HomeMy WebLinkAboutBuilding Permit # 10/31/2016 n.
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BUILDING PERMIT ,�� +` '^ �Z.
TOWN OF NORTH ANDOVER ° is
APPLICATION FOR PLAN EXAMINATION
Permit NO: �� Date Received t °+ ��—�- . • #
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Date Issued: C �— t
IMPORTANT: A licarat must cora lete all items on this a e
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
[I Addition ❑Two or more family [I Industrial
El Alteration No. of units: ❑ Commercial
,yAepair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
W rA/Q®RJ 5
Identification Please Type or Print Clearly)
OWNER: Name: Gary Davis and Lorraine Davis Phone'. 978-590-5010
Address: 174 Johnson Street, North Andover, MA 01845
4
ARCHITECT/ENGINEER 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: $ s 843 FEE: $ 84.00
Check No.: 0 ' Y . Receipt No.: i
NOTE: Persons contracting with unregistered contractors do not have access to the ar ty fund
OORTy
own of i ndover
o
No. ,r
T �O LAME
NI-Ah " ver, Mass, O • • Q/
c oc NIC.tE W.G.. Ok'
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S �
BOARD OF HEALTH
PER
Food/Kitchen
IT T D Septic System
THIS CERTIFIES THAT ........ ..., �i .. ............. ..... A. tr Al.a.0. BUILDING INSPECTOR
has permission to erect.......................... buildings on .....(.7... .....a 1 OvS. JV........... Foundation
to ... ..,.........W'COV...: 4.V' .......... ..1 .... .b............ Rough
be 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 16 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT STARTS Rough
...
Service
... ..,. .........................................
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupaner Permit Required to Occupy Buildin-e Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wail To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
hA ersen.
ReneWal Agree
nt Document and Payment Terms
9 �Lrltl aselx•�� sae c� rfMng.4n.r$Gary Douls
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YOU,'n.-1E BUYER, �IkfA-Y CANCE L THIS' RANS k+GnON.M'ANN TIME NOT LATER THAN MIDNIGHT
WHICHEVER DIVUE,I �
UVFE ..SE °I`HE��TIACHEI) €YVICC_ .OF C�#. I;.LI�t�'�1 OIN F�" R RAN
MILANX11ON OF THIS MIDI-1'f.
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�lC�!EEE.�'ILllti ul �.11cr l€iY.tii!rt' �"ll;tt:313A!>3'•�' �iE�l.rYtitar
Gerald Perron Lorraine Davis Gary Davis
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Renewal Itemized Order receipt
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ANDECOR-01 SALWANJV
�.. CERTIFICATE OF LIABILITY INSURANCEGATE( R!D)Y"
913fl12016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUMR(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED,the polley(les)must be Endorsed, if SUBROIiA I WN IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in Ileo of such endorsame s.
PRODUCER CNAME,cT Willis Towers Wauan Certificate Center
Willis of Minnesota,Inc.
c10 28 Century Blvd PINE 877)US 7378
Nashv/Ie,TN 37230-6191 ADDRE •E.mMillCetas@wlllls,epm Na; 888 467-237$
INSURER(b)AFFORDING COnRACE MAIC/
INSURED
INSURERA,Old Re Ub#ic Insurance COMPOnV 24147
INSURER N.,
Renewal by Anderson INSURER C:
30 Forbes Road INSURERD:
Northborough,MA 01332
INSURER L:
INSURER p;
COVERAGES NUMBER: REVISION HUMBER;
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
CERTlFlCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE CH T S,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE ADD
POLICY NUMBER PO DD MM
A X COMMERCIAL GENERAL LIABILITY Lasts
CLAIM84AADE X OCCUR M WZY 306234 EACH OCCURRENCE S 1,400,000
iol01124ts 101x112017 PRE EA Ce $ 500,00
! MEDEXP yore n $ 10,00
GEITLAGGREGATE LWIT APPLIES PER; PERSONAL&ADVMJURY S 1,000,000
X POLMY❑, �LCC GENERAL ACGRt5GATE $ 4,000,00
OER3 PRODUCTS-COMPIDPAOG S
TH4,o4a,o40
AUTOMOBILE LIABILITY $
COMBINFO SIN LP LIMIT $ 6,000,00
A X ANYAUTO MWTB 300232 141011x016 1010112017 BODILY INJURY Per
A�ED AAUTO9llLED ( prion) s
NON.OWNEO BODILY INJURY(Per scadenl) S
NIREOAUTOe AUTOS
PRO
Par a I ent S
UMBRELLA LIAR OCCUR _ S
EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE S
I Dim RETENTION$ AGGREGATE $
wORNTRS COMPENSATION $
AND EMPLPYERS'LIABILITY YIN J( $T E ETRH-
A OFFiCERRNI BERWEX�aEa?ECUTIVE N N1A WC30823100 14/0112416 10101f2017
(Mandatory In NH) ❑ EJ EACH ACCIDENT $ 1,000,000
If oEedR°IP°WTION of OPERATIONS bN ow E.L.DISEASE.EA EMKOYE $ 1,000,000
E L D]BEASE•POLICY LIMIT S 11000100
DESCRIPTION Op OPERATIONS I LOCATIONS 1 VEHICLEa(ACORD 101,AddRIOnpl Remarks Schedule,may ba attachedM more apace Ie rcqulrotl)
CERTIFICATE HOI Deft CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBE!)POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORMzD REPRESENTATNE
PE99 of Insurance
ACORD 25(2014141) The ACORD name and 1090 are registered marks of ACORD D CORPORATION. Ali rights reserved,
The Cosimonwa&h 0fMffsSaehWe&
Deparment ofInd uWrW.4cc1&n&
Offlee of 1nvvsZfga&ns
600 Washington Sired
Boston,HA 02111
WWw.mas&goy1d1a
Workers' compensation Insurance Affidavit: Buffders/COntract'ors/Electriciene/PluniberIg
A2121-1cant AILOMIMUR ass]W&S6 T
Name(Dusitimfiftwindon4ndividud)-
RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
city/state/zip: NORTHBORO.MA 01632 Phone#: 508-351-2214
Are you an employer?Check the appropriate box,
1.RI I am a employer with 30 4. El I am a general contractor and I Type Of protect(required):
employe"("And/or part-time).* have hired the sub-contractora 6. D New construction
2.El I am a sole proprietor or partner- listed on the attached sheet, 7. FL]Remodeling
ship and have no employees Thew sub-contractors have 8. 0 Demolibon
wotiCing for me in any capacity. employees and have workers,
[No workers'comp.insurance comp.insuranceJ 9. ❑Building addition
required,] 5. D We are 8 corporation and its 10. Electrical repairg or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I,El Plumbing repairs or additions
Myself[No workers'comp. right of exemption per MGL
Insurance required.]t c.15Z§1(4),and we have no 12.0 Roof rup4irs
employees.[No workers' 13.[:]Other
COM.insurance required.]
*Any applicant that checks box#1 must ew fill out the section Wow-showing their workers"cm
t Homeowners who nbmh ibis dMavit Mcstiqg they an dolog an wok ad then him 0,Wj& paswon polfay framu&",
tCautmatus that check this box most attached an additional sheet showing the=wlo of the sab,=Dntado�w most mxbmh a mew uffi&vit bAicaft sah-
wv1qecs, Mthosub-conhwtoubavcaqgoyvw.they muinpmW&&eir wed=,comp"Poley ew,,ber.nnd state whether or nW gme angfift have
14M 4X eAVIOYer&W 1sPriWdbS9 workers'coxrewa&n
&WIP"Cefor MW
14fors"WO& Betoy,to thePoNly aNdjob sb
Insurance Company Name: OLD REPUBLIC INSURANCE COMPANY
Policy#orSWf-;ins.Lio.#. MWC30823100 mon Date: 10/0112017
Job Site Address: 174 Johnson Street City/Statalzip. North Andover, MA 01845
Attach a copy of the workers'compensation Policy declaration page(showing the policy number and eVirstlon date).
Failure to secure coverage as requhvd under Section 25A ofMGL c. 152 can lead to the impodtion of mfininal penal
fine UP to$1,500.00 and/or one-year imprisonment,a well as civil p ties of a
of up to$250.00 a day against the violator. Be advised dint a c onal"es in the form of a STOP WORK ORDER and a&a
corky of this statement may be forwarded to the Offir
1nVest12dti22eE!Lik�IA for fimmulce coverage VWi&atjoz e of
Ido-h cM& or Mw pains andpmaitkir ofprjujy ftt dw bjfbr*#&&x above is MW............
wd
016
8-351-2214
OffloW we on&. Do not write in&&area, a be ca
mpiefod by efty or town offiew
City or Town: PerniWUcen"#
Issuing Authority(circle one).
1.Board of Health 2.Building Department 3.CftYfrswn Clerk 4.Electrical Inspector S.Plumbing IM7
6.Other tpr
Contact Person: Phone
' Massachusetts Department of Public Safety 1
Board of Building Regulations an.d.Stanciards
License:.C9400j25
Construction Supervisor ,
JAIME L MORIN
86 GAROINIM ST :...s' :`rm,�4
LYNN MA 09806
44,
C.J_ Expiration_
Coinrnlssioner yQO t$
Construction Supervisor
Restrided to:
Unrestricted-Buildings of any use group which contain
less than 355 ODO cubic feet(981 cubic meters)of
enclosed space.
Failure to possess a currerit adkim mithe Maasachuseft
Std*91uildittg Code is cause for revocation of this license.
DPS Licensing krom Monvisk:WWW.MASS.G0VMft,
09L
c
c of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
'
_ == Type: i
p1 Supplement Card
RENEWAL BY AND
JAIME MORIN
30 FORBES RC} :u `
NORTHBOROUGH,MA 01532 — � ----
Undermcretary
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