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HomeMy WebLinkAboutBuilding Permit # 2/15/2017 s►QR7� BUILDING PERMIT oF=KLen ,6 9,y TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION OSA ~ Permit No#• 1-75 i7 Date Received �r oTATED j4�\ (`• Date Issued: I aR, INUOR, Applicant must complete all items on this page LOCATION Pnnt r PROPERTY O Pn no nt 1 oD Year Stfucture yes MAP - PARCEL ZONING'DISTRICT_ Hic District yes; ria Machine ShopVilla e es no gam. Y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building % One family ❑Addition ❑Two or more family ❑ Industrial Iteration No, of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ` ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed District El Water/Sevier - DESCRIPTION OFWO K TO DE P RFORMED: G ` " Ideutiifcation- Please Type or Print Clearly OWNER: Name: Phone: Address: (� V� Contractor Name: ��� Phone,- Address:. -. 128LLM ( L 1 Supervisor's Construction License_ A n7sTi9.-a Exp Date: f _ cr Home Improvement License � Exp., Date. ARCHITECT/ENGINEER Phone.- Address: Reg. No.. FEE SCHEDULE.B ULDING PERMIT.•.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S_, Lot:al Project Cost: $_ Ld `` - FEE: Check No.: q Receipt Na,: If S- NOTE: Persons contracting with unregistered contractors do not have:access to the guaranty fund S_igriature of AgentLOwner Signature of contractor TAORTN -9 Town of 4Andover No. , ver, Mass, o S 17 Coc"l v1 ATED 0? S BOARD OF HEALTH PERM T LD Food/Kitchen Septic System i s THIS CERTIFIES THAT ...........�..�, .........�. .v..�. .....��. ..........................I.... BUILDING INSPECTOR .Q .a.Ia ® oundation has permission to erect.......................... buildin on ... ......._ ..•.•...., Rough to be occupied as .��'_.... ... !�.�._ -alp....1�-................��..�.,...,.���t I!�..�,. 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. IN Final PERMITEXPIRES l 6 MONTHS ELECTRICAL INSPECTOR UNLESS.CONSTRUCTION.. S � Rough Service ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® ccu uilriin 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. • �yo�7y BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION permit No#• Date Received ��°04Aroo iR t R�SACHLjS � pate Issued: S­ i ORTANT: Applicant must complete all items on this page �OCATI,ON f PrEnt PROPERTY ®WNER _ _ Pnnt 1 D(3 Year Struofre yes no PARGEh Z®NING,`D1STRICT H[storfc D[stnct yes ria Machine 5l�op Vl [Iage yes na_ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R9=One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement 1j Assessory Bldg ❑ Others: ❑ Demolition ❑ Other . . �`Sept[c ❑ 11Veli ❑ Flaodplain 0 Wetld da D Watershed Distr[cfi _Vllater/Sewer - DESCRIPTION OF WO K TO DE P RFORMED: catIdentification- Please Type or Print Clearly' OWNER: Name: Phone: Cd � Address: - Cantractor Name_ .:� • Jl�,k Phone: �_. . last W 5fapervisar's Construetion Lieerise � ���-oZ Exp `Datefi Name lmprovemerit License t .�. ,. �..: _ ..: _ .._ _E p: Date , : bs ARCHITECT/ENGINEER Phone: Address: Reg, No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost-- $ t-' FEE: $ � Check Na.: I Receipt No.: DOTE: Persons contracting with unregistered contractors do not have:access to the gucrranty funri :SiririatillP:Of_,AC1E?rl'I/nWrlE-:rSi�__, nature cif contractar'� The Commonwealth of Massaeh usetts A Department of Industrial Accidents s I Congress Street,Suite .100 Boston,MA 02114-2017 •' www.mass.gov/dia y Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILET}WITH TETE PERMITTING AUTHORITY. Agglicant.Information Please Print Le 'bl Name (Business/OrganizatiorOndividual): Builder Services Group dib/a Quality insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03060 Phone#: 603-324-1984 Are you an employer?Check the appropriate box: Type of project(required)' 1.®I am a employerwith 100 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'camp.insurance required.] g. Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.] 10 Building addition 4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.�] ectr Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole p proprietors with no employees. 12.❑Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.®Other Weatherizatian 6.❑We are a corporation and its officers have exercised their right of exempt per MGI c. 152,§1(4),and we have no employees.[No workers'comp_insurance required.) *Any applicant that checks box N1 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. 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ACE ArnedLajlIns UranceC rrI n Policy#or Self-ins.Lic.#: WLR C 48151553 Expiration Date: 6/30/2017 Cit Job Site Address: C y/State/Zip: Attach a copy of the workers'camsation policy declaration page(showing the policy num pe ber and expiration data). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I da hereby certify ande�thepo�tns ndpen es=Da— Si n provided above is true and correct. nature: te: Phone#: 603-324-1984 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Phone#: Contact Person: DATE(MMIDDNYYY) -d► CERTIFICATE OF LIABILITY INSURANCE °125 °�s 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 I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURIWD provisions or 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). CONTACT PRODUCER NAME: Aon Risk services central, Inc. PHONE (866) 283-7122 FAX No , (800) 363-U1i35 (AIC.No.Ext): southfield MI Office E-MAIL ° 3000 Town center ADDRESS: suite 3000 Southfield MI 48075 USA INSURER(S)AFFORDING COVERAGE NAIL 4 INSURER A: Old Republic Insurance company 24147 '',, INSURED 22667 TrUTeam Builder Services Group, Inc. INSURER e: ACE American Insurance Company d/b/a Quality Insulation INSURER C: A Topauild company j 110 Perimeter Rd INSURER D: E9 Nashua NH 03063 USA INSURER E: 0 INSURER F: COVERAGES CERTIFICATE NUMBER.570064230317 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED NAMED ABOVE FOR THE POLICY PERIO€7 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. Limits shown are as requested SR DD BR POLICY NUMBER MMlODIY FF MMIOD E L1MET5 LTR TYPE OF INSURANCE INS❑ WVD 01 Z $2,000 000 A X COMMERCIAL GENERAL LIABELITY MWZY 0 51 EACH pCCURftENCE AMAG TO RENTED $2,000>000 CLAIMSMADE OCCUR PREMISES Ea occurrence MED EXP(Any one person) S25,000 PERSONAL&ADV INJURY $2,000,000 r` io GENERAL AGGREGATE $4,000,000 M GENT AGGREGATE LIMIT APPLIES PER: X POLICY ❑PRO LOG PRODUCTS-COMPIOP AGG $4,000,000 JECT o pTHER: MWTB 307519 06/30/201606/30/2017 COMBINED SINGLE LIMIT S5,000,000 A AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) O Z X ANYAUTO BODILY INJURY(Per accident) ID OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE E�3 X HIRED AUTOS X NON-OWNED Peraccideni) ONLY AUTOS ONLY W U EACH OCCURRENCE UMBRELLALIAB OCCUR AGGREGATE EXCESS LIAB CLAIMS-MADE DEC) RETENTION _ B WORKERS COMPENSATION AND WLRC47860180 06/30/2016 06/30/2DI7EEACHACCUDENT EER TH EMPLOYERS'LIABILITY Y!N All Other States $1,000,000 B ANY PROPRIETORIPARTNERIEXECUTNE NIA sCFC47860209 06/30/2016 06/30/2017 OFFICERWEMBER EXCLUDED? WI only MPLOYEE $1,000,000 (Mandatory in NH)If yes,describe under CY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) RMLJ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover AUTHORIZED REPRESENTATIVE , Building De artment war. Attn: Donald Belanger �^� � 7.600 Osgood street, suite 2035 North Andover MA 01845 USA ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD f k Massachusetts Departanent of Public Safety Board of Building Regulations and Standards License, CSSL-1059912 Construction Supervisor Specialty y 260 ilIMMY ANN 9 DAYTON€'i BEACH O" Cothmissioner 4912+a#�lilti Construction Supervisor Specialty Restricted to: CSSL-IC-Insulation Contractor Failure to passe"a current edition of the Wasachusetts State Building Code is cau&lc for revocation Ot tide license, IDP`3 Llconsing infbmatian visit:WWW.i'd ASS-G lDPS q?fifWoons�umerairs (d�u6e�sse�guaSM 10 Park Plaza - Sure 5170 Boston, sachusetts 02116 Horne Improvem ��ontractor Registration Registration: 179141 n Type: Supplement Card '4f-'' Expiration: &2512010 BUILDER SERVICES GROUP INC � t RICHARD SCHWARTZ � - ........... 260 JIMMY ANN DRIVE DAYTONA BEACH, FL 32114 Yn ♦Sl Update Address and return card.lliark reason fur change- SCA 11 ❑ Address E] Renewal E] Employment 71 J Lost Card @t:Jlze C%�9�ra�crrieroer[ll�a�C��.izs:rr�i�4e11�` i gee'or Consumer Al7airs&Susieess Regulation License or registration valid for individual use only IE 1MPRQV I IdI CDN ACTOR before the expiration date. If found return to: �. Office of Consumer Affairs and Business Regulation F2eIstratlon; 10Park Plaz$-Su[Ie 5170 ::- Type: ExpITat3K� 8?, Supplement Card Boston,iVIA Oa 116 bVILULK_I=RVICES� ass ItSTGr= t RICHARD SCHWAR 110 PERIMETER RD � Undemcretary Not valid without signature Rd"tQ 91 urlrbdvt PJSE Engineering N*tmlv RISELt1 a3axnststa#lttmd.(.'mnlazW%L%01011 CONTRACT {::11.i-iii' rMausaawau�a�rxussa�ra+yraaR�a 219M groves raw 28 thlir*u C 0 Nodh Atlduvtm MA MW AnJovcr,MA 01945 joB DESCRUMON 1111AW ONY.- IN-73i 40f parorwojiib other lrtO44s� ;Tfil=� sit vx6mp;abd ib, Alf qAuly.sliticMU to It OW to Iva)yc%z bm;:cdinchok cm" p -�d =d*thzrmhc4 W4%I fat WAL in C%NC fW hA;h- he a+tn},atiutt 00' orlhe VzAjh".x4 jots AolL.Anti 4 r.-4AM iodJ cbvf Air qulcly :s hZ ill c ro:1 tot du=b; r R-38 tiara" -Mum.mmi pmVW tow m4alwerialo to initall 12*13yvr 4) XrTlC HAT;VtOM0 Wwm4 tnntrsiab 1U hss#xtf a V rcss CrOM:41ic tcq=tj rltc""n r%0 PvV.,L-1,.b*r -jilk 10 inU"C AVIC AMSR Pm%i�k TatraZ-W mW a lha odw vrib4 bmuiA%db%c%Ilh"6PPbr, Ary i ACIMR Pm VW i Again This%*91 alkl%h IIW covct'-,it'll:V74 ;k ICA uil-h Af-tl:&*L Pfmick tibOl A--d tat$ jIV 3Tl*r flAlItYs"pro%-,&tzb&U.-I t. Fadats3 f410S0i0aGhi rtl cc la of ltaglWatlon 90 am RISE Engitrecting UAC4 ,trae+er q4wnvan Io IMM cir cart aw 11.pl awca tiOC it70 RISSt".=ica.U.ON:I CONTRACT sr.'4tRs .317-S02�G3]S FM1�C339-�#!2-l,,H.S [. pop � PROGRAM a.seesrtalesae+na,o+rtoolt+.ts# t'ALbE� cu.adarra��.n am aat esm+r. woe*.aaex [mbas2Ctiittitl (�J7ii)GRYN9'1+ tFul=17 .i1KVA : X32 3 =Apia oft SING><now 28 MUMPS CnM t0171Y�C)L dTt,tLltt.6r tyLi.W err:69ltLR+ A)Ab Andover.MA OW5 1tiattls t�7i¢'CT.MA 01945 JOB DESCRII° ON SZ'SfYfl vrWrilATIOR:Provi&Labor arra wa,aists,a iudall rcnl dol M eb+tea in(IQ$)"Aer"to mairit+tsrs sir M S�r7�fl L�I3�i.42(Ati WN.J�PtnsiL•Isbar aetJ nia#etialaty�s,dF ri�dboatdsa tl:lU of prsler uif5,hc raa:s+eet t)tr taiitt�to(64).r� ron oieommon%esil Ar= rtf+,A0 it)5 E,i�ater s sD � is tiretsottziscaiutsa- -ywillaatlybet+iWibcdelt ss1. i" nih. rot elig�le tneaxitY7.CAhmbra Lin afTcYs Tya ascrxsne.eot is e�raca'J$tow W--Ik jaryew.=4an in tits or l0 v for lie,Sir 5calasga�cma +i+tc the fEtx S68u s�dms a+idtianat 534Q if iarinssare jvuaib4!6e u0nar. 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