HomeMy WebLinkAboutBuilding Permit # 1/4/2017 BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATIOW,
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Permit Not#: � � �� Date Received RArE0^per,
Date Issued. 4SSACHUB
L"PORTANT:Applicant must complete all items on this'page
LOCATION .._W... rG
PROPERTY OWNER
Pnnt 1 DO Year 5truct�re yes no
MAP PARCEL. ZONING DfSTRIcwt.._` . Hrstarrc District yes no
M
- -. . ..achrne 8h Villa -yes rip.
TYPE OF IMPROVEMENT PROPOSED USE
Residential . Non- Residential
❑ New Building 9 One family
❑Addition ❑ Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
Repair, replacement C]Assessory Bldg ❑ Others.-
El
thers:❑ Demolition ❑ Other
0 Septic q 11VelI ❑ Floodplain U Wetlands 0 Vllatershecf Drstr c
❑.Vllater]Sewer:
/ DESCRIPTION OF WORK TO BE PERFORMED:
Identification.-- Please Type or Print Clearly
OWNER: Name: M, . Act,&.,,d C ArMre1V Phone: 711- a5 C
Address: c7l Avb& LER (4 a y,-5;—
COnttA0tbr NaM-q 9t.A 4CJ'6e1k Phehe_. .
Address: �: Ir27 �A6_ o ► rrds � c�
Supervisors Gatistructiori Lrcense � Exp. Date:
Home :
Irnprouemert License ! 7�? / Ex Date X3.1._7
_ . .
ARCHITECT/ENGINEER /U/�i ' Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER 5 F
G
__ .rotal Project Cost: $ c2& i ' FEE: $
Check No.: Receipt.No- : iso
NOTE: PeFsons contrae ing �al nregistered contra t1grr,,.do not ve:access to the guaranfy fund
5ignatuie_of.Agenf/Ovtirerm0
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own of �� _ LAndover
No.
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roc M1[++[wrcw �1'
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U BOARD OF HEALTH
Food/Kitchen
P E Septic System
THIS CERTIFIES THAT . .. ... .. .. .......... ... ..... ... .. ..... BUILDING INSPECTOR
. �. .� Foundation
has permission to erect ...................... .. buildings on ,. ... .... .. .. ,....
Rough
to be occupied as .....l.. ......� . .�.�.. ........... .....
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Workers" Compemation liunrance Affidavit:Bui:d=s Coxktrzetor*We tx4.cb dPlnmbers
It
Name : RENEWAL BY ANDERSEN
Address: SO F'ORBES ROAD
13tateJ2 NORTHBORO,MA 01532 Phone#: 50"51-2214
Are yo t m empfaper'd Chwk dw approprkto bon T1 Te of prate(required):
g0 4. ❑1 am a gtawral cootractur and 1
stn a employar vd� 6. ❑Now aotasSruGkitm
eataployem(&U endlnr parmimu)." have hired the smb-contractors
2.Q 1
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ehig and have no taatploytxs
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wording for the to any capacity. employot s ttnrl 11 ve worltcrs' 9. ❑Danding addita !
o wrnc M,Qcm hwumme p•it�sarence.$
p• 10.❑E1rctriQal rapsus or additiunr
S. ❑ Wo tate a corpocatitnt and ite
3.❑ I stn a ho�neo�vnet doing all workoilitcars bave asauoised their' 11.[�Plttmbing repairs os xMitiom
myself(No wo dms'oomp. 0.I5 of 1(4),a otr per MOL 12.C]Roof repairs
tnsurastce�.)t c.1 S2, 1(4),and we 11aru�t nn 13.0 Odutr
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ratlGecbmp�►Name. OLD REPUBLIC INSURANCE COMPANY'
Policy#orS�eli�ins. N;lMC308231 U0 H pimticmt Date: 10/01/2017
obSite Addreffs: 57 Candlestick Road City/Sbt op. North Andover, MA 01845
Attrtcdt a copy of the workm,rompansatiou ponq clan atton gnp(tlho ft trlrti pvlky number aid a*-MtZvn date .
Failure to secure cavmgs as required under Sa tkm 25A of Mt31.,e. 152 can lead to Poe impos rboll of mimimd peltalties of t
floe up to$1,500.00 and/or one-year imprisonment,as wish&o civil penalties in the fbi m of a S'L`OP WORK ORDER and a fine
of up to$250.00 a day against the violahm Bo advised ftt a e4py of this sbatet mt maybe forwarded to the Oftico of
IRvas# is #haDU for unsure =coverage varlflceti=
I{gyp aMie psoirla to'd periai�of pr�trtry the#lea&�vrs�ar�ttao pmut��arbays is ire ram'aor�
12/09/16
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8-351-2214
Quo W Un off. Do rent write in tftfa a ma,sw be compwd by MY or Gown ogiicz d �
Myor'faww. I'crituii�t �l �
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L Hoard of Malth 2,BvBdtq Dt ppAment 3.C ltyPpmm C3o;k 4.FAKIrlcal I=pwWr S.lgwmbbg luapecto r
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ANDECOR-01 DUSEAA
CERTIFICATE OF LIABILITY INSURANCE °ATE(IAMlDUIYYYYI
9/29/2016
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 HOLDIEIL
IMPORTANT: N the csrtlflcate holder is an ADDITIONAL INSURED,the policy(IOS)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terns 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 endorsems s.
PRODUCER am Willis Towers Watson CertMcate Center
Willis of Minnesota Inc. PHONEI'd),IBM 945-7378 No;(888)467-2378
c!o 26 Century Blvd
P.O.Box 305191 ADDRE :cerufficateg@MRIS.com
Nashville,TN 3723MI91 INSUIIE s AFFOROINGCpvaRAGE NAIC0
INSURERA.Old Republic Insurance Company 24147
INSURED INSURER B:
Renewal by Andersen LLC INSURERC:
104 Ott:Street 14SUREI D
Northborough,MA 01532 INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CEFrnFY 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 CONTRACTOR 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.
XP
L TYPEOFENUURANC! POLICY NUMBER PAID OLICY F ItMND LIMITS
A X COMMERCIALGENEiALLIANILITY EACH OCCURRENCE S 1,8118,011
W"140 TO 11101TED
CLJUMS•MADE OCCUR MWZY 309234 10101/2018 1010112097 PREMISES Ea ommen $ 500,000
MED 1E XP(Any One pMaOn $ 10,08
PERSONAL&ADV KMRY S 1,000.000
GEWLAGGREGATEUMITAPPLIES PER GENERALAGG151E AT£ $ 4,000,000
X
POLICY❑JPEGT ❑LOC PRODUCTS-COMPdXWAGG $ 4,000,08
111
OTHER
IiYT
AUTOMOWLELIITY COMBIN SINOLEL
LABS 5,000,000
AX ANNAIIlO MWTS 500232 9010112018 10101/2011 BODLLYINJURY(Parparaon) S
TOS
O ED ASCHHEEDULEO BODILYINJURY(Per ao*enl)
S
AGE
HIRED AUTOS AUTOS 1 Par I S
S
UMBRELLALJAe HO=R EACHOCCURRENCE S
EXCESS LIAS CI.AIMS•MADE AGGREGATE S
i
DED RETENTIONS
'I WOMMCOWENSATION X PEFI ER
AND aNPLOMS'L IABILITY
A ANr PRoPwETowPAwNER&KEcunvE YIN NFA WC30123100 10101/2010 1010112017 F.L,EACH ACCIDENT 5 1,000,00
(arandibory In NH}ExCLu�o t E,L.DISEASE-EA EMPW $ 1,000,00
M d E.L.DISEASE.POLICY UMrT S 11000.08
D OPERl1 Sbelow
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Addltloml RertlorkS Schaduie,may be atteched Lr aver!space Is required)
Evidence of Insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN
ACCORDANCE YAM THE POLICY PROVISIONS,
Town of North Andover AUTHORIED REPRESENTATIVE
120 Main Street 1 1
Norlh Andover,MA 01045 /y
019BB-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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