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HomeMy WebLinkAboutBuilding Permit # 11/21/2016 O� t%ORTH "1 BUILDING PERMIT ,&D .b•��'a TOWN OF NORTH ANDOVER . APPLICATION FOR PLAN EXAMINATION Permit NO: � Date Received Date Issued: I t acHus IMPORTANT: Applicant must com fete all items on this page LOCATION "rlrit; PROPERTY 0, r1ri MAP NO F CS : � �Il � I �STRJCT:, Historic District' yrs lachind$Foo'Village, yes TYPE OF IMPROVEMENT PROPOSED USE --- Residential Rion- Residential New Building ne family Addition ❑ Two or more family ❑ Industrial -Alteration No. of units: ❑ Commercial ;i pair, replacement E Assessory Bldg [.l Others: Demolition I] Other Septile, 0,Floodplain Q'Wetian s € Watershed District 'd'yiP teds wdr 4- � � � 1 , Identification Please"Type or Print Clearly) DWNER: Name: 1_ Z_, 14.7 Phone: '° � Nddress: � . 1 CON TRACTOR N � Phohe: 2524 Address,., $pp risr'S CfriuctidLirsea Date: Horne Im royern nt License, E cDate" ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925'.00 PER S.F. 1 r ... Total Project Cost: , FEE: f Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Ag nt/O ner � ure,of contractor2LAI ................ .............. ...................................... ........................................................... ............ Town o : {;_ Lndover No. 0, a� 'k 0" LANE J h ver, Mass, Ab COCHIC"JW... ,VnE D 01 U BOARD OF HEALTH PERMIT T Food/Kitchen Septic System THIS CERTIFIES THAT ........rJr.$q.f4 0.k G a LD ... !!.!4................................... BUILDING INSPECTOR has permission to erect .......................... buildings on .,... (f.Q....... Foundation 4 ............. to be occupied as ..........QP.#F(4 . ...... Rough .. .......... . &...................... ......... f!! b" provided that the person accepting this permit shall in every respect conform to the terms of the applications. Chimney' F on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and inal 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 TS Rough Service ' BUILDING INSPECTORFinal GAS INSPECTOR Occupancy Permit RCquired to Occum Building 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. PAdamsPART Carbonless PROPOSALMINIMUM MNNNWMMWNM: iii:: NONE= pJ3fdsIM--No _ h � i sF14 i+y0 DATE ' PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: - - , - -:�-'�Ufa ..t,s�.:•r,�, � �" ��°,s. �� .�.�.�. �.<� - '. ADDRESS s r � DATA qF READS PHONE NO, ARCHITECT. `" ,�,"i f - ..- "_ s w.:;, ,e' r: �s� z� :,{..���'��w✓,�` �a 13�",,� +a''�i s-,.%y4�'��..,.e ,'�`� � �- 1R+e ftereby pr�� �;t:��tts�t��I�tn�ter��l�aid p�rfcsrrrt-t-be labor n�e �sy hof'��x;�� ���r '`-. �_ .�,.: . .,, ..;,,�°..n�.�.'s'. � nary✓'-_.".��"�" .::::. a ...:.: .. ...:...a... . :. :.a,..�.�N - s.��"'�s _^c:' _ - v - '-;v5 .:�". ... .-' ..��'.:� ��� ,�.�..4:�i.,�V�'���.�..,....-. .a.�GrCAY Y .f.n �-...r � >�✓. ,';�� _:c ersim , ,r' -7777 r ri f� A All Material is.gttaranteed to be as specified, and the,above.work to be performed in accordance with'the drawings and specifi- cations submitted-for:above work and completed.in a substantial workmanlike manner for the sum'.of 7�rI�' �i✓'P �y�c%��� `Dollars ($ with payten#s to 1?e trade as follows. Respectfully submitted— Any ubmitted Any alteration or deviation from above specifications involving extra costs will he executed only upon written order,and.will become an extra charge Per over and above the estimate.All agreements contingent upon str€Ices,ac- cidents,or delays beyond our control" Note=Thisprod al m withdrawn by us if notepte ithin days. �1CCITl'7ANCE '.'bP�SAl� The above prices spectfloatlprls acid conditions are satisfactory,and,.are heby accepted' �t ate authortzetl oto d0,1 he vuor•k i as specified.Payments Will•�e rt�ade as of tllnetl al�ave:- Signatur. Date 1� Signature---- . Tlae Conxmoitwealtli.of Afassa.Clzu z -= Departftient of Industrial Accidents = Office of Investigations 600 rulas�i.i� oli ;Ca1ree 1 Boston, MA 02111 w}1m1 mass,golt/dia Workers' Compensation Insurance Affidavit: Builders�Contraetors/Eleetr'icians/Plumbers Applicant Information 11 Please Print Le ibl , Name(Businessiorganization/Individual): Address, 5evl7�A is y 4— City/State/Zip: Sc, �/ /I A/ 61307 Phone#: e 4eI3 PY4 4v 7 Are yo a employer? Check the appropriate box; - Tape tff prisjezit(i'equia ed): 1• I aemployer with �? 4. ❑ [am a.general contractor and•I employees (full and/or part-time}.* have hired the sub-contractors 6, []New'construction 2•❑ I am a sole proprietor or partner- listed on the attached.sheet [7. ❑Remodeling ship and have no einployecs These suli-contractors-have g, ❑Demolition, working for rine in any capacity, �mplayees and have workers' com insurance. g ❑Building addition [No workexs'�comp.insurance P' required.] 5. ❑ We are a corporation and its ' 10.❑l3loOrical repairs or additions 3.❑ I am••a homeowner doing all work offieets have exercised their 11•❑Plumburg'mpairs'or additions myself. [No workers' comp, fight of exemption per MGL . 12 Roof repairs insurance required.]l e,152,§1(4),and we have no employees:[No workers' 1 •❑ Qtlrer , 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 workand then him outside contractors must submit a neVaftidavit indicating such. tContractors'that check this box must attached an additional sheet showing the nalre of the subcontractors and state whether or not those entities have e€nployees, If the sub-contractors have employees,they must provide their workers'conip.policy numben lam an vngth er Mai icprmmin'rg irmk'as'compensation insurance for rosy errcployee�. Belo}ti is t/aepolicy andjoL sire itzfortnation, Insurance Company Name: Policy#or Self itis.Lia. r 3 d f _ Expiration Date,, J Yob Site Adchess:__-/ City/State/Zip: Al, 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 ofAIGL 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 M 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 iris statement may be fore.Hided to the Office of investigations of the DIA for insurance coverage verification. T do laerel�y rer fv r rtdpi.tfre pains nrrd aides ofp w/j,that the Y'-Anwation provided above is rme a-d correct. Sign To: Date: /f /Z A� Phone#: Official use only, Do riot write iia this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3, City/Town Clerk .4.Electrical Inspector S,Plumbing Inspector. 6. Other Contact Person: Phone#: �"a,«r�.x•.:.,.r'��'�� ::;_•xyf y�-�- .�-f'.%:i��cwi-f"��.:ySz'�...-a�.:��:a{�,Wi�ts'f.`,�,,,' l,ra,};'.s�.!�.`5.. 'n�='`43.�..�•�. ?�� ar _ �.ry' :'"'rte.?•k•:�':�':_ ;..+s.::�:>'.. 7EjIMMjDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE /18/2016 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 have ADDITIONAL INSURED provisions or 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 CT Jim Lafond R.C. Lafond Insurance Agency, Inc. PHONi FAx 396 Andover Street c o E . 978-68fi-3826 Arc No):978-682-0713 North Andover,MAO 1845 ADDRESS: jlm@rclafond.com INSURER 5 AFFORDING COVERAGE NAIC p INSURER A: The Main Street America Group/NGM INSURED NH Sunrooms&Conservatories, Inc. INSURERB: Liberty Mutual Insurance Co. Frank J. Rullo 40 South Policy Street INSURER C: Salem, NH 03079 INSURER D: 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 BEEN REDUCED BY PAID CLAIMS. INSR I POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDDIYYYY A COMMERCIAL GENERAL LIABILITY MPT1284R 02/11/2016 02/11/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 71 CLAIMS-MADE Q OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO El LOC PRODUCTS•COMPIOP AGO $ 2,000,000 JECT OTHER: $ t3 AUTOMOBILE LIABILITY B1T1276R 02/11/2016 02/11/2017 COMBINED SINGLE LIMIT $ 500,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Por ac'dent UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC-31S-605215-016 06/01/2016 06/01/2017 STATUTE °RH AND EMPLOYERS'LIABILITY Y I N ANY AROPRIETORIPARTNERIEXECUTIVENIR E.L,EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? I Y1 (Mandatory In NHI E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES {ACORD 101,Additional Remarks Schedule,may be attached If more space is required] Operations usual to the installation of sunrooms and conservatories. Corporate officers excluded from workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Inspector ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall Main Street AUTHORIZED REPRESENTATIVE North Andover,MA 01845 ooi��. �. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 3 fGGGIL dP� .hdCT6U4P, 1 (;Fill �QO)7A/709lCOE office of Coesumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration 100290 TYpe' Explrat�on_ 6�i5�2018 Private Corporation RLILLO CONSTRUCTION} E01r INC ', Frank Ruilo 14 Stonepost Rd c,,J ""'—"— Salem, NH 03079 Undersecretary ublic SatgtY De�a�tTf o aid Standard uses- Mations Massactl ualding goaK �, rt�act 43156CS I eose. Y � y� •l �4 Sx 439`'� -=` �Xptration 1 ��,,m�`y5forisY