HomeMy WebLinkAboutBuilding Permit # 11/14/2016 OORT"
BUILDING PERMIT 6 wo
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINATION 1%'L
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Permit NO.
Date Received....&/
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A4Teo '
4SSAC1dl15�S
Date Issued:� ,
IMPORTANT: A licant must com late all items on this a e
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
11 Addition El Two or more family Industria]
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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REPLACEMENT OF 2 DOORS-NO STRUCTURAL WORK TO BE PERFORMED
sa
Identification Please Type or Print Clearly)
OWNER: Name: TOM O'CONNELL Phone: 978-394-1086
Address: 44 KARA DRIVE NORTH ANDOVER, MA 01845
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ARCH ITECTIENGIN EER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: 5755.00 FEE: $ -
Check No.: 1 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Jee- q-(3ree f
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own of
No.
h ver, Mass, bt &,wh*
-
T O LAME
COCMICNEW.CR
,95 R�rEo
U BOARD OF HEALTH
Food/Kitchen
PERVIT T LD Septic System
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THIS CERTIFIES THATBUILDING INSPECTOR
............. ..... ..,...C�►, .. .....a?04&r.. .....�►
has permission to erect buildings on Foundation
Rough
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 C®NSTRUC N STA Rough
Service
..... ,. ...... �i..... , ... .. ........................... Final
BUILDING INSPECTOR
GAS INSPECTOR
OccupaMeE Permit ReguaYedto_Occupy BuildinRough
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.
Renewal Agreement Document and Payment Terns
'�AM- ersen Tom Wrarinall
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Cwivnwi's) Nainc TOM WtOnflell
Cumomei l'i) Siocct ALWTIt*: 44 Kara Drive, No(thAAdOvOrA
M 01 .845
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Pa i Him y Eluail,toconnel 11tomotomcast'net S
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A;JctScn of An arcorklamrv.with dW"WTIM IRd &w.rdwd III dsis Arrevaticni Dorument awl Rayn
Mnicc 4cawdLi6on' hVillk(4,Op&r 1tocdpi.'1'ernv,;ind.ConJiti-mi-s of Sile—If Lkinga mw
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ski Bqj}erlkl^heldly"Irrmt
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1Wn;11Cti0I1(VIt'lr IL-111`031' 'f njIjrtCjr 11,1
IV %counilered all vwrk undcr ihir Arreemew-
T14,41 Job A numot: $5,755 By-ii:V611g,this ilgivVillet'll, VUU 14210AIArr,that 11a: Billalti;c Dac,it dic Amoinit
1Xj,qx,,h Rixdvcd. $1,910 FI"An"e'j a i Im hi!In.'I'liv by'rc".rt laal AvA, lmnk�chv,,:k,rrv-jir mcl,i5r
IkAlrwe Dix: 53,837 Estiffll:34'j slarl: hitinured CUzIIF4xI kin:
Asnowlt 1"irlaami.. $0 8 weeks 1 day
Melholl(d Nymem: Credit Card lxiietl 00 6,-dali of(lie iignvdd,xmqoct and sccov.Jatily�in
dw Jare in III-hidt IN-J.' J"ljtj-raE nic-a.wrejumm Thc m%tAftatimi&itv akarNulcs: MasterCard 113, We arc pl'ovwIng at this thll'v i'Li Only'),q. es'11111,1TC,We Wiffximmunkate all officid d"Ate
Start of install 1,13 -1114,dMW I'Atet tlaW. R;Wt arid&Ucltle WCIILficj;JrJ7.IILC Irp'4rit�til"t1WIl tjUs�-s J.'Ul'
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NOTICETO OWNFR. Du jkaj sigla 11ii1 vorltuLt 10,4A
YOU,THE BUYER, 1MAY CANCEL THIS TRANSAMON AT ANY TIME NOT LATER THAN MIDN]Gfr]T
OF 09124/2016 OR.THE THIRD 1311-SINM5 DAY Ar,URTHE DATE OFTHM TRANSA(MON,
WHICHEVER DxrE is LAYER.SEE THEUAACHED N(,YrtCE CIT(ANCELtArION FORM FOR ALN
EXPLANATION OF]'HIS RIGHT.
UcA Namei Cr mewaJ by Anderma LK
Kevfn Manahao Torn O'connell
NA21,1C Prim Nirm,
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ReneWal Itemized: order Receipt
hAndersen
Rtac-A 6 Andin-am of OwAem Tom O'cannall
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The CommonweaM ofMassachuse&
Department of InduWddAccMents
Qfflce of Investigations
600 Washington Sheet
Boston,M.4 02II1
wwwonassgor+/dla
Workers' Compensation Insurance Affidavit:Buflders/Contractors/Electricians/Plumbers
Appleaut Informatin Please Print L
Name(BuainessMrpnizadonQ&viduaQ: RENEWAL BY ANDERSEN
Addm9s: 30 FORBES ROAD
city/state/zip, NORTHBORO,MA 01532 Phone#: 508-351-2214
Are you an employer?Check the appropriste boat
1.Q I am a employer with 30 4. ❑I am it general contractor and I Type of project(requires:
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a wale proprietor or partner- Bated on the attached sheet, T. Remodeling
ship and have no employ= These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp,insurance t 9. [:]Building addition
r"Fira&I 5. ❑ We ue a corporation and its 10.[]Eloetrical repairs or ad floes
3.❑ I am a homeowner doing all work officers have exercised their 11,❑pigrepain 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.[2 Other
comp.insurance required.]
'!►ay applicamtthat checks box fill must also fill out the=tim bolow showing their worlxrs'eompansation policy f ftanation.
t Iiomeowuez8 who submit this affittavit kdimft they axe doing all work and than hire ontside cmtmdors nnmt submit anew affidavit indimtiag such.
:Contracbors that checkthio boa musi attached an additional sheet ahowieeg the nano of the m&=*wt=and state whether ornot thine entMm have
employees. Nth*sub-corttract m have evploycw.they moat pmvide their woricma'comp,.policy number.
fans an emphyear dW lCpr Wdbg workers'cohVmratlon twwasce for my employee& Below B the policy=d jab side
informarlon.
Insurance Company Name: OLD REPUBLIC INSURANCE COMPANY
Policy#or Self iris.Lia.#: MWC30823100 10/0112017
l�piration Date:
Job Site Address., 44 KARA DRIVE City/Stawzip: NORTH ANDOVER, MA 01845
Attach it copy of the workers'compensation policy declaration page(showing the polky number and tV#rsiHols date).
Failure to securo eovmage as requited under Section 25A ofMGL o. 152 can lead to the irnpoftm of criminal penalties of a
rine up to$1,500.00 and/or one-year imprisonment as well as civil ptm W"es in the farm 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
lavesdgatioSAMQU for insurance coverage verification,
dA li coo" er ike pain aMdPOM dlJ"O.f pePJI FY Owt the WbttYlfdtJ1'Ipmided ab4wl S?lYfe Md 00"Ift
Si l] 10/28/16
8-351-2214
offl d rrae on(v. Do not wrde in d&arae,to be congdeterd'by eaty or town of]'lclat
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cky/Town Clerk 4.Mectrical Inspector 5.Plumb Inspector
6.Other
Contact Person: Phone#,.
F
I
i
A#iDECOR-01 SALWANJV
CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DD)YYYY)
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 WANED,subject to
the terms and conditions of the policy,certain policles may require an endorsement. A statement on this certiRCate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME: Willis Towers Watson Certificate Center
doWil2 of Century
I Inc. pall.
ll 877 945-73_78 P
�0 2s Ce1Th1 Bhrd N .f ? Na:(088)467-2378
P.O.Box 305191 L-MAILs:cE,rtf#iCateB0nrllll».com
Nashville,TN 37230-5181
[NSURER(8 AFFORDINGCOVBRASP F
#
.......�.
INSURER Republic Insurance Company
INSURED
INSURER B
Renewal by Andersen INSURER C:
30 Forbes Road INSURER D:
Northborough,MA 01532 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 CONTRACT OR 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 13EEN REDUCED DY PAID CCCLAIMS,
LTR TYPE OF INSURANCE POLICY NUMBER MIDD MHlLDD LIMITS
A COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS MADE OCCUR MWZY 308234 1014712016 1010112017 PREM 9 S Fa rr a $ $00,00
MED EXP{Anyone n) $ 10,000
PERSONAL a ADV INJURY 1,000,wo
GEN'LAGGREGATFUMIT�APPLIESPER: GENERAL AGGREGATE $ 4,000,00
x
POLI CY❑dEGT F LOC PRODUGTB-COMPOPAGG S 4,000,000
OTHER S
AUTOMOBILE LIABILITY I COMSIINdEBDSIN�GLPLIMIT $ 91000,000
A X ANYAWO MWTB 308232 1010112016 10/0112017 BODILY INJURY(Per pawn) S
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Par aoddenl) $
HIREDAUTOS NON-OWNED PROPERTY DA MAGE $
AUT45 # Per daft _
S $
UMBRELLALUAB OCCUR EACHOCCURRENCE $
EXCESSI-tO CLAIMS-MADE I AGGREGATE $
DEC) I I RETENTIONS $
WORKERS COMPENSATION KM
OTH-
AND OMPLOYERS'LIABILITY YIN I � ST TUTE ER
A ANY PROPMETORIPARTNFRA=XECUTIVEAM
€ �,�,fpcHAGC[DENrWC30023100 10101120'16 10101f2017
OFFICERIMEMBEREXCLUDED? �NIAE $ 1,000,000
(Mandatory In HH)
Ifyaa,AosorWe Under I E.L.DISEASE-EA EMPLOYE $ 110001000
DESCRIPTlONOFOPERAT1ONSheklw I E,L.DISEASE-POLICY umrr $ 1,000100
DESCRIPTION OP OPERATIONS 1LOCATIONS 1 VEHICLES IACORO 101,Addltlenal RarnoWe Schedule.may be attached K more spAee Is required)
CERTIFICATE HOLDER
CANCELLATION �
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL INE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATNE
Proof of Insurance �• l d�
0 1938-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
4
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS4MI26
Construction Supervisor
JAIME L MORIN
88 QARDIN9R STt 4 t Qe e
LYNN MA 01005
Sy,(����xG 5{•
lz;:;K CA, Expiration:
Commissioner 10/0812098
Construction Supervisor
Restricted to:
Unrestricted-Buildings of any use group whlc h contain
less than 35,000 cubic feet(991 cubic meters)of
enclosed space.
Failure to possess a current sedition ofthe Massachusetts
State Bonding Code is rause fair revoeallim of this license.
DPS Licensing Wornation visit:WWW.MASS&OVIM
r
C��e�omaan�ur�ea�o�G�avQa�uaella
ace of Consumer Affairs&Business ftuiation
1PME IMPROVEMENT CONTRACTOR
RegistratlA' , ,,�, 'TYI=e:
Expirati __x Supplement Card
RENEWAL BY AND s i
JAIMI= MORIN
30 FORBES RD �2
NORTHBOROUGH,MA 01532
Undersecretary
a