HomeMy WebLinkAboutBuilding Permit # 10/17/2016 t&ORTRy
BUILDING PERMIT oFsLED '6��U
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 4/07 9-01 7 Date Received ^TED 0-f
�SsacHus�t
Date Issued: `
IMPORTANT: Applicant must complete all items on this page
LOCATION t c k ov €- Ls3g5-
Print
PROPERTY OWNER FyiL-afi d e is
Print 100 Year Structure yes
MAP Q1'-_1 5,0 PARCEL: ZONING DISTRICT: 11 0 11 Historic District yes
��ol���.0-Dr 000v.c Machine Shop Village yes OD
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
s Septic ❑1111e11 r , r t7 Floocplam I�Wetlands y n71 ❑ Watershcl Dsfrrcfi
b f
_ �. .v.-.K--. � �a,r✓.i���� F G � � r �' a .�:.,Erma ,-�� ,.,�,rwl y,^r.
❑WaterfSewer . ...YF. �, s � t
DESCRIPTION OF WORK TO BE PERFORMED:
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tile- tiu,�n d&t,,� NO �- t
Cr�7a � a ,
y / Identification- Please Type or Print Clearly
V
OWNER: Name: i'r} ri'l in _&r5 Phone: q-75 - gS09
Address: ¢0
Contractor Name: zi N . Phone. 4sps i�o44
Email. rnGrin ►te a s .n H
Address: F�, &7cLroLt-r)ev- 5 ,, A1,4 &)qC
Supervisor's Construction License: CS- 0!2 p Exp. Date: I o - o( -act
Home Improvement License: 1 `7 C-9/ Exp. Date: i 3 0 1
F �pRT� 'i1
Town of
ndoi
10L $ h
ver, Mass
QRATED
V
PERMIT . T
Foc
a L D Sep
THIS CERTIFIES THAT tV
.....,.... .IA..�.! 1. ...........+'.1!.�!� .......................................................
has permission to erect.......................... buildings on .................................................................... Fou
Rou
to be occupied as .......... /1/� 04 x....13.9.�!r.1........,.t b �!. . .. .., ^
..,.... r............�................... ....... � Chir
provided that the person accepting this permit shall in every respect conform to the terms of the application
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and ring
Construction of Buildings in the Town of North Andover.
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rou
Fina
PERMIT EXPIRES 1N 6 MONTHS
UNLESS C®NSTRUCTI® STARTS Rou,
Sery
.. .. .. .. ................
BUILDING INSPECTOR Fina
OccupancE Permit Required to_0CcypE Building
Roup
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done
Until Inspected and Approved by the Building Inspector. Burn
Stree
SM01
Renewal Agreement Document and Payment Terms
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Landers-North andover
)w Selection Page `u"°"1er
Andersen of eostan
Address:
mal by Andersen LLC
City,sae,23p Code:
NorthbDmgh,MA 01532
MOI Fax:(508)985.70721 RbABostoroOparabonsgAndemenCorp.torn
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Dlkc,newal Itemized Order Receipt
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'VANDOWS: 1 PATIO,DOORS:0 SPECAALTYl-0 NIBSC; t TGTAL $10.., 36
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ENERGY PERFORMANCE RAnNGS I
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ADDMONAL PERPOSMANCP RATINGS
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The CommonweaNh eflliManwhirrseus
Department of Industrial Accidents
Office of Inves4plUns
600 Washington Street
Bostnx,MA 02111
www mass govldia
Workers'Compensation Insurance Affidavit:Bwildere/ContractomfElecttrldanMumben
At'MUcalat Informstlon _ Please Frits#Le�bly
Name(BumneadOrganizstionllndividual): RENEWAL BY ANDERSEN
Andress: 30 FORBES ROAM
Ci /State0% NORTHBORO,MA 01532 Phone#. 508-WI-2294
Are you an employer?Check the appropriate box: TYPO Of PrIDJOd
1.Q I ama employer with 30 4. ❑ I am a general contractor and I ( '
employees{full ancl/or part time}.
* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed an th®attached shoat 7. Ramodelnng
ship and have no ernployeas Thi sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
kers'
[No workers'comp.insurance Comp.insurance.t 9. ❑Builliftig addition
5. ❑ We am a corporation and its 1011 Electrical hairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plurnbing repairs or additions
myself[No workers'compright of exemption per MOL 12.❑Roof repairs
insurance required.]t C.152,¢1(4),and we have no
employees.[No workers' ME]Other
Comp.insurance required,]
'Aqy app}�nt that cheeks box#1 mint aloes fill out thaasetton below&nvh*their workers'oompensaiioa policy loge nagon.
#I-oareown=who submit this affidavit indicating they are doing all wmir and thea hire outside ountawton mast submit a sew affidivit iedicatiag such.
tCoattactma the cheaktbis box must atosched an addWond sheet showing the new of the sub oemwtucs and smte whether or net dme a&=have
employees. If the sub-onaltaotes have emp1wiecs,they must probe their waskers'coin,policy number.
law an esq&yer dim tc provMft rtwrkm'conrewad m liriawm a for my eatp7oyesm A*W k theptAicy and fab she
of o"watlo&
Insurance Company Name: OLD REPUBLIC INSURANCE COMPANY
Policy#or Self ins.Iac.#: MWC30823100 B:spirstion Date: 10/01/2017
Job Site Address: Yd Cd u r4 `rc �l`(o c,vv e P-to
citylStatelZ�p.I
Attach a copy of the Workers'compensation policy declaration page(showing the policy,number rind expiration date).
Failure to seoure 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 imprisormrent,as well as civil penalties in the fcum 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 f(wwarded to the Office of
Invc&dVdoSAtdwQDIA for insurance coverage verification.
Ido h cM& ar&epahm a ndponaklm ofperjmy Oat sire trio ,int above�&e eon
`7 /t
ANDECOR-01 DUBEAA
AC[7R0°' DATE(MMIDDIYYYY)
CERTIFICATE 4F LIABILITY INSURANCE
9/30/2016
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 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 Willis Towers Watson Certificate Center _
Willis of Minnesota Inc. PHONE ��- Fax
c/o 26 Century Blvd AIC No Ext:(877)945-7378 (Arc No: /$88 467-2378
P.O.Box 305191 ADDRESS:certificates@willis.com
Nashville,TN 37230-5191
INSURER(S)AFFORDING COVERAGE _NAIC p
INSURER A:Old Republic Insurance Company 24147
INSURED INSURER B:
Renewal by Andersen LLC INSURER C:
104 Otis Street 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 PER"T"AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
€L7 TYPE OF INSURANCE AI
NSD WVD _m POLICY NUMBER MM10DmYY MMIDDIYYYY LIMITS
A X COMMERCIAL GENERAL.LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE I " OCCUR MWZY 308234 10/0112016 1010112017 pREMISEs Ea occurrence $ 500,040
MED EXP(Anyone person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000 '..
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000
X POLICY E JEO El LOC PRODUCTS-COMPIOPAGG $ 4,000,000
OTHER: $
AUTOMOBILE LIABILITY COMPaacBINED BINDLE LIMITcident $ 5,000,000
A ANYAUTO MWTB 308232 1010112016 1010112017 BOOILYINJURY(Per person) S
ALL OWNED L SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION �(
AND EMPLOYERS'LIABILITY STATUTE ERH
Y1 N
A ANY PROPRIETOWPARTNERIEXECUTIVE MWC30823100 10/0112016 10/01/2017 F,L,FACHACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? � N N 1 A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 11000,000
If yes
D SC RIPTIONOFOPERATIONSbetow E.L,DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Evidence of Insurance.
KI Ma$sachuseft DOPartment of Public Safety
130ard of Building Regulations and Standards
License; 054090125
Construction Supervisor
JAIME L MORIN
W GARtl VIER ST p,
LYNN MA 01005
-•
CoFiirnlssioner
Expiration
_ 10/0612018 R
Construction Supervisor
RestricAed to.
Unrestricted-BUiidings of any use roup which contain
loss than 35,000 cubic feet{9g9 CUDIC meters)of
enclosed spec®,
m -
FaRwe to pessess a emywd edKIM efthe M&Mchusetts
State sumo Code 7s cause for meeau"of this rrcenss.
DPS LloensingiMormWpnvisit:WWW.MA55:fiNmps
ce of Cvnrumer Aihirs&Busineer Regptation
ME IMPROVEMENT CONTRACTOR
Registratl Type- I
t31s -.t=' ..,
,,�:: Supplement Card
RENEWAL 19Y AND