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HomeMy WebLinkAboutBuilding Permit # 1/31/2017 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION , Permit NO:– 2(� �"1 Date Re6 ceived Datelssued: L� I )-) RTANT: ApRLicant roust—GOIIIRI-eje all items on this .i-ocA:r.TON- Print PROPERTYOWNERk Z MAP NO: Q�_PARCEL: f Print ZONING DISTRICT:-- Historic District yes no )it Machine Shop Village yes no 100year-oldstructure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building —9-dn—efamily R Residential R D Addition fED Two or more family 11 Industrial ZfIN Iteration _No. of units: 0 Co 0 Commercial ry 0 Ot 0 Repair, replacement 0 Assessory Bldg 0 Others: 0 Demolition Li Other LJ _!VIA LtiJl DESCWT19N OF WORK TO BE PERFORMED: Atka (Identi ication Please Type or Print Clearly) OWNER: Name: --:i;t Address, I /-C CONTRACTOR Mame:.&-�,- Phone: Address: 3 AX f Supervisor's Construction License: 7 9 7 -7 Date: Home Improvement License: --../yz10 L-?_ Exp. Date: 3/j2-z 1 ARCH ITECT/ENGINEER Phone: Address: Reg. Na. FEE SCHEDULE.-BULDING PERMIT:$lZoo PER$1000.00 OF THE TOTALESTMATED1 BASED ON$ 2500PCOST PER S.F. Total Project Cost: $ <) FEE: G Check No.: �f Receipt No.: 7 - NOTE: Persons contracting wilk unregistere contractors'do not have access to,,the 0 , _E g aran, fp, ghature of A ent/own'er *(--4�4. ignature of contractor 4AVL -_9 ........... .....................- .................................................................................- t%ORT Town of Andover. 0 12 No. "- h ver, Mass, .1 7 C00041c"twick BOARD OF HEALTH Food/Kitchen PERMIT L D Septic System THIS CERTIFIES THAT ..._......f!!Ikle #0 IV I / I*M BUILDING INSPECTOR . ............. ...................... ............ ................. has permission to erect ............................buildings on ....... .......... 1W..FW......5::n..... Foundation Rough .. . . . . C4 to be occupied as . .0.1... 4.. .. f...........0. 1AM................(0 Us............................ 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 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 CONST RUCTIOYATRT*;,, Rough Service ........ .. .... ......... ..................... Final B GINSPECTOR GAS INSPECTOR Occupancy Permit Required to OccupV Buildink 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. Massachusetts Department of public Safety Construction Supervisor Board ofBuilding Regulations and Standards Restricted to_ License: C U67977 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of . enclosed space. ERIC IN PALM ` 3 MILTON ST SALEM MA 09970 = I Failure to possess a current edition ofthe Massachusetts Expiration: .State wilding Code is cause for revocation oftt►is license. CoPhniissioner 09123/2090 UIaS LIc43rtsirig information Visit:rdUUtlUIt.MAtS5.GOV/OTOS �%r. n.�r�,enrrrurrE/d r f+ ft�rrsxrrr rrwrf: License or registration valid For iindividul use OnlY `�_ Office ofConsumer Alffairs&Business Regulation before the expiration date. TFfound return to: �ME IMPROVEMENT CONTRACTOR Office of Consumer AffAirs and Business Regulation l0 e istration: 142069 Type: Park Plaza-Suite 5170 ti~ 1- 9 $ r expiration: W12/2018 Ltd Liabliiry Corpor Boston,IWA 02116 ATLANTIC WEATHI~RIZAtIQN'f.:.L.C_ ERIC PALMy� 61 JEFFERSON AVE SALEM,MA 01970 Not valid without..signatureUndersecretary I i I E ACOWEPQ GATE(MMII7 CERTIFICATE F LIABILITY INSURANCE 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 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 Ifeu of such endorsdment(s). PRODUCER 7 c0,MT TACT Co truction N Eastern Insurance Group LLC: PHONE (800)333-7234NC a; 233 West Central St EMAIL ADDRESS - INSURER 5 AFFORDING COVERAGE NAIC it Natick ISA 01760 INSURERA:Arbella Protection. Ins. Co. 41360 INSURED INSURER B Z3autiluS Insurance CO Atlantic Weatherization INSURERC: 61 Recur Je$Eerson Avenue INSURERIS: INSURER E: Salem MA 01970 1 INSURER F: COVERAGES CERTIFICATE NUMBER aster 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 POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN TYPETYPE OF INSURANCE A60 E POLICY NUMBER MOIL68 EFF MODIE EWP LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO TED X COMMERCIAL GENERAL LIABILITY PREMISES Ea oc ---, $ 50,000 ASCLAIMS-MADE a]OCCUR 8500042816 /20/2026 /20/2037 MED EXP(Any One Pe(sOn) $ 5,000 X CONTRACTUAL, LIABILITXPER50NAL$ADVINJURY 5 1,000,000 X CG0001 10/01 FORM GENERAL AGGREGATE S 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,000 POLICY X PRO LOC S AUTOMOBIL@ LIABILITY Ea acolCOMBIdentED 51NGLE LIMIT S 1,000,000 ANY AUTO BODILY INJURY(Per person) 5 A ALL OWNED X SCHEDULED 10200158'71 /20/2016 /20/2017 AUTOS AUTOS BODILY INJURY(Peraccitlen0 $ NON•OWNEDPROPERTY DAMAGE $ HIREO AUTOS X AUTO$ Peraccldent PIP-Basic S X UMBRELLA LIAS X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS 10,00 4600058654 /20/2015 /20/2017 S WORM COMPENSATION VYC STAT - OTIi- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUR\IE E.L.EACH ACCIDENT $ N1'A OFFICERWEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ S POLLUTION PL200378614 0/1/2015 0/1/2016 EA POLLUTION CONDITION $1,000,000 GENERAL AGGREGATE $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES,(Attact€ACORD 707,Additional Remarlis Schedu€e,it more space Is required) 'u CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 1600 OSGOOD STREET NORTH ANDOVER, NA. 02845 AUTHORIZED REPRESENTATIVE Jahn Koegel/SNM ji ACORD 25(209005) ©9988-2090 ACORD CORPORATION, All rights reserved. j.. INSn25 fminn.m ni T:he Af:()Prl name anri Inns era raniatnrarll Marls nF Al'f%V2n I�' ,.... 1�1L.Of f-..jLU o. 1242 ,L7 rxr t1tikir, Lf UUc. rd1S L7Gr VCr CERTIFICATE OF LIABILITY INSURANCE DAT!"{MMlDD/YYYYi TUM40SKTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOSS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE O P ODUCE THCERTIFICAT ODER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy{iesj must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 W CENTRAL STREET (A1C,No,Ext): (AIC,No): E41 RAIL NATICK,MA 01750 ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE NAILS INSURED INSURERA: AMERICAN ZURICH TNSURAN CH COMPANY ATLANTIC WEATHERIZATION LLC INSURERS: INSURER C. INSURER D. 61 REAR JEFFERSON AVE INSURER E: SALEM,MA 01970 INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 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 GE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES OESCRMEO HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAW CLAIMS. rP7SR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE 01:INSURANCE L R POLICYNUMBER INEAIDDIYYYYI tomo IYYYYI LIMITS GENERAL LIABILITY :ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AMAGEToRENTED $ CLAIMS MADE ®OCCUR.: PREMISES(Ea occurrence) PIED EXP(Anyone person) S ERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:; ENERAL AGGREGATE $ POLICY [—]PROJECT I.00 DRODUCTS-COMP/OP A S AUTOMOBILE LIABILITY COMBINED SINGLE S ANY AUTO LIMIT(Ea aCdclent) ALL OWNED AUTOS BODILY INJURY S SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Ter accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR El CLAIMS-MADE AGGREGATE= $ .—._ DEDUCTIBLE $ RETENTION S $ py WORKER'S COMPENSATION AND WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-58270121-16 03/2012018 OI2012017 LIMITS ANY PRaFEf21TONrFAF2TPlER1FrtECtlrlvE M NIA E.L EACH ACCIDENT 3 500,000 OFFICERIMEMBER EXCLUDED? (Manuutnry In NHI E.L.DISEASE-EA EMPLOYEE $ 500,000 S1 yes, e under E.L DISEASE-POLICY LIMIT S 500,000 D65CRIPrIO1Pr'ION CF OPERATIONS belaw DESCRIPTION OF OPE ATIONSILOCATION$NEHICLESIRESTRICTIONSISPECIAL ITEMS 7MS REPLACES ANY PRIOR CERTIFICATES ISSUED TO THE CERTIF€CATS FOLDER AFFECTING WORKERS CONIP COVERAGE. V CERTIFICATE HOLDER CANCELLATION 6 `('OWN OF NORTH ANDOVER SHOVLOANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED 1600 05G00D ST BEFORE THIS EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRIjo TA N.ANDOVER,MA 01845 '- ";rte$ Fk ACORD 25(2010106) The ACORD name and toga are registered marks of ACORD 19813=2Q1t?ACORT)CORPORATION. All rights reserved. 3 The C0112910" letafth of Mas.sachuseta = r DePtirttnent of.1ndustrialAccirients Office of. nvertigradons .l Congress Street, suite 104 BOVOYI,MA 02.1.14-2017 M wlvtuaraassgort/ilia Applicant�i�ft�rfat�tl Workers, CaarapensatFiark Irasaaa•anceAffidavit: Builders/Contractors/Electricians/plumberslBuilders/Contractors/Electricians/plumbers> l?�► Please Print�e ibl Name (Business/Organization/individual): Atlantic Westherization� LLC Address: OUR h—Serson City/Stade/Zip: Phone #: ` 74N- �l1-1 3 Are yo an employer? Cheelt the appropriate box: I: Tam a employer with__02 4. ❑ I am a general contractor and T Type of project(required): employees (fall and/or part-time),* have hired the sub-contractors 5. ❑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 working for me in any capacity. employees and have workers' E]Demolition [No workers' comp, insurance comp.insurance.t 9• ❑Building addition required.] 5, ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I 11 Plumbing repairs or additions rrsyselF [No workers' romp, right of exemption per MGL insurance required,]t c. 152,§1(4),and we have no 12.❑Roo repairs employees, [No workers' 13. Other camp,insurance required.] "Any Applicant that checks box##1 must also fit out the section below showing their Nvorkers'compensation policy information. J lomea�vncrs wlta submit this affidavit indicating they are doing all work and then hue outside contractors must submit a nety affidavit indicating such. tCantractors that check this boa must allaehed an additional sheet showing the name of the sub-contractors and sist employers_ If the sub-contractors have employees,they must provide(heir workers'comp,policy number, a whelhar or not thoso entities have 1 trot an employer that:Is provirlittg tvorlters'compensatlon ifxsrrrallce for my etitplovees. Belotp is the policy and job site 1itfarination, Insurance Company Name: '17 i Pokey#or Self-ins. Lie,#: B 70 /a Expiration Date: -5120 Job Site Address-.__1a&__ ddress: a Ci€y/State/dip: Attacha copy of the workers' compensation policy declaration page(showing tate policy number and expiration date). Failure to secure coverage as required under Section 25A of MGI,c. 152 can lead to the imposition of criminal penalties of fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a gine 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 DTA for insurance coverage verification. X do hereby cello) [ der tile pains alt ellatties of perjury tltttt the irzforination provided above is true alai cop eel. 0 signature: Phone M. Official ifse only. Do tint tnrite iia tltis area,to be completed by cioy or totpn offrciul. City or Town: ;3ermit/License# Issuing Authority(circle one): i. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical inspector S. Plumbing Inspector b.Other Contact Verson: Phone#: page 3 of 4 i ivIassachRsaa", m� ¢,. 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