HomeMy WebLinkAboutBuilding Permit # 3/1/2017 RTH
UILDI G PERMIT � rD
ofT� a <
TOWN OF NORTH ANDOVER : :,
APPLICATION FOR PLAN EXAMINATION '— �
hermit No#: `" � Date Received
Mw
� actau `�c
Date lssued_ �'
EMTORTANT: Applicant in-ast complete all items on this page
LOCATION � n� �
/" Z"j"ni
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DlSTR1CT:� Historic District y
Machine Shop Village Y.,
TYPE OF IMPROVEMENT PROPOSED USE
Reside taE _. Residential
_.. iNon,- Residential
ne family
El New Building ��.._._.__. y
E Addition E Two or more family ❑ Industrial
Cl Alteration No. of units: ❑ Commercial
__. .. ___ _._-- ___._..---__._....__-___--
impair, replacement Ei Assessory Bldg Cl Others:
Demolition ❑ Other
® Septic E Well P Floodplain ❑Wetlands _ D Watershed D strict
E Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
lficaition
idenA ase T pe or Print Clearly
OWNER: Name: t, '� Phone:
gp
.._._•-- iA Mum
w
Address:
e'
Phone: '
Address:
Soperviaor' °on uctio'License: 22 > Exp. Date:
Horne Irnproivem.ent License: Exp.p Date
ARCHITECT/ENGINEER Phone:
Address-. Reg. No.
FEE SCHEDULE.BULD/NG PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIIY7ATED COST BASED 0 $125.00 PER S.F.
i rotal Project Cost: FEE:
Check No.: w ,� " Receipt No.,,
NOTA: Persons contracting with unregistered coratr errs t10 1110 ve:access to the gu ar arty fund
Sig��atur� of A ent/Owner Si nature cif �i
%AORTA '4
Town of
., . 4, ndover
6
No.
Q LAKE h ver, Mass, 03 D /
coc"tCn;wKM A. 19
ADRAT E D A4�`�,��
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD�
` Septic System
THIS CERTIFIES THAT �i.&0$#1.4......r4..,-072f, BUILDING INSPECTOR
..
has permission to erect.......................... buildings on ...�.�..Z�..... Foundation�i.'!!1, ,,, .,�,`�,�.
.4. .. pf*^QL, .. ,.� � Rough
to be occupied as ..................................... chimney
provided that the person accepting this permit shall in eve 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 Forth Andover, PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
® Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR...
UNLESS I!=:::aBUIEDI
T Rough
Now
Service
Ono
... ..... Final
N INSP CTOR
GAS INSPECTOR
®ccu ancv Permit Required to Occupv Buildin.9 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.
159L"
ep,
WS
o6,
C 1-7
..The Commgnwealtli of Alassaebosefis
.Department of.fx dustrialAr-cide is
M Z Congregg Street,,5`i!M 100
Voston,.VA 0.2114-2017
www masss;go-P7dicc
exa.sa.tionXpsrrx•axace davit:J3�der19/Coxttxa�c'arsl.EXectrXczaxa.s/ 'X .;m. exs.
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l�icant nforzaaia on
Name(,tizsiuessJ(ofgai�iz
aiionitndividtxal}: f r
Cype oittprojeot(,Tegn!xo,1), '
c you an employex•? her,r tI eapprlate box: 7- Nei costxnCtlaxt
employees(�u1C andlar part tikue):k
1. I aua a employer wi th_._.
8. 1,em o delitig
2.�Iamasole proprictarorpartnershipandbaysnoemployees zarkirtgioxxacinTJC73xo�117ax7
any capacity:[t`tav'var1mrs'co-P.insuranco required.]
9.3.E]I am ahomeow.uer doing all work myself PTO workers'comp,insoranocrequired.]f .10 E Lluilding addition
.�lam ahomeowner and will be hiring eontxacters to conduct all work on my property_ 1W ilt
Fleatrical xepairs ox~a.dditiaps
erasure that an coatraotozs cithorhavewarkaxs'compensation insurauas ar axe solo ]� :1?lunllxixag repaixS ox additions
proprietors with no emp��yees. L -t
5.Fj I am a general contraatoz and Ilrayshired'ths sub-contractors listed on.tlae attached sheet.
13-.E FD6f reliairs
Thsss sub-contraatoxs have eu�playecs andlaavcwarkers'comp,insurauoe 14.Cl Other _ —
,,�'�e arcacorporaticn.audits,officersbays`nrcisedthcirrightoi emptionperMGICc.
152,§l(4),and s have no employeies.rNo work err°comp.znsonauce_required] _
kc yapplicanithatchec1 13i� k1, ust lSotZllouEthesectionbeta�vshowSngthair`workers'compemsat3onpaficYin fozmatian`
i Flameawnars who snQt flus ajd�a� eded an g the ar.shenetgallvorkpdthanhiro show gthsnamc oftll<�stirb confraataside r�and sintsewhth o ��indicating
j�-such
tcontractors that claockibis baxrnust a t rovide thew worlcsrs°comp.policy number.
surplaysss. Ifthe sub-contractors have,employees,they murmur p" • _ _ _- ---
_ �-
-workers'compensation insuFancefor my ernplr�yees, Below is daepoficy a1d)0.6
errrfoer tliat is praviding
'site
f am an p Y
inforxrzation.
7"'
;fos,Lraace Company flame:
I'allcy. or Sclfins.Lie. OR
E sp rafxonT7atc_ �
CatyfStato/dip: 6
l'obSiteAddress- rho-WiRg-the olicyn�sr�aberand expixa "oxo date).
Attach.a copy'Of"�th''- "kcrs' coxnpez saGxon policy decl�SA�a c�irr�inalvzolatZanpuzusiiab�c EKY a fldb un to$1,500.00
I aila e to secure rorxage as teclui�ed undex MUL c.152,§ fu�to
orad/ox aye yCa�xrupxisonznent,ae forin
s o el[as civClp na �b carded to the of�`i.�o�"h o ttg ns o tb.a:L l&:f'oxi�suxancd a
day again t tho violator.A copy ofthis statemeu may _
cayexage-verification.
1 da riex eby certify,xrrader t ie peens arzcipenallies of perjury that th--zrz�orrnation provided above is, zee ai—carred
one
(J cztal us_afery. lav taut°write iia trizs area,to be corfipWed by city or tUWI'z a� cza1
i
My or Town.
perrait/Licerase# _ -- — — --
1ssxxing'.�uthox ty(circleone): '
:f.l3oa�'ct aSS1e alth 2,Building 3)e-
3.Cityl.Ca'yvn Cfeik. 4. lecfrxeal lnsper.i:ar �. 'l xxrbizxg ns c;ctar
6.Other
Mone 0.
Date Prepared: 09117/16
DIRECT BILL
WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
MERCHANTS MUTUAL INSURANCE COMPANY
BUFFALO, NY 14202 NCCI COMPANY NUMBER: 15652
INFORMATION PAGE
POLICY NUMBER: WCA9098619 TRANSACTION TYPE: RENEWAL
AGENCY/BROKER: BYAM-BROS-MAHONEY INS AGENCY RENEWAL OF NUMBER: WCA9098619
AGENT CODE: 396271NER061032 BUSINESS TYPE: CORPORATION
1. THE DAVID M MURPHY PLUMBING INTERSTATE/INTRASTATE RISK ID:
INSURED HEATING AND GAS FITTING INC BOARD FILE NUMBER:
AILING 3 CHAMBERS STREET
MAILING
LOWELL, MA 01852-4165 FEDERAL EMPLOYER
IDENTIFICATION NUMBER: 043086385
OTHER WORKPLACES NOT SHOWN ABOVE: (ADDRESS, CITY, STATE, ZIP CODE.)
2. POLICY PERIOD is from 10/17/16 to 10/17/17 12:01 AM standard time at the insured's mailing address.
3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are:
Bodily Injury by Accident $1 ,000,000 each accident
Bodily Injury by Disease $1 ,000,000 policy limit
Bodily Injury by Disease $1 ,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
D. This policy includes these endorsements and schedules:
MS IU 05 11 99 MU 06 3,1 10 14 WC 00 00 00 C WC 00 00 01 A WC 00 04 06 A
WC 00 04 21 C WC 00 04 22 B WC 20 03 01 WC 20 03 02 A WC 20 03 03 D
WC 20 04 01 WC 20 04 03 WC 20 04 04 WC 20 06 01 A
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All
information required below is subject to verification and change by audit.
Code Premium Basis Rates Per Estimated Annual
Classifications No. Total Estimated Annual $100 of Premium
Remuneration Remuneration
SEE EXTENSION OF INFORMATION PAGE
MINIMUM PREMIUM $ 330
DEPOSIT PREMIUM $ 11 ,877
TOTAL ESTIMATED ANNUAL PREMIUM $ 11 ,877
Interim adjustments of premiums shall be made: ANNUAL
Countersigned by: , �.
Authoriz4lrepresentativi Date
COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A
INSURED COPY
03-01-'17 10:54 FROM-Byam BrosNahcny Inc 978-937--0745 T-799 P0001/0001 F-196
CERTIFICATE OF LIA131LITY INSURANCE DATEIMMIDDIYYYYj
�... 0310112017
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 certiflcato holder Is an ADDITIONAL. INSURED,the policy(les) must be endorsed, If SUBROGATION I9 WAIVED,subject to
the terms and conditlons of the policy, certain policies may requite an endorSomonL A Stat6rnent on this certificate does not confer rights to the
C601ficate holder In Ilsu of such endorsements.
PRODUCER NAMN 7 2
NAME: B em Bros {
B im Bros Mahoney Ins.Agancy PHONE FAx
191 Pawtucket Blvd 411 Nn EKI>97"8-454-2926 Arc N,):975-997.0745
Lowell,MAGI 854 E.MA1L
oyarn Bros INSURErt S WORDING COVERAGE NAIC 0
INSUpsRA:Merchants Insurance Co. f
INSURED David M.Murphy Plumbing luau RERB:
Heating&Gas Fitting(nG. $
3 Chambe,rs Street INSURER G
Lowell,MA 01852 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 REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i
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. I
LTR TYPI:OP INSURANCE 'TIENEPOLICY NUMBER MMtDDIYYYY 1dMlppY}y+(i%Y I LIMITS E
s
A X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ 1,000rA�
CLA)MS-MADE Q OCCUR BOPID72406 0611512016 05/1512017 s 500,00
MED EXP Any one person) 5 16,00
PERSONAL&ADV INJURY $ Included
GEN'L ARGREGATE LiM$Y APPLIE8 PER: GENERAL AGGREGATE E 2,000,00
POLICY❑JECT ❑LOC PRODUCY8-COMPIOPAGO 3 21000100
OTHER: $
AUTOMOBILE LIABILITY COMBINb 0 SINGLE LIMIT $ 1,000,00
A ANYAUTO MCA0000041 0811212016 6911212017 BODILY INJURY(Perpwm) $
RUT03 NEO AJ%SULED BODILY INJURY(Por accidant) S
NON-OWNED PROPERTYDAMAGE t
X HIREDAUT08 x AUTOS Peraccrden!
5
X UMBRELLA LIAR x OCCUR EACH OCCURRENCE $ 2,000,00
A EXCESSUAG CLAIM3a1WUE CUP9145600 0511512016 0511912017 AGGREUATE $ 2,000,00
DEEo I X I RETENTION$ 10,000 s
WORNER8COMPENSATIDN x RT TktiE ERH i
AND EMPLOYERS'LIABILITY
A ANY PROPRIE70RIPARTN>RJSJcsCUTIVI; Ya NIA WCA9098$19 7011712016 10/17/2017 4,L,FA $ 1,000,00
OFrJ0er WI)eR M(OLUOE09
(MandatarylnNH) E.L.0E8EASE-EAEMPLOYE 6: 11000,00
11yyes,dascdba under
DESCRIPTION OF OPERATI NS WOW E.L.DISEASE-POLIOY LIMIT 8 1,00D-00
i
!
I
1
i
DBSCRIPTEON OF OPERATIONS 1 LOOATIONS E VEHICLES{ACORD 101,Addlllonal Romurke Schedule,rRay b(+aH6thrld It mere 6gaceld required)
I
I
CANCELLATION
CERTII�ICATi;HOLDERI
TOwOFAN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WELL BE DELIVERED IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
120 Main Street
North Andover,MA 01045 AUTHORIZED'
Byam 8r
198 1 r is reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks o RD
Fold,Then Detach Along All Perforations
I'L»UnP113PI:5 a I�ASFiTT�RS " i
ISSUES TMS FULL®Wl1�G LtGPf�alp t
LI L4 1?AS A MASTED PLUMBER
D AVIS M MU1 V..;.:
131 FAIRMOUNT,ST
LOWELi�=11�Pf�.O't55? 3779 "N;� U
r. 0
9723 _ U5/ff1/24'15 r 45193
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