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HomeMy WebLinkAboutBuilding Permit # 10/18/2016 �.to17TF{ BUILDING PEr.vilT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION a Permit No#: Date Received �SSRCIiU5EC Date Issued: IMPORTANT Applicant must complete feall items o this page � 1 , 'c ,J c✓' � � s�� � cc,! i sky ✓ � u i�Tl3l� `` f�c YE31"�f.��1CtLlI'@ i �l$5 � :;Jr1Q MAP PARCEL ZONING DISTRI�CT�r �H�storEc'D�strmct des ono Macn:�ne Shop„1111age ye„s no 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 ❑ Septic ❑Well © 1=f0od lain Wetlands ❑ Watershed D�stnct' p ❑;WaterlSev�ier DESCRIPTION OF WORK TO BE PERFORMED' leak �iyvuq ? Identification- Please Type or Print Clearly ��� OWNER; Name: Phone: Address: Cprtractar Na e. Phone Erriail1Aff Address k` S�pennsors Construcfiton License P Homme lmprouernenLicense ARCHITECTIENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.E. Total Project Cost: $ slodo FEE: $ Check No.- Receipt No.: 1 NOTE: Persons contracting with egistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of..contractn'r Towno . � ..:�}� 6 over 0 0 No. LAKE h ver, Mass, .v_ C0 C.41CKEw1CK 7,q 4°RATe o 0r,¢,��(�3 S � BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT ................ .f ,.ov- ..._ BUILDING INSPECTOR .Y = Foundation has permission to erect.. ................... buildings ......* p ... " . .. .... .,�*.�......(.� 1 leappticati-on ) Rough to be occupied as .. .. ',r Chimney provided that the personaccepting thl permit sha in every respect conform to the terms of Fina) 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 C®NSTR I S Rough Service amp ............. ..se ...... Final BUILDING INS P TOR GAS INSPECTOR Occupancy .Permit required to„Occupy Buildinz 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. 'Fie Comuzonwealth of MHassachasetts -_• x Department aflndust;rialAceldents n f I Congress Street,Suite 100 _Sosta , NIA 02114-2017 www.mass.gov/die 5 Workers'Compensation bmuranceAffidavit:Builder/Cont �ctorsl leetrzczaiasfPZanaToers. TO BE SrILF-D VaTSTHE rBRllfl'I.'TI XG.A.UTHORI X'. pease Print Le lbl A licantlnformation Namo(Buslness/(jigariizationad:iviJ.d�ual}: Address: City/8tate/Zip: :: .:. .. . x3.: Areyon an employer?Chaekfhc appr.prlatebDx: Type of pro f eet(recluiaed) l,�m a employer with_„�_„_employees{full and/or part time). 7. ❑New'donstriio#ion 2.�1mnasole proprietororpartnersbipand.havenoemployeeswvorking fozmein 8. emOdeliri any capacity-[Novvorkers'comp.insurance required.] 9. ❑Dezn0liti94 3.0 I am a h-mlowuat doing all workmyself [No workers'comp.iosuranae required.]' 10 Building addition ¢.❑I am ahomeewner and will be hiring contractors to conduct all work on my propeY• Twill ❑Electrical xepatxs or additions ensurethat all contractors eitherhave workers'cornpensation insurance orate sole T2_[ T'liim ring repairs or additions pzopriotars with no employees. f—t contractgx and Ihavehized the sub-contractors listed onthe attached sheet. 5.❑I am a general l 3.[Rbofrears These sub-contractors have oinployees and have workers'comp.insuzauce.t 14.0 Other 6.❑We are a corpozatiort and its.officers have exercised their night of exemption get MGL e. 152,§I(4},and we have no employees.[No workers'comp.insurance required.] y applicantthat cheoks bbx#1 must also fill out the sectionbelaw showing their workers'compensatlonpo nlist s ibmit EL tion. Homeowners who submit•tall work andthm his Nd attached indirato aadditional share eetshOwing the name of the sub-contractors and statewhethr o1r til tics hate TContractors that checkthis boxm employees. If-the sub-contractors have employees,they must provide their workers'comp-policy num rt- I am an employer that is providingwor7rers'compensation in suratzee fol°my employees Below is the policy and jots site information. f (� i� �� V f"(y :✓t `7 5 Insurance Company Naxne: BXpi:rationDate- policy#or Self-ins.Lic.#:. . /t/ /yrs dl���✓' wG��� � 'R,� GitylStatel2ip: ' lob Site Address, the olio number axial expiration.date)- Attach a copy of the workers' coxnpepsation policy'declaration page(showing h p olatiol,punishable by a fuib up to$1,5 00-0() Failure to 86CY7re coverage as required under MGL §he f's of O1'mWoRx ORDER and fine oof P to $250.00 a and/or one-year'impxiso ament,as well as Divi penalties in sta#ement maybe forwarded to the Office of Znvestlgatians of the DTA.fox insurance day against the violator.A.cagy ofthis coverage verifleation. Ido liereliy cert er thepaixs andpenalties of pe11 ry tliat ibe infa�7nation provided al ave is true and,car rect. - Date; Si ature: 7 �l`J` 77� Official use Drily. po Prot write in this area,to he eampleted by city ax to official • permi�tlLicense# City or Torun- issuing A-athoxaty(circle one): E �.Board ofl�ealth 2.Euildingl)epaz•tment 3.City)TOVn Cle'r1 4.LilectricalZnspector 5.Pluxnbixtgxnspectar 6,Other Phone#: Contact Person: OP ID:GOGL '...,. DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 08/2412016 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(ies)must he 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 Phone: 978-688-6921 N'DMNE cT Hannah Courtemanche,AAI,CISIR Macdonald&Pangione Insurance 104 Main Street Fax: 978-688-5350 Axc No): 978-688-5350 North Andover,MA 01846 AODAIEss:hannah@mpins.net Donald Schemack PRODUCER CUSTOMER ID#:DGCON-1 INSURERS)AFFORDING COVERAGE NAIL# INSURED D G Contracting,Inc ID 646648 INSURER A:Travelers Prop&Casualty CL 25674 428 Pleasant St INSURER B:Safe Insurance Company 39454 North Andover,MA 01845 INsuRERc:National Liability&Fire Ins INSURER 0: 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 ENSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERN! 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. !NSRTYPE OF INSURANCE D L R POLICY NUMBER MMInUY EFF MMIDD EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 680-15531118 05/17/2016 OS11712017 DA A ET R NTEU 300 000 _PREMk5E5 t=a occurrence , $ CLAIMS-MADE [X OCCUR MED FXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 POLICY X JCfPRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) ANYAUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Peraccident) $ B X SCHEDULED AUTOS 3116538 07112/2016 07112!2017 PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NDN-OWNED AUTOS $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,00 A CUP-0090153321 0611712016 05/17/2017 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X TWC LATU ER AND EMPLOYERS'LIABILITY C ANY PROPRIETORIPARTNERIEXECUTIVEYNIA V9WC704542 03/3112016 03131/2017 E.L.EACHACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,01)0,00 If yes,describe under DESCRWTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000,00 A Property 680-1553818 05117/2016 05/1712017 LsdlRent 20,00 Equip DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if mare space Is required) Fax: 978-688-9542 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 ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Dept 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover,MA 01845 O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD Oro �(bM1'Yll � 11� A1113 1 sR YALE # _:sECr# fl 6'f 'Dg uw k fID T'VLiI1:'.G�Z1M11� 3. ST � „ PLEASANT NgFtT1 ANDOVER IVI � DAVID] GULEMAIN a 2$�'' N'T$T �hAIc 98432 _ _