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HomeMy WebLinkAboutBuilding Permit # 11/28/2016 BUILDING PERMIT of TOWN OF NORTH ANDOVER } h ,j Y6 APPLICATION FOR PLAN EXAMINATION ${{q L permit No#: 9 ® Date Received i� 79�flR gTn fYR�{ `� SRcous� ©ate Issued: L� t ORTANT:Applicant must complete all 'items on this page LOCATION �. � �� Pnnt - Pnnt 1�p Year Structs�re : es j1lfAP _- PARCEL ___ ZUNING``DISTRICT _. Hrstartc Ditr[ct yes h Machrne 511op V[Ilage; no., TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 1`One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial �1 Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other I Septic ] 1Ne[1 q lloodpla[n ❑Wetlands ❑ Watershed'D[strrct FI OW/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 1���F✓' - -� �.?�!'S�"!K .S`Z=� Ic �� �..- +'!�s�-�`C ��1r -�'Pc-� o-�' C1 erG.C� C,yl�. 3�1 �"" �'�C H i}�C�'U r^�� •�e r�. �tS• �a\ d' � f�C� U ('r tj- 04 br'd.f4- f�c.�-� �G� ["! p¢�e 4 �- Identifiication- Please Type or Print Clearly OWNER: Name: Iz Ate, s�� Phone: Address: Contract ar: Name: r �5c.� Phone Address:. . . :.__.. - Supervisor's -bnstruct[on Lrcen.s. ' l ;. �.- Exp.'' Date ARCHITECT/ENGINEER Phone: Address: Reg. leo. ,GEE SCHEDULE.BULDING PERMIT.$12,00 PFR$1000.00 OFTHE TOTAL FSTIMATED COST BASED ON$125 00 PER S.F. [, J "® aI Project Cost: $ �, C� 5• '� FEE: $ - Check No.: Receipt No,: -- NOTE: Persons contracting with urare isteFecrr contractors do not have:access to theguxccnty fund 5`ignaiae af.AgentlOrvte.r' Signature of coritracta 'T F �QRT own of 1Andover O - 0 AF No, �4— �, �� . i .R* h ver, Mass • �F a l�� 9 comicNlWICK 41' 04ATED rPK U BOARD OF HEALTH PERM L D Food/Kitchen Septic System e .!..!..... .. QJI`r�.... '^• Ir ,{/� BUILDING INSPECTOR THIS CERTIFIES THAT ...........+. .R.....,..... """ ....... ..., .. ............ buildings on Foundation has permission to erect .......... ....,...... ..,...... .. ........ �.. ................... Rough tobe occupied as .............. . . .' .....d ..,... ... . ...... .. .,........................................,................... Chimney provided that the person accepting thi 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI N STA Rauh ., ..................... Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy 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. Roofing, , 3 Forms way Phone# 978-774-8111 Middleton,MA 01949 Un iplyroofing@comcastmet Iaax# 978-750-4888 NAME/ADDRESS PROPOSAL Keith Thompson l _,.. __._..... _.,w.._. 2 Berry Street North Andover,MA I DATE PROPOSAL# G f�� 11/2/2016 W� 2874 DESCRIPTION TOTAL New roof at above address: Roof is approximately 1,200 square feet: Metal roof(roof must be leveled by owner in advance): $6.50/ft $7,800.00 Asphalt shingles, 30 year: $5.35/ft=$6,420.00 New fascia c&gutters: 80 lineal feet of gutter: $1,440.00 80 LF fascia(1 x8")and 80 LF drip board(10")@55.75/ft=$460.00 60 LF rake board (1x8")and 60 LF of drip board (10")@$5.75/ft=$345.00 Cover fascia with bronze metal The specifications,prices and conditions are satisfactory and are hereby accepted, llni-Ply Roofing,Inc., is authorized to perform the work as specified, Payment will be made as outlined. Signature Final Pay ent(due on completion) 8,665.00 plus metal over fascia 0.00 TOTAL I i I $81665.00 i The payment schedule associated with this contract shall be strictly adhered to during t"gZe! course of this project. Any deviation from this schedule without sufficient cause (i.e. led,I-s fr^oin the re-roofed section) will constitute breach of contract and the project''will be shut down until resolved. Invoices are due upon receipt. 11129/2016 Google Maps Uoogle s \\ gggggw- 0,01511 . NMI \` Imagery @2016 Google,Map data 02016 Google 10 ft https://www.google.com/maps/a@42.6357926r 71.0700332,43m/data=!3m1!le3 1/1 Ine Uommonwealtit of massacitusetts -„ "- Department of lndustriaLAccidents 5"r i._ ttr1 Ojjice of Investigations r ' I Congress Street, Suite 100 Boston, MA 02114-2017 - -= www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/ludividual): i Address: 3 nok is CA-/ City/State/Zip: Itc{�� tl ote14 ((f Phone #: cI -7 yI&N Are you an employer? Check the appropriate box: Type of project(required). 1.D�I amt a employer with_12= 4. ❑ 1 ain a general contractor and I have hired the sub-contractors G. ❑New construction employees(full and/orpart-time),a" 2.❑ I ani a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ DemoIition working for me in any capacity. employees and have workers' corn insurance.t E] Building addition [No workers' comp. insurance p• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4), and we have no employees. [No workers' 13.0 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. +Contractors 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 worlt:efs'compensation insurance for my employees. Below is the policy and jab site information. l' Insurance Company Name: `I `"'�� SC.y4.7Ce- Cd` Policy#or Self-ins. Lic. #: C G 33 S Expiration Date: 2- t"7 Job Site Address: tl tU. _ 13er y 54 City/State/Zip: 4), A-0( eOL r-- T 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 iniprisomuent, as well as civil penalties in the forth 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. I do hereby cet if a erooains andpenalties of er'ur that the in orrnadon provided above is true and correct. Si nature: Date: Phone#: -:07-7,f—4('7, - 1Ge y Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/I icense# 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#: A�® CERTIFICATE OF LIABILITY INSURANCE bA7E(MM10DlYYYY) 11/28/2016 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(ies) 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 endorsement(s). PRODUCER CONTACT Laura Wiesner NAME: C & S Insurance Agency, Inc. PHONE Extl: (508)339-2951 FA(A/CX ":(508)339-4911 190 Chauncy Street/P.O Box 406 _4DURIEss:laura@candsins.com INSURERLS},AFFORDING COVERAGE NAIC# Mansfield MA 02048 INSURERAAcadia Insurance Company INSURED INSURERB:Star Insurance Uni.-Ply Roofing Inc. INSURER 0: 3 Forms Way INSURER D: INSURER E: Middleton MA 01949 INSURERF: COVERAGES CERTIFICATENUMBER:policy Synchronization 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. NOTW€THSTANDING 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. IN5R TYpp OF INSURANCE ADDLSUBR wvn POLICY NUMBER MMIDDNYYY PO ICY YYY LIMITS L X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE �OCCUR DAMAGE TO RENTED $ 250,000 PREMISES Ea occurrence CPA0074506-24 2-15-2015 2-15-2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POL€CYJECT PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY accid COMBINED SINGLE LIMIT $ 11000,000 Ea ent) _ A ANY AUTO HAA0074476-24 2-15-2016 2-15-2017 BODILY INJURY(Per person) S ALL OWNED X SCHEDULED BODILY INJURY(Per accident) 5 AUTOS AUTOS ----- S NON-OWNED HIRED AUTOS X Pena cdent DAMAGE $ AUTOS ---- $ A X UMBRELLA LIAB X OCCUR EACH OGCURRENCE $ __ 1,000,000 EXCESS LIAB CLAIMS-MADE COA0074507-24 2-15-2016 2-15-2017 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ B WORKERS COMPENSATION X STATUTE ORH AND EMPLOYERS`LIABILITY "ER ANY PROPRIETORIPARTNERIEXECUTIVE YIN N!A WC0719335 2-26-2016 2-26-2017 E.L.EACHACCIDEN7 $ 500,000 OFFICERIMEMBER EXCLUDED? LN1 (Mandatory in NHI E.L.DISEASE-EA EMPLOYE $ 500,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACQRD 901,Additional Remarks Schedule,may be attached If more space is required) Project: Keith Thompson 142 Berry Street N Andover MA 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 120 Main Street: ACCORDANCE WITH THE POLICY PROVISIONS. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE Laura Wiesner/JAS 06 ©1988-2014 ACQRD CORPORATION. All rights reserved. ACQRD 25(2014101) The ACORD name and logo are registered marks of ACQRD NS025 rent aryl) \\ Massachusetts _Department of Public Safety Commonwealth of Massachusetts Board of Building Regulations and Standards Department of Public Safety I.i'3 r,11r'.b4,rr4 t , r" 's:)1 �9�r �i�v' License NE,-076413 License: CS-084282 KEVIN CA.WL C9 S ��� �' KEVIN A CAMPONESCKI 3 Norman Road 3 NORMAN ROAD Reading bM 01867 �� ; 'READING MA 01867Expiration Commissioner 02/04/2017 1 Expiration: Commissioner 02/0412018 Office of Consumer Affairs&Business Regulation Ucense or registration valid for individul use only IMPROVEMENT CONTRACTOR before the expiration date, If found return to: elk ➢^' r l`t Registration: 140376 Type: Office of Consumer Affairs and Business Regulation Expiration: 10128/2017 individual 10 Park Plaza-Suite 5170 Boston,MA 02116 I' KEVIN A CAMPONESCKI KEVIN CAMPONESCKI 3 NORMAN RD READING, MA 01867 un - — Jersecretfiry Not valid without ' nature gtEOICALEX'W11NEn's CEM1T1p1CATP " '« � "" ^.� I I '' ttwnftonr�lU CFR I91Af)f}A91 SNIIA Imab gb flAnar➢ anrin.l find tp4prm q in drp dl ff rpplimWgbalPn hml Larmrr 1p.. 1. .L.:+n<: IA eta �NEW ydL�yqs ap Ia m pini p 1 r �d TT HEU 'E'T' '"Rl ��IV � pan ryntN4� � pdrhinb p.hhla an urwpll I—.... 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STATE ��/ �� AnnttoFnn➢vErs ONo wee l 1� 6 N ANf, jai 3 NORMAN RD orf READING,MA 09887.2744 9 .M1IE0IC,LCEOTIFICATION E7U'IRATIO4UATI: ! s OD4LOti•2015R6Y07.1"r•FI09 Off!�7�/�''