HomeMy WebLinkAboutBuilding Permit # 2/15/2017 BUILDING PERMIT �oRTy
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
{��l� Date Received
Permit Nod• VSss��
Ac1u
Date Issued: Y
IMPORTANT: Applicant must com fete all ite�rn.s on this page
LOCATION
,-, Print
PROPERTY OWNER
Print 100 Year Structure yes Ono
MAP PARCEL: ® ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
0 Alteration No. of units: ❑ Commercial
❑ Repair, replacement- ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic �„q1Ne[I ❑ Floodplain .�Wetlands ❑ Watershed District
rmr ;
❑INaterlSewer� ,6 �.�' ` � e "'�
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address: '
Contractor Name: 1 1LZ Phone:
Email: e i� `A i ci� //W,/t
Address:
1149-?`�
Supervisor's Construction License: ' Exp. Date: _ f
Home Improvement License: �� Exp. Date: z
ARCH ITECTIENGI NEER 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: $ 0�2 C� e FEE: $
Check No.: t Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
........... ......... ... .............................
FORTH
own of . 71 ....4,
ndover .
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No.
Thy r
h ver, Mass,
COC
Ab
A're D ev
BOARD OF HEALTH
Food/Kitchen
IV �T� T Lu
FSeptic System
THIS CERTIFIES THAT ......
BUILDING INSPECTOR
has permission to erect Y .. ................ buildings on Foundation
Rough
to be occupied as ......... ............. .......................................... Chimney
... 11 t a. ... ... .... .........*.................*.......*
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
Fina[
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CON Rough
I 015ervice
... ....... B INSPECT Final
GAS INSPECTOR
Occupancy Permit REquired t® Occuuildin 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.
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 25,000.00 m
$ - $ 300.00
Plumbing Fee $ 37.50
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 37.50
Total fees collected $ 475.00
387 Mass Ave
773-2017 on 2/15/17
Kitchen remodel
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Phone
Proposal Sub --.w,.. ate
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re,s r Jab Name
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Job Location
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j,71 1—, specifications and estimates for: �
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WE
PROPOSE h r by to ftur furnish waterloo and labor .n�compl�t in orlon Faith specifications below, for the surn of: �
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dollars
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Payment to be made as follows
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All material is guaranteed to be as specified,All week to be completed in a workmanlike Authorized r
manner according to standard practices.Any alteriMon or deviation from above specifications Signature, ..—
involving extra costs will be executed only upon written orders,ane➢will became an extra
charge over and above the estimate.All agreements contingent upon strikes,accidents or Note: This proposal may be withdrawn
delays beyond car control Owner,to carry fire,tornado and otter necessary insurance.Our by vas it not accepted within
worker;are fully covered by Workman's Compensation Insurance.
Acceptance lams,
thear ove ptices, specifications art(]condition are s atisfactor�y and are hereby accepted.
You lo do the work as specifie➢a Payment will be made as outlined above, Signature ..........._....._........
Dateof Acr:,epkance. _........ .. _. ... Sigrratrare ........_._....__.....w...w._......................... ..._....... _.. __ _ ......................_-__..................._. ......_. ..
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� s ..trice of Consume CC3NTRACTOR
. M iMpROVEMENr TYp '
nr
egistration: 18262() 1ndiVidul
xpir�tiok� 716!2017
y n.
DAVID MORIN
DAVID MORIN
365 SUTTON ST Undersecretary',-
N.ANDWER'MA()1845
Massachusetts Department Of Public Safety
3
� Board of Building Regulations and Standards
--License: CS-040898
Construction Supervisor
DAVID M MORIN ,
' 365 SUTTON S717EET,'
NORTH ANDOVER MIl< 1
Expiration:
F
Commissioner 07/04/2017
i
X-hp, Commonwealth mf Hass xchuseAs
I.?epcafta�ee t of'1 dustrialAccidents
Cong-esw Sheet,Suite 1'00
Roston,MA 02114-2 017'
= wwta.rnass.gov/dza
Warlrers'Compe)nsatjoit InsuranceAffidanit:)auaders/Conftaeiors/RXeetxzciaas/PlAmbers.
TO BE FILED WXTR TM BERARTTJNG AfJT)'ORTTY.
Alica-at Information fleas tint Le °bl
Namo(Business/grganizationLCurlivzdua]}:
/ r , �-'�j`�
.�.ddrross: rd S _� y > J
itylS atelZi : Phone
Are you an employer? Cheac&a aplixapriate hex: Type of project( �C�tllced}:
LEI I am ploya-Mth f employees(full.aadtor part time).* 7. p Nevi cozisf'uction
2,' amasolopropdatororpartuershipaadhavenoemployeesworlcingformein $. R81YLodelhig
anY capacity.[No workers'comp.insuranea required-] 9. ❑Demotion.
10 lam a homeownerdoiag all'vrorkmyselt[No workers'comp..insamoe required J 10 ❑)3uilqing addition
4.ElI am.ahomeownez andwilt he hiring contraetors to conduct all-work onmy property. swill ME]F-leetrical xepairs or additions
ensurethat all contra.cfors either hava-Workers'compensation insurance or are sale "
propiiators withno employees. 12:0 Plumbing repairs or add Mons
5,E]I am a general coptractor and I haye hired the sub-contractors listed en the attached sheet. 13.,0 Roofxepairs
These sub-contractor4d,a employees audhaveworkers'comp.instuauce. 1COther
6.Q We are acozporat 9a pd ifs officers have exercisedtheirright of exemption perMGL c.
152,§1(4),andwshaveno-.e plgyeF.W9workers'camp.insinancercquired.l
`AnYaPplicantfihatchacl�shox�#lmusfalsodillouttizesec onbeivwshowingtheirworkets'compensationpolicy Mormatien.
i Florueowners tiyfio siilimi# is affidavit indicatiugthey are doixtg all a ark and thenhire outside contractors must sTJbmft anew a£ffdavit indicating such
Contractors that checleflzis box must attacped an additional sheet shouting the name of the sub-contractors and state whether orpat those entities have
employees. If the suh-cantraotars have employees,}liey znusE provide their workers'comp.policy number, •. .' .
Iain axe erriplayertlzatispYol�iaiixgvr�orke>s'compensation insur'anceformy 9mployees.'Belaitf rs thepolicy arzdjab site
informatiorz. �
Ins-uranco Company Name;
i
Policy#or SOW ins.Lic.#: Expiration Date:
rob Site A ddress: City/State/Zip:
3 .(attach a copy of the�oykers' coxapepsation p olley declaration p age(showing the P olicy numAr �Vexpihra�tioM te)
Failure to secure coverage as requixed under MGL C. 152, §25A is a csimival violation punishable by a Erne up to$1,500.00
and/or on.e year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDS.and a fine of up to$250.0 4 a
V dap against the violator.A,copy oftbLb statement may bo forwarded to tb o Office of IoLvestigatious of the MA for insuraaxoe
coverage verifioatioa.
iat—uraly—1
erec �zder tliep ° s at2dgerzalties ofpetjWy that the informadonpro7:idecirbcre isLrue ancicar�ectDate: 1:
Phone#: n1/1 z Zr
Official arse only. 1?o notlpr�ite in this area,to be completed by city or town ofcia
City or Town: l?ermitTJ zcense#
lssuiugAuthority-(circle one): i
1.)30arc of Cealt76 2.BuildingDepartm.ent 3.CitylTown Clerk 4.Electrical inspect-or 5.Plumbing Inspector
6.Other
Contact Person: Ph°ne#'
I'
A,V CERTIFICATE OF LIABILITY INSURANCE 02117/20177 or YYl
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 BOLDER.
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 lieu of such endorsements.
PRODUCER CONTACT Paychex Insurance Agency Inc
PAYCHEX INSURANCE AGENCY,INC.
150 SAWGRASS DRIVE . 877-266-6850 FAX
PHONE 685 889 7A26
ROCHESTER,NY 14620 E-MAIL Certs@paychex.cam
INSURERS)AFFORDING COVERAGE NAIC#
INSURED INSURER A:AmGUARQ Insurance Company
David M. Morin INSURER B:
365 Sutton Street INSURER C:
North Andover, MA 01845 INSURER D:
INSURER E:
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 REQU€REMEN7,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAW,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.
'NsR TYPE OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFP POLICY EXP LIMITS
LTR INSR D !MMD II(
Cf NERAL LIABfUTY t 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
CLAIMS-MADE X OCCUR MED EXP(Anyone person) s 1r3 flf!(1
A i I �- - LDA3030-5270 0611312016 0611312017 PERSONAL8ADV INJURY g rNrr
ENLAGGREGATE LIMIT APPLIE8PER: I LLstLiInLMV 1[LLYi1L z7 t'Inr€nt'€t]
MUCY n PROJECT Loc rRenuaT4-ooM11;"/or+pao w 2 000 000
AUTOM0131LE LIABILITY IEa BEND SINGLE LIA11T �
ANY AUTO
ALL f€WNEO '� SCNEOULEO BODILY INJUR4' $
AUTOS �---- AUTOS (Per person)
HIREDAUTOS I.,.........."..".e ARNOrnS'UNEEI BODILY INJURY $
PROPERTY DAMAGE A
UMBRELLAUAB :(:CUR EACH OCCURRENCE $
ExcESs tJAa CLAIMS-MADE AGGREGATE $
bED RETENTIONS $
WORKERS COMPENZATIO14 ANO ,x4 slnl�-
EMPLOYERS'UABIUTY -_-
ANYPRGPRIETOITMARTNERExFCUTNE
OFFICERNfEJJBERExCLUDED? YfN E.L.DLSEASE`EA EA1PLOYEE
l�"dam.y I"ktn i I NIA E.L.DISEASE-POLICY LIMIT $
G,
deo ,eag
DESCRIPTION OF OPERATIONS!LOCATIONS I VEH€CLES(Attach ACORD 101,Add€Eicnal Remarks Sahedule,if more space Is required)
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER DAanuuw"I'Tul'.'""Uyv uu Munurcuvlty unnrntttvudtutttlntaxntwrwv
TE THEREOF.NOTICE WILL BE DELEVERED EN ACCORDANCE WITH THE POLICY
ACORD 25(2010105) 01088-2010 ACORD CORPORATION. All rights raserrred.
The ACORD name and logo are registered marks of ACORD