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Home My WebLink AboutBuilding Permit # 11/21/2016 tkORT11 BUILDING PERMIT TOWN OF NORTH ANDOVER so APPLICATION FOR PLAN EXAMINATION Permit No#: ;I-oo 7 Date Received k L 0 i C Date Issued. im—pokfA—Ny::Applicant must complete all items on tbis�ag� nmi LOCATION �4 Print PROPERTY OWNER 100 Year Structure yes no MAP )`,'2;w PARCEL: ZONING DISTRICT: — _ Historic - yes no s MachineDistrict Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [I New Building Ei one family o industrial El Addition 04 Two or more family o Alteration No. of units: ❑ Commercial l Repair, replacement– El Assessory Bldg [i Others: hed'Di [i Demolition ❑Ei Other ""a,lain', , " "",d "'D rs e 7777 -,,Wat6................ strict "ETWetloh", g&/l "0 ,2 3005, e .10, R & ❑ /6t r/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Gtr c" Iclentaf cation- Please Type or Print Clearly Name: (1, OWNER Phone: (L I Address: L4 hone: 5 Contractor Name: P Email: Address: 13 t OIL Supervisor's Construction License: &'Q ei 3 Exp. Date: Home improvement License* U C1 Exp. Date: ARCH ITECT/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: FEE: $ 0 Check No.:— Receipt No e3 NOTF,: persons contracting with unregistered contractors do not have access to the guarantyfund ure, of.Lontracto t4ORTy own of aAndover 0 - : h ver, Mass, It I - dV®I 6 COCNICoemcm Y^ �.45 RATED 19 BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..�+..Cl4864. ......e!�. q... ..../.*. f.t�. ......... BUILDING INSPECTOR has permission to erect ........ buildings on �' � ......, ,1, ,! Foundation .....�.. ,.,.. _ .. ...... .. Rough tobe occupied as ....... .. ........�., .......... ........... .... .. ................................................ Chimney provided that the person accepting this permit sha I 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 Fina[ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI®;.t T TS Rough Service --- ...,...... , . ........................................ Fina[ BUILDING INSPECTOR GAS INSPECTOR Occupanap .Permit Required to Occupy Buildin Rough 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. The Commonwealth of Massachusetts Department of Industrial Accidents 159 Office of Investigations 1 wo 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le 'bl Name (Business/Organizationllndividual): &S T .S 1..� Address: 3 R Q Ti) IN S-1 1Z CET ON I_r 3 City/State/Zip: o. A m o v tr MA Phone#: �� lu� � �'�� Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I have hired the sub-contractors 6. New construction employees (full and/or part-time). listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp, insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' camp. right of exemption per MGL 12 ❑ Roof repairs insurance required.]# c. 152, §1(4),and we have no employees. [No workers' 1311 Other comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance CompanyName: 11 : S I I t- t4 IZA t,4 C Policy#or Self-ins. Lic.#: V V O 3 Expiration Date: 'c�3 -c�L ) Job Site Address: q`C S City/State/Zip:� +? < k0(M Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure 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 imprisonment,as well as civil penalties in the form 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 Investigations of the DIA for insurance coverage verification. Ido hereby certify u r the4 ains an penalties ofperjury that the information provided above is true and correct as Cws�s.-ems Date: Signature: Phone#: 9_7� IJ3 3qdO — Offacial use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AC� CERTIFICATE OF LIABILITY GATE{MMi0IYYY) TY INSURANCE 9�27�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, EXTENT] 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 polley(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 endorsements, PRODUCER CT NAME. SelectCONT Department Eastern Insurance Group LLC PHONE . (1300);72-4538 A1C Nol:761-586-9244 ION,�10 E0233 West Central StApngFgs.selectwork@easterninsurance.com INSURERS AFFORDING COVERAGE NAIC Natick MA 01760 INSURER A:Western World Insurance Co INSURED INSURERB,24AFFRE Commerce Insurance 34754 David Castricone Roofing & Siding Inc, DBA: tNSURERC:Granite State Insurance Co. 231 Rear Sutton Street, Unit 3A INSURER D: INSURER E North Andover MA 01845 INSURERF: COVERAGES CERTIFICATE NUMBER:Master 16/17 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE S POLICY NUMBER hdMIDDJYYYY MM1Oo YYYP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIANLfTY DAIAM E TO RENTED PREMISE Ea a wnence $ 5()'000 A CLAIMS 4ADE 2OCCUR FBA GL 2015 /6/2016 9/6/2017 MED EXP_(Any oneperson) $ 1,000 PERSONAL&ADV fNJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PE"'LAG GREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC ICT f AUTOMOBILE LIABILnYEaaaident I 1 OOQ 000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED CNGCV /1/20X& /1/2017 AUTOS AUTOS BODILY INJURY{Par accident] $ X HiREDAUT05 NIX NON-OWNED PROPERTY DAMAGE '.. AUTOS Per acadent) $ '.. $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ '.. EXCESS LIAR CLAIMS-MADE AGGREGATE $ FOEDRE�TEITION $ C WORKERS COMPENSATION TiCYTATfU- OTR- ANO EMPLOYERS'LIABILITY Y!N ANY PROFP#ETOWPARTNER1E>cECUTWE OFFICEWMEMBER EXCLUDED? 7 NIA E.L.EACH ACCIDENT $ 100 QQQ {Mandatory In NH) 003989723 /23/2016 /23/2017 EL,DISEASE-EAEMPLOYE $ 100,000 3t s,describe under DESCRIPTION OF OPERATIONS below E L-DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS i VEHICLES (Attach ACORD 191,Addltlonel Remarks Schedule,If more apace i— -E s required) ROOFING & SIDING INSTALLATION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING INSPECTOR 1600 OSGOOD STREET AUTHORUEDREPRESENTATIVE NORTH ANDOVER, MA 01845 John Koegel/I ET � ACORD 25(2010105) p 1988-2010 ACORD CORPORATION. All rights reserved, INS0251261005t01 Tho ArnRn namq ant{ Innn ora rAniafarnrl mark!:of ArORn Town of North Andover01 Bi6lding Depirtment 27 Chiu les Street 'a' } North Andover, Massachusetts 01845 iE i (978) 689-9545 Pax (978) 688-9542 '�q CG4illc 111 wlcH �naR�ran �( DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a coadition of. Building permit 4- the debris re, .iiting froln the work s1,211 be disposed of in a DfOpefly licensed Solid waste disposal facillh .is defined by MGL G11, s150a. The debris will be disposed of in tat: Facility l�;l,;akiozi Saguature of Applicant F Date NOTE: .A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Zris.pector, !-'f r :,,,».rra.•rn///r/r ll��..3a�fa.r/f, License or registration valid for individual use only . Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Registration: 104589 Type: Office of Consumer Affairs and Business Regulation a �C9 10 Park Plaza-Suite 5170 Expiration: 7114/2018 Private Cprpoiatlon Boston,,MA 02116 DAVID CASTRICONE ROOFING,SIDING 8 i David Castricone ' 231 R SUTTON ST SUITE 3A NORTH ANDOVER, MIA 01845 Undersecretary Not valid without signature ' Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-099358 Construction Supervisor Specialty DAVID T CASTRECONEn 31 COURT STREE=T NORTH ANDOVER MA 01845 Expiration: Commissioner 12118/2017