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HomeMy WebLinkAboutBuilding Permit # 11/30/2016 NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION Date Received 1 1 ' ' yy, �RATPD Permit No#: �ssaCHU��� Date Issued,—Ii __ a IWORTANT: Applicant must complete all items on this page LOCATION ��Or le " Print PROPERTY OWNER Jan C- ���r^' Prin 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT. Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building W-CMe family ❑Addition ❑ Two or more family Li Industrial C�fiferation No. of units ❑ Comm rcial ❑ Repair, replacement ❑Assessory Bldg ❑ Demolition ❑ Other F O Septic '❑Well �� ❑floodplain ❑Wetlands ❑ 1lllatersned District ©ESCRIPTION OF WORK TO BE PERFORMED: Identification- PIease Type or Print Clearly OWNER: Name: Phone: 79-1- 2�Z'��7 7 Address: t'/ 4eell Contractor Name: � Cl �� l Phone: Email: Address: Supervisor's Construction License: $-7 17 7 Exp. LH,me Improvement License: it,Z-0�7 Exp. Date: ARCH ITECTIENGINEER 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: $ 3000 - - FEE: Check No.: 108 Receipt No.: � I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund . own of A 0 No. to _ 9 (� h ver, Mass _ p'Q COCMIC emcm 1 RATED 0¢'�(y S U BOARD OF HEALTH Food/Kitchen PERMIT D Septic System THIS CERTIFIES THAT .. 11� .. , +r� ., BUILDING INSPECTOR has permission to erect ................... buildings on ...... .j. .... .,, ,..,....,......:..... Foundation . .. % Rough t0 be OCCUpled a5 ....Ar .. ..., N � .. .. .... . ....,*. �.. chimney provided that the person accepting this 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 In tion,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 CONSTRUCT ....,. .S...T... RS Rough Final........ BUILDING INSPECTOR Service GAS INSPECTOR OccupancyOccypancy 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. �isfotmsatis&tsallha5icrequiremmfsafUtnslas�TnmcTmpmvcmcntCantractarLatitr C�. guaEnpratehameStrts 5selcteadvieeuAec¢ ury.Aaypetsanplanniaghmneimp;ovnlenlss[onlddfitsCablaivaaapyaf A� duset;sConstrmerGuidebiIama�provamnentnbefates i�tglannywnr3,an otalesidertce Yattms obtain ttfibtp Ok cevPCoasumerA#�y;aac( a Re$uigtiau's�ansttraex3nfotiv ion Hatllneskfil7.9733757ort-QQQ� pyb`m&gthe �pmeor er o aEen 2M3757oronourwebsile: Name on tmetorlF31<OR737811(3£3 .$ CotnpaaylVmnc Strer:triddr�.s(do tuseaPastptfiaa8a�dr�) I� ContlaotadRel suer. atao CitylTots t �r tot e .AvAue dav-�c p °iii_ »nit n�at�s(tt�t 970 Day4irnePhoae _ 8:m�tiiigphann ' _ 73 Cihj"uwa state Zigcode t�tailins Adbrr;s(Etdi&'creRk front above) Basine�pioae Fcd:mt feierlDorS.S.Numb� t- tFt�tmr�:tI—nL trni NY�tanrrstanL••ro ���] r/� �+ �I��l ' TheCantracioragva2iltodothe folloWIigr,vt'.r:Aur Ede s alutw�Ttet: (D=nbe ire dvaR dlauntk to completed spcifytag the typ;tuantt and grade of����trz uisd,oscnddhienalsheetsirr era_) Regtttred Perm'�-Tiiefolfntvingbuddmgpsa�mitsarerartafttrtl I�anosczi�izu'rand aTd tviA bo6ecnred by the CGRdiietaraS ttICI10ED2C0YrIla'i'S S�etlt' baadheted to tmless��a�oa si�edate-I'hefallarringsoheduletr+r�l ( ern(lMWhOReCEIrethou•fl�r jyt a�c`5triT1s circtanstastnesbeyondthe contractor'scoeb-aiarise e�e�ucle�k'rasa���Et13sa�€�Frzmt���x�tZ�os @ter g'4^-i ) Date nen eanitactartrilIbegincannactedloud Datelvllea contracted work will ha substantially completed. Total%ontmet Price and?agtacnt�raer3txie The Contractor agrasstopfio;mthe tvarl:,fmnlstt}temateaalrmdl arsg:citiBdahavefa;tbBto fnana r— �a) Fmmtenlsvri116em2tteaccardingtatnefnLlatrrin�sckedale; 3 upon sifPEUS couh=(nut to exccrd 113 of the total contract priaz nr the costnfsptcialnrdaritems,tiNtbumr1sgm-w r? -— by 1 ! or upon cempleYan of S by! _upon completion of 1 �� S�epaoeamplationaftftcanntrxct. f�� CEmvfoiittdsdrmandrag.fultpymeutonEi caat,`ie:;sc m lelecitnhalh 'feefolfca3rt p pariy'ssat(sFection} 5saatesiallttiamrntmaslbsapacial S to „idf r orddbefottihewntsa- teuzd �att b3inc[der le meet thn eampl4onschedule(oa) S bo i far Idti a rs:()InctuuiR,ell Frnanrw.rA�(�=f Ia�rirgnirs ifr,[err d oatn=dsthaelten of(a}aaalitradre Y epcaitardoxu• hgnsMay utOcaar(b)ieactual cost aFanS6A kl”4a+Amentarcuaaadon2ler inEgenieTmwt6a, _catOrderdietome:ttheamltedonscltcduh 5rn 1rr:rrr:rn( -rA ane srsnrrani h^irtsr ravtdndtr:ttzeeaR----tnr2 i\n Y nSlfe-Utz:arthccvnr.Rntvmtrilraa:tac]tccltnEiteor Int 1 Stihcunsctot5-1ltecaalracoragzccsto6esnlelyrrtlnnstblefa:-cvmpAction a:thet�ur q[acrifiadr part;lsubennf;rtatorutil .4 bytileeOnLacor Thacnntrcrorfiirtfiara t z:�dl=0, lheacdowofmyam tateri�}sartdlalrartutdcrthis rr�eama t ar,.rsto4CSolelyrspOasioleforallpnym©]s 10 all sttbanatrac�orsfor CanractSL cspinnc _Unaasignutg,adsdomlzentlseculfltsabiptiitlgenntrnBtund [ate UnitssotErenrisanoted tti#Linthisdocument>be cattttacts oraretimplytltsccu eonrotbctsectrit},ittie ,fib b 012 anrhBr idcttce Rcviatvtfiefalla►vingcaaEinnsandumir careft3lly UcFara signing this cantract. i?aa't l e prassutt d Cato signing the cantsnct Talre time to r,,ad anti fully ttnderstond it: M,,questions ifsomething is ttnclt�r. a itFnitBntrelLocanu cont' savali liatnuIttl rnvamentCnnlraclarP, [ration. Taela^tsnag[aresmnsthomaimprac+smaaEcvntras[orsantl snbsantr dors to be scgistcrerl vritb thaDimataroffdame registration byxa�(iogto theDin+»tornt tO Par c Pl ant Cantrzatari gish�tiera you n-Iz,inquin:Ahput conimaior l7o s 31te contraBlor it ase ittsttraacc? 1Zoatn 517Q,Ba;#ory AIA pZ1 p6 or Is}�e3Wag 617-973-8787 or sell-243-3757. seeacor afau AslsthOCan[ractarfarltisinsantnwRtpnnyinfvrmntiansnttuyonr�rtcottfrrmcnvcagB,oras to 1Y 7rvafafinsll_*anr^daskihet I tIdetotuRom bmrwpaasi6ilitirs.Reade§a Lnpatfontlnfura>uiaannthe rcvetseSide ofteasformand get acopy aflhaCoasamcr Guide toohosiaaleIt;lrovaatcntCoatract dLhex Etbird nt a nrel Zis 3°rctmeatifithrsbesgaecla€aplacentlteribanthee3atreial'snaanalplaeoofbusin metar in xritittg atluJher main o cn nr Inuch office try oTdinsry[hail pa w,b tele- grotndad you noiii}rthe tltl5inrssday:a310tvin;ythC min afihiSaSre ant SwtLcmrc Y -M=seatorbydellvay,notlawtbnnmid4ghtoFtha shed ndttaO aPcaaeellatiott foam for an c1 ltmatzan o€3hls riiL ii ytl ?Q�ii1* ,Z' aJr i 5 ^ T Z'r,n id^L;.1�piwar:i:c ?`='-A - �I, ;"r Ei`ARIMt'AMI�b'LAIMP-'iSPACE,8... eprr��cat4eca:�fa;.;1:.�3�5�-O�rnFt':1a�S-u t�lt;at:n'n» 'FBect'^.s 4 Ip �4ptb .ec HontL t tVA Wa Strttaittre COnt acto,SSimattttr 1 lam+t6 The Commoizwerzltla of Massachusetts Deparnaent o I;aclp8slrarzlAeclarents t 0ffice of h2vestigations 600 W aslzii,gosz Street Bo ion, 1 M 02.1.11 S wwiv.$;ass govldM Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibi Name (Business/Organization/Individual): 'M LKI Address: 37flcn VI1, 111970 City/State/Zip: Phone#: 17 7,�-' 7/M~ E—'lly Are yoti-i employer? Check the appropriate box: Type of project(required) 1.❑r' atn a employer with� 4• ❑ 1 am a general contractor and I employees (full and/or part-time),* have hired the sub-contractors E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. F-1 Demolition working for the in any capacity. employees and have workers- 9. ❑ Building addition [No workers' comp. insurance comp. insurance.- ZP required.] 5. ❑ We are a corporation and its l0.❑ Electrical repairs or additions 3 i❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself, [No workers' comp. right of exemption per MGL 12.❑ Roof r pairs insurance required.] c. 152, §1(4), and we have no employees. [Ni o workers' 13. Cher Sri/ a� comp. insurance required.] 'Any applicant that checks box m1 must also fill out the section below sitowing their workers'compensation policy information. Flaiueoceners who submit this affidavit indicating they are doing all worts and then hire outside contractors must submit anew affidavit indicating such. tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp_policy number, l alll a;l elllpl0ye1'that is proviriilzg fuol•iret's'colrrpelzsatiorr litszti'atzce for lizy errrployees Below is the policy and job site hifibrination. Insurance Company Natne: v(4 P"7 G Policy T or Self-ins. Lie.#: 2 2'7 0 Expiration Date: 31Z_0 ) 7 Job Site Address: e r 1$ City/State/Zip: Attach a copy of the rvoa iters' corriperzsation po]icy declaration page(showing the policy number and expiration date). i Fai lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to 51,500.00 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 I nvestigations.of the DIA for insurance coverage verification. I do her-eby cer-t// P azlz(lei,the pahis and pen a[ties of petJiiry that the Nfortuation provided above is trite[111d correct. Signature: (( ! Date: /! Z Phone r: 7W - d7 y Official Ilse Only. Do not write h?this alert,to he completed by city or town official. City or Town: Permit/License# Fssuino-Authority(circle orae): 1. Board of jlealtb 2. wilding Department 3. City/Town Cleric 4.Electrical Inspector 5.Plumbing inspector 6. Other ' Contact Person: Phone#. AC C>RhPDATE(MMIDDIm Y) CERTIFICATE OF LIABILITY INSURANCE 3/9/2016 THIS CERTIFICATE IS ISSUED AS A MPTTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVPLY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSU�ANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder isan 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 endorselment(s). PRODUCER I NAME.-TA AME CT Construction Eastern Insurance Group LLC PHONE ($00)333-7234 FAc No: 233 West Central St i E-MAIL A ESS: INSURERS AFFORDING COVERAGE NAIC# Natick MA 0176 INSURER Arballa Protection Ins. CO. 4x.360 INSURED INSURERS Nautilus Insurance CO Atlantic Weatherizati on INSURER C. 61 Rear 4Tefferson Avenue INSURERD; " INSURER E- Salem MA 0100 INSURER F: COVERAGES CERTIFICATE NUMBERMa.ster 2016 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 PQLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCEFID0 POLICY EFF POLICY EXP WVD POLICY NUMBER DD MMIDDIYYYY LIMITS GENERAL LIABILITY EACH CCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY I A E O RENTS PREMISES c mance S 50,000 A CLAIMS-MADE OCCUR 500042616 /20/2016 /20/2017 MEDEXP(An one parson) $ 5,400 X CONTRACTUAL LIABILITY PERSONAL&ADV INJURY S 11000,000 X CG0001 10/01 FORM GENERALAGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,000 POLICY[E PRO- LOC j S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee a 1,000,000 A ANY AUTO BODILY INJURY(Par person) 5 ALL OWNED x SCHEDULED 1020015871 /20/2016 /20/2017 AUTOS AUTOS ] BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accl%t S PIP-Basic S �( UMBRELLA LIAB }C OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB CLA€MS•MADE AGGREGATE $ 1,000,000 OED RETENT€ONS 10,00 i 600058689 /20/2016 /20/2017 S WORKERS COMPENSATION &=.I 1VC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTiVE YIN 1 OFFICERIMEMBER EXCLUDED? N I A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S B POLLUTION PL200378619 0/1/2015 0/1/2016 EA POLLUTION CONDITION $1,000,000 i GENERAL AGGREGATE $1,000,000 DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES{(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) �I 1 CERTIFICATE BOLDER 11 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OE NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE 9 John Koegel/SME ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved. INS025 f7ntnn�f At The nt-.11 Irl nama nnA Inn^mra rank*&md marka of Ari')Pn ••••. c I c yr c U-LLj QP 'a .[.'Y ori t-r+vr. 61VV6 rax otil,vt l- V I CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY1 7(;ERnF FICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS E DOES NOT AFFIRMATIV LY OR NEGATIVELY AMEND,EXTEND OR ALTIER THE COVERAGE AFFORDED BY THE POLICIES BELOW.. ICATE OF INSURANCE Do s NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHDRIZED REPRESENTATIVE ER THE CERTIF TE HO R. :If the certificate holder is n ADDITIONAL INSURED,the policy)les)roust be endorsed. If 3Ui3ROGATION IS WAIVED,subject to the terms and conditions of the policy, ertain policies may require and endorsement. A statement ort this certificate does not confer rights to the certificate holder in lieu of such end rsement s . PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 W CENTRAL.STREET (AIC,No,Ext}: (AIC,Not: E-MAIL NATICK,MA 01760 ADDRESS: i 22MLW MA: AMIMICAN ORDING COVERAGE NAIL# INSURED c RICHINSURANCECOMPANY ATLANTIC WEATHERIZATION L.L61 REAR JEFFERSON AVE SALEM,MA 01970 ! INSURER E: j 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 OFANYECONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY REISSUED OR MAY PERTAIN. THE INSURAHCE AFFORDED BY THE POLICIES DESCRIBED HEREIN r*SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- E INISR ADP SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER IRMDD%YYYY) 1341hM umyyWl LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S CLAIMS MADEEj OCCUR REMISES(Ea occurrence) I MED EXP(Any one person) $ EGEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY $ENERAL AGGREGATE $ POLICY PROJECT LOO RODUCTS-COM PIOP AGG 8 AUTOMOBILE LIABILITY I COMBINED SINGLE $ ANY AUTO Lr14fIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) I PROPERTY DAMAGE S 0 {Per accident) I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE �� $ DEDUCTIBLE $ RETENTION $ I g A WORKER'S COMPENSATION AND i i XWC 57'ATUrORY OT}-IEFi EMPLOYER'S LIABILITY WIN U13-611270121-16 03/2012016 03/2012017 LIMITS ANY PROPERITORIPARTNERrEXECUTIVE NIA E.L EACH ACCIDENT S 500,000 OFFiGGRIMEMBER EXGLUDED7 (Mandatary in HH) F.L.DISEASE-EA EMPLOYEE $ 500,000 IF YES,describe Under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONBILOCATION$tVkHICLEeSIRESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTMCATf3 ISSUED TO THE CERTIFICATB HOLIER AFFECTING WORKERS COMP COVERAGE. j II 1 CERTIFICATE HOLDER i CANCELLATION `["OWN OF NORTH ANDOVER SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST i BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL HE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR TA VE N.ANDOVER,MA 01845 --- A CORD 26(2010105) The ACORD name and logo are registered marks of ACORD 1999-2010ACORD CORPORATION. All rights reserved. Massachusetts Department of Public Safety Construction Supervisor Board of Building Regulations and Standards Restricted to: License: CS-007977 Unrestricted-Buildings of any use group which contain less than 35.000 cubic feet(991 cubic meters)of . enclosed space. ERIC W PALM 3 HILTON ST SALEM MA 01970 Failure to Possess a'current edition of the:Massachusetts `- Expiration: State Building Code Is cause for revocation of 1i,is license. Commissioner 04/23/201$ BPS Licensing information visit:UIlUUUIi'.MASS.CtDV/CIAS License or registration valla for indtvidul use only „ Office of Consumer Affairs&Business Regulation before tate expiration date. If found return to: 11 Q ,,,�L°TOME IMPROVEMENT C014TRACTOR Old office of Consumer Pelfairs send Business Regulation I egistratlon: 1420gg Type: 10 Park Plaza-Suite 5170 -, ycpiratlon: 31121209$- Ltd Liability Carpor Boston,MA 02116 ATLANTIC WEATHERIZATION-L.L.C. ERIC PALM s1R JEFFERSON AVE SALEM,MA 01970 Undersecretary valid avitlaoutsignature