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HomeMy WebLinkAboutBuilding Permit # 11/18/2016 BUILDING PERMIT _D i TOWN OF NORTH ANDOVER APPLICATION FOR.PLAN EXAMINATION . p L 20 PermitIwlo#: Date Deceived � - Ir2f "° areown4�` � AC HUS Date Issued: _ -- — EVR ORT.ANT: Applicant must complete all,items on this page LO aX ATI OIC 2 Z c 43 .� mm.. r'rirtt'' PROPERTY w OWNI�� D " Ak ',f"( m Print 10D Year Sfructur� yes o MAP _.. _ _: . F'AREL: .. _ZC�NI�JG DISTRICT: Historic District yes iso Machine pShop,Villa9 _..__y _ nci. TYPE OF IMPROVEMENT PROPOSED USE (—on Residential Non- Residential ❑ New Building Q06e family ❑Addition ❑ Two or mare family ❑ Industrial ❑Alteration No. of units: _ ❑ Commercial ,hair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition E Septic q lNell 11FCoadp(airi 11/1/ tlaricls CI Wafiershee! District 7 Wates/Sv�ie - DESCRIPTION OF WORK TO BE PERFORMED: W Identification- Please Type or Print Clearly' OWNER: Dame: __ Phone: r Contractor I�larne. .: LA Phone•::. "'wC . Address °2 �. . -,H14,V i L. upenrisar's Construct€ori Lid�nse _r ,Lm -; . : _ . Exp. Date. w Ci _. Ex Dates Horne Impro�rement License _ _ I?, _ ARCHITECT/ENGINEER Phone: Address: Reg. No._. FEE SCHED ULE.BULDING PERMIT;$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$'125.00 PER S.F. P Dotal Projeot Cost- $ 0 FEE: $ Check No.: ` ee No.: � I - - -- ---- --- - �Person conirccctcnwrtli ccae rtrec;rcont r cit cue caccEsa �ie a�ccrcre uz i�°Si'l7,_.._ are of AgenlOwrirp ". . _.___.. Signature of contracte�r own of ndover O No. r3ja__>q ,it C% h ver, Mass, 11 - i $ ,.a- R coc LAKE S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT 0b RkverleAb.k.eA1!k LIQ ' " �" BUILDING INSPECTOR ........ ................................... ............. .......,,.. .... ...... ... �....., C I.. ......gook.... Foundation has permission to erect .......................... buildings on ...,.. ............ . .. .. ,. ..... r .�. a � Rough tobe occupied as ....... ..., .. .......,. ............................................................... Chimney provided that the person accepting this permit s all 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 CONSTRUCTIO TP Rough Service ............ ,.Y _.. . BUILDING.INSPECTOR Fina] GAS INSPECTOR Occupancy Permit Required to Occupy Building Ro6gh 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. T — ��em[]s Home Improvement Commercial & Residential Uc{kIns 186 8reedens Lane, Revere MA 02151;Jose Mario Lemous; 617-438'3653 Homeowner's Information: Date: November 1CL2Ol6 Roge� 29 Columbia Rd North Andover MA,01845 The following contractl estimate are for the alteration. This paragraph describes the work to be performed. With this price it/ndudes/ubnrondnmotoriab: - Remove existing roof - install new shingles (tiOnberhn8) - Install ice & water(on all flat) - Install liner paper (for the roof) - Install [88d in ChiD0O8y - We dispose Oftrash - Install ventilation OOthe edge of roof — TA ("'t- � 'j Posts Note: Any alteration or deviation from above specifications involving extra coasts will be executed only upon written order, and will become an extra charge over and above the estimate. Note: you may cancel this agreement provided you notify the contractor in writing at the address above by ordinary mail posted, by telegram sent or delivery, not later than midnight of the third business day following the signing ofthis-agnaement. Notes :(*) any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. (**)Any alteration or deviation from above specifications involving extra costs will beexecuted only upon written order, and will become anextra charge over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. TOTAL AMOUNT: $7,800.00 DATE: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their ernplayces. Pursuant to this statute,an employee is defined as"...every person in the scrvice of another under any contract of hife, express or implied,oral or written!' An employer is&ffiad as"an individual;partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and'including the legal representatives of a deceased employer,or the receiver'or<trustee cif art individual,partnership,association or other legal entity,employing employ ecs.-However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the:issuance or ranewv l of a Hearse or permit to opdrate a business or to construct buildiugs in the com�moawealtli for any applicaAt VU leas not produced-acceptable evidence of compliance with the insurance coverage xequi'red" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been pros ented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. 13 e advised that this affidavit may be submitted to the D apartment of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign-and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the D epaz tment of IndustrialAccidents. Shouldyou have any questions regarding the law or if you are requircd to obtain a workers' compensation policy,please call the Department at tho number listed below. Self-insurod companies should enter their self-insurance license number on the appropriate find. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in tho pexmit/Iicense number which will be used as a referenoe number, In addition,an applicant that must submit multiple permit/license applications in any giver year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in {city or town,)."A,copy of the affidavit thathas been officially stamped ormarked by the city ortownmay be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a homo owner or citizen is obtaining a license or permit riot related to any business or commercialventure (i.e_a dog license or permit to burry leaves etc.)said person is NOT required to complete this affidavit. I The Department's address,telephone and fix number: The Commonwealth ofMassachusetts Depaitiaent of ThdustrialAooidents 1 Congress Street, Suite MO Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7405 or 1-877-MASSAFB ax#617-727-7749 Revised 0223-15 wwwmaSs.gov/dia -om:Marian Cruz Fax:(.781)581-3940 To:19786889542&cfax.cc Fax: +19786889542 Page 2 of 2 11118/2016 9:23 AM DATE(MWDOlYYYY) CERTIFICATE OF LIABILITY INSURANCE 11/18/206 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 Hou of Such endorsement(s). 100UCER NAW T Christopher Kennedy arquhar b Black Insurance Agency (A1C No,Erd); (781)599-2200 (AIC No),(781)581-3900 5 Exchange Street - Suite 101 ADDAIL RESS:Chris@FandBlnsvrance_com INSURER($)AFFORDING COVERAGE NAIC d ynn MA 01901-1475 INSURERA:Acceptance Indemnity Insurance SURED INSURER B: od's Home Improvement, DBA: Roderick Rivera INSURER C 6 Haviland Avenue INSURER D: INSURER E ynn MA 01902 INSURER F OVERAGES CERTIFICATE NUMBER:Town of North Andover 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 BEEN REDUCED BY PAID CLAIMS. iR TYPE OF INSURANCE ADL]L UEIR POLICY NU POLICY EFF POLICY ERP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 50,000 PREMI�f�p(Ea occurrence) ,$ CLOO186638 2/26/2016 2/26/2017 MED ExP(Any one personl $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 _GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 xPRO- POLICY JECT LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea.accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE g HIREDAUTOS _ AUTOS ,(Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADEAGGREGATE $ DED RETENTION $ WORKERS COMPENSATION OTW AND EMPLOYERS'LIABILITY Y 1 N ;STATUTE fR ANY PROPRIETOR/PARTNERlEXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICERIMEMOER EXCLUDED? .. .. ... (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S ?SCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be affached if more space is required) ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE nET ESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH TY PROVISIONS, North Andover, MA 01845 AUTHORIZED REPRESENT I E l J C Kennedy/MART N ©19813- 4 ACORD CO ORATION. All rights reserved. CORD 25(2014101 The ACORD name and logo are registered marks of ACORD 5025(2014041 j Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-082273 .,r;;lr;tip_r;.ICt19n St.pPrVlabr RODERICK RIVERA 36 HAVILAND AVENUE LYNN MA 01902 ^^� �✓� Expiration: ? Commissioner 06/28/2018 n n�rr/rrcc�rrcacrrll�v�0 l Offierr un/rcrrcL/,t ce of`Consumer Affairs&Busrness Regulation I<;l • `OMI_IMPROVI✓MENT CONTRACTOR registration ;174926 — Type ; i 8xptratron:..^4 � 0� Individual ROD RIVERA ROD RIVERA 36 HAVILAND AVE: LYNN, MA 01902 Cfndcrsecr•ctacy k"s A wuJjp flu l+ J Yx( N l vrR'Yr � VC 4 9 V � s �T'Qtf'`li' `s¢�� Y ,✓�+ll��f�'ll$ 2'$ t37�4 'a� f'f t i r �+ U::S Dept-4- Of IA,' f c �, � �ecup�tlon�liSalel i�-!e IITAdrnwstr�Iigh �; RDIz { � } f}a sur cesqtufry cornplsiewa lR. iti., Q5, fes' Tf7inlr)c�L�¢u�se lfi � �upa;�lontil'�ate3K arkq,'�I t11E ` :: t s — SSlci 4t3H