Renewal Agreement Document and Payment Terms:
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Cumi'mr.1 k) Ssi vix Mdre-,a.: 740 SAM St, North Andover, MA 01845
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NNOTICA::TO OWNER. l iwt mj,,st tbis:Lwitrict If kILI& you mc Clidded toat iopik kif I lie conitac,f af dw I i1mv�,mj 61m.
YOU,THE BUYER, MAY CANCEL THIS TRANSACTION ATA. NYn,ME NOT LATER THAN MIDNIGHT
OF 1012112016 OR THE m IRD RUSI N M' S DAY MTER,r"F.DATE,Or'THIS TRANSACTION,
W1 i M-1-MVER CII? rr.is UTER.SEE'FIE All"ACHED NES CE 0 F(ANCELIMION FORM F[;0 R AN
EXPLANATION OF THIS RIGHT.
U9111 Namrl MMtWd by M&Mm,tic
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Tommy Kelley Wayne Chana
Nint Nazi iv of Sale..y Mvon ftInc Nitme
ReneWal Itemized Order Receipt
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HIC 4110810i;ikr.PJA 01 11"
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The Commonwrralkh of Massachusetts
Department of Indugirial AccNents
Owe of Inyesdgadons
IF 600 WashhWon,Street
Doston,]NA 0.2111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: BaildeWContract ore/Electrician®/Plumbers
Applicant Infog lit i n _Please Print Legibly
Name RENEWAL.BY ANDERSEN
Address: 30 FORBES ROAD
Ci /Statelzip. NORTHBORO,MA 01532 Phone t 508.351-2214
Are you an employer?Check the appropriate box:
1.0 1 am a employer with 30 4. ❑I am a gwmal contractor and I Type°f project(required):
employees(full and/or 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 employm These sub-contractors have g. Q DemDljWn
working for me in any capacity. employees and have workers'
[No worker'comp.hmrance comp.insurance t 9- ❑Building addition
>ovirect] 5. ❑ We are a corporation and its 10.0 Eleotrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGI. 12.0 Roof repairs
insurance required.]t c.1,52,§1(4),and we have no 13.❑Other
employees.[No vsrorkeaa'
camtp.insurance required.]
*Any awficant flu#checlo boat iii must also fill out the aeetien below showing their woders'oompaasatian policy informsdon.
as
t Humcownwho suttmathis affidavit kdk3ft*oy oxo doing all W o*yud thm hire uotaide wntmcto m=dg=ft=ft a nee+a£6davl#iardioating such.
$Cn atraatus that 6 mkthla box must attachad an addhfond sheet showing the name of the mb4wnuw ra and elate whdha cr not tome amities have
employees. If the sub-contmaton lava employ—,they moat provide flu&WW1wxa'coznp.poHvy umbsc.
lam art mVkya*dw hpPvWd&g workrrs'c0Jrmr9a6?J a'ttartrantce for nW eopkWes. Btti'ow h the policy msdlab she
fttfotrrta0m
lnsammmCompany Name. OLD REPUBLIC INSURANCE COMPANY
Policy#or Self ins.Lic.M M WC3082310q Sxp1010112017
iratxon nate:
Job SiteAddresa: 740 SALEM STREET Clty/StatclZip; NORTH ANDOVER, MA 01845
Attach a copy of the workers'compensation policy declaration page(showing the policy ntnmber and ertpirahloit date), j
Faille to secure coverage as requited under Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a
due up to$1,500.00 tmdlor one-year imprism mens as well as civil penalties in the form of a STOP WORK ORDER add a fine
of up to$250.00 a day against the violator. He advised that a ccspy of this statement may be forwarded to the Office of a
Investigations 1A for insurance coverage verification,.
I do 6 een y ar dwpar m a nd pa>h dd es ofpaduxy drat dee it{forMar&n p vWed rib W its puss sari a ontct
' 1l 10/28/16
Phone 4: 8-351-2214
Q,J�tdd twee only. Do trot wi fte tet tC&wea,to be eampWM by d*or town offldaL
City or Town: pernait/Llcense#
Issuhrg Authority(circle one):
1.Board of Health 2.Haildhig Department I Cityrfowrn Clerk 9.Electrical Inspector S.Plwoug In
bNspector
6.Other
Contact Person.• Phone#.
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ANDECOR-01 SALWANN
CERTIFICATE OF LIABILITY
INSURANCE
OATEIMMIDDIYYYYI
913012016
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 c �cT Willis Towers Watson Certificate Center
Willis of Minnesota Inc. PINK :(877)945-7378 No; 8813 467.2378
do 26 Century Sivl� )
P.O.Box 305191 ADnRE certificate lllis.coM
Nashville.TN 37230-5191
INSURERM AFFORDING COVERAGE MAIC g
INSURERA;Old Republic insurance Company 24147
INSURED
INSURERS!
Renewal by Andersen INSURERC:
30 Forbes Road INSURERD:
Northborough,MA 01532 IN3URERE;
ENSURER 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 RESPECTTO 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.
ILTR TYPE OF INSURANCE POLICY NUMBER %DIDIYYYY M�frmp _ LNITS
A X CORIMERCIALGENERAL LIABILIrY EACH OCCURRENCE $ 110001000
CLAIM84AADE u OCCUR MWZY 308234 1010112018 1010712877 PREMISES Ea omrrancei a 500,00
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 11000,000
'GEN'LAGGREGATELIMIT APPLIES PER: GENERALAGGREEGATE _ $ 4,000,00
X POLICY DJPP& 0 LOC 1 [PRODUCTS-COMPIOPAGG S 4,000,086
OTHER [ $
AUTOMOBILE LIABILITY cam B�31ev��DSINGI.ELIMIT § 5.0001000
A X ANYAUTO MWTB 308232 1010712016 1010112017 BODILY INJURY(Per parson) $
ALLOWNED SCHEDULED
AUTOS AUTOS BODILY IMURY(Peraoctdant) $
NON-OWNED I PIaPoEoMent A $
HIREOAUi08 AUTOS
( S
UMBRELLALUiB OCCUR EACH OCCURRENCE $
f37tC23S LIAR CLAIMS-MADE AGGREGATE $
I DED RETENTION$ $
WORKERS COMPENSATION PER
AND EMPLOYERS'LtAEILITY YIN X $T TTJTE ER
A ANY OFFICEOWPMEM ERPEXmCLLUUDDED?ecumE N❑NIA AAWC30823700 1010712076 1010112017 E.LEACH ACCIDENT $ 11000,000
(Mandatory In NH) E.L.DISEASE•EA EMPLOYE $ 1 000 000
Uyea descrlbo under I
OESLIRIPTION OF OPERNnDNS below E.L DISEASE,POLICY OMIT r4 1,000,00
I
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Addtdanai Remarks Schedule,may be aUsehad If more spaca Is raquirad)
CERTIFICATE HOLDER CANCELLATION
i
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Proof of Insurance ' • `
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
VWMassachusetts Department of;Public Safety
Board of Building Regulations and-Standards
IVV•/
License:.CS4*0125
Construction Supervisor
JAIME L MORIN
88 GARl)iNEft S7
LYNN MA 01905 .` r
�� � c
eS,,-.W.. i
Lam..-- Expiration:
Commissioner 46106f2018 j
Construction Supervisor
Resttiated to:
Unrestricted-Buildings of any use group which contain
less than 35,000 cubic feet(891 cubic meters)of
enclosed space.
FARWe to possess a eunud edition of the Massachusetts
St"Wuile "Coda is cause for revoca inrt ofthis license.
WS Licensing Wormatbnn vieft:WWW.MAG8.G0VltfS
CT1e rpom:maa�r*r�ecz/.d/r.o��a�ac�cueefta
'Ce of Coiasumer Affairs&Business Regulation
ME IM PROVEMENT CONTRACTOR
ReBEstretl to _` L Type:
Expira � SuErpiement Card
RENEWAL,BY AND
JAIME MORIN
30 FORBES Rb
NORTHBOROUGH,MA 01532 Undersecretary
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