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HomeMy WebLinkAboutBuilding Permit # 3/1/2017 SAORTy BUILDING PERMIT TOWN OF NORTH ANDOVER r� APPLICATION FOR PLAN EXAMINATION l permit No#: 1rZ�� . mate Received 'dry�aa�r�nrR�`q ACFiusui .pate Issued:,0 3 OR T- Applicant must complete all items on.this page Prin PRC?PERTY CQWNIw R Q Print lob Year Structure yes no MAP PARCEL: _ ZONING DISTRICT:_ _ Historic District yes no Machine Shop Village .Yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential _ - 17 New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: Lel Commercial CI Repair, replacement E Assessory Bldg ❑ Others: Demolition L] Other E, Septic b well p Floodplain i_Wetland ' `" Ll Watershed pistrict d.Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: . Vn Identification- Please Type or Print Clearly OWNER: Name: - Phone: Address: � ,�.j karatr Name Phone o� Address-j? h Supervisor's Gonstruetien License: - _ w C.- . . t .. .. .._ Exp. Date: w Home Irnproyeinent License: _ Exp. D8te ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE.SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 dF THE TOTAL ESTAMM-D COST BASED $125.00 PER S.F. rotal Project OOSt.- $ 1Y d6 FEE: $ " Check No. _ Receipt No,....... _ � NOTE: Peryons contracting with unregistered contractors do not have.-access to the guarant.fund Gigiiature efA ent/Owher Signature of ntr� t _- t%®RTH '9 Town of1r ndover ® .�.• 4n ; No. �o �.N� h ver, Mass, 3 0 ZW coc"Icnewtc 41' Il BOARD OF HEALTH Food/Kitchen P E R.. &J.LT T D Septic System THIS CERTIFIES THAT , BUILDING INSPECTOR ............. ........................ ® ... Foundation has permission to erect .......................... buildings on ..s.. .. �/1M ... . Rough tobe occupied as ... ......................................................................... Chimney provided that the person accepting this permit shalt In ery 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 CONSTUNLESS 10 Rough Service ... .........APE Final BUILDNG OR GAS INSPECTOR Occupancy Permit Required to Occupy Puildin Rough Display in a Conspicuous Place on the Premises - Do Not Remove Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the wilding Inspector. Burner Street No. Smoke Det. I commonwealth of.l{�as�achr�s�etts ent ofindustrialAc elde�ts Department f i.= I Congress street,Sto 10 0 b www.rnasss-govldla � -W,, kers' compensatlon ensu ra=6 AMd E P � i A�U Ozt C trxcxa a sCC' ers. TOBEI?ffyD fff- Wease>?xirrt :Le 'dal Alzcant;Information �": Namo(BwiuessloKgawzatio,,A a lividuaI):_— C �„ - ' U-2— TYPO o9project,(Mtec7;)_ tAxe pan enrplo'pex?Glpeck the appxapxiate box; 7. jqe' '`t;on.nsil fiction I. a exapinyaz With _ ?.mployees(full and/or part tiuia)-" } 1 g. ❑ReznodeliYi 2.F]XanasoleproprietororpartnersbipanclhavenoemplayaesWarkin iormein —i ep7o17t7oI] any capacity:U7o-yvorkere chap.insuranca required.] I —1 3.�I am,ahoineowner doing all workmys'x(Novorkers'comp.imuraucerequired.] ` 10 L]Building addition anntraatnrs to conduct all vrork onany pzopazty_ I will s Orad diti 4, ca�as 1].�Elecyarical seRaix FIjam ahomeownher audwill be hiring , ensurethat all contractors githezava workers'eorapensation Somme, solo xcpails oraddzixanS pxapriators vrith.na 6woyee3. OIL t l 3 :Ciaofro&irs 5-EI am a general contraotox anti IAsavo hiredthesub-contractoxs listed uran e attached sheet �4 � These sub-contractors have eaployees andhava'�O&ers'comp.insurance s,�Wa are a nozpnraii.a�.and its•,eff"icens have exereisediheiz xiglnt of exemption per MC%Cj c. 14. 152, r cics�b #�7 eNawnrkescomp- nstnanoe.reqired[ §1(4),andwe)aveno employees. i �nrkJe Gontr s'compensat3onpor , Mouttholcctoablowshowigthe6tsaboitnow affidavit-all work indicating h nYapplcantatahehbluomEudstaaittaichdidoing � � ct_ _,. — ha_v emus Romeawners who submttnd:uadditional sbactors ahnt saghcon "dotheiz workestomp polcysunbeTCantrantnrs that ahecrfishaveemplcyeesthwYM[stproverno -consactnrs yam arz ernplayer tliat xspt'ovxdi,-tg"1,va)-lcer�s'carnpensadolz zrzsa�a�xcefor any erriployees, j3pla�is tliepalrcy arr.�;iotr szte [nsuxance CompanYNaane:� Expiration Date' ]?olicy#or Selfhm•Liu. r. ,� ,,„ CztylStatel�Gi ¢ -�____._------- rola Site Address: ' �` `- — - — -— the olky number ar�.cl exp7a at aaa date)• Attach a copy Offhe`W#kers' Co"npexLsatzanpolxcy cteelaxat onpa e(showcag' p Failuxeto secure cavexaga asa:ecluz�eclunclerMGL o'esZtnt- eform of OP-WORT<&l�E'�l25A fi;a Criminal-do attldaal�e ofu�rto �25�0-�0 a and/or one�yeaxivoprisonment,as-wel!as civil pena[t� day against tha violator.A copy of113js datomon-t may be forwarded to the Office of TnV6Rtti"tions o.Ctlze DIA i is°a Bance cover age-Ve i f cation. _ _--__ =. --— __ - t — ~--— — 1 ly l da lze eby ter under'&-&pains andpenal'mss o c�'u t7iat tPze 1N. .by above z t hand ea r�c� .• w; �,. -____ date__._____.��� ----- S natture: zczc�Z ruse anZy. Da of r2 trzis a ea,to lir corner city ar ta-WIz official, Cuff City or To-wu,:_ _-.— ----- -- IssuiugAuthox`ity(cir6le ane): ' ].. 3a�xrciofLealth u rling7lepaxtr�aenG3.G'1fY1 'a`fGf(-rk. 4.Facef,xxealxnspectox5.l'Lum ingxaasaectox G.pflxex clon:tactI-lexsora. LUONG-1 OP ID: SG ACRD' DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 03/01/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVE=LY 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(ies) 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 ondorsement s. PRODUCER CONTACT I NAME: NorthStar Ins.Services,Inc. PHONEFAX 300 First Ave,Suite 100 Arc No. o E1111:781-431-2500 AIC'No): 781-431-6134 Needham,MA 02494 EWAIL ADDRESS: INSURER S AFFORDING COVERAGE NAIC# INSURER A:Central Insurance Com an 20230 INSURED Luongo Sprinklers, LLC INSURER B:Evanston Insurance James Luongo INSURERc:Hanover Insurance Compan 22292 PO Box 463 Billerica,MA 01821 INSURER D: =INSURER 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 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, EXP INSR TYPE OF INSURANCE ADDL SUER pOLICV NUMBER MM©DYIYYYY MM DDEFF lYYYY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 TO A X COMMERCIAL GENERAL LIABILITY CLP8871996 05116/2016 05/16/2017 DAMAGEPREMISES S(Ea occc ❑urrence) $ 300,000 CLAIMS-MADE 1K OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident C ANY AUTO AW PA58255502 04/20/2016 04/20/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 B EXCESS LIAR CLAIMS-MADE XOBW6260116 05/1612016 0511612017 AGGREGATE $ 2,000,000 DER I X I RETENTION$ 0 1 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY L FR A ANY PROPRIETORWARTNEWEXFCUTIVE Y l�N NIA WC887199719 05/1612016 05116/2017 E-L,EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) N E,L,DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proof of Insurance CERTIFICATE HOLDER CANCELLATION PROOFOF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD =` Commonwealth of Massachusetts Department of Public Safety License: SC-114814 Sprinkler Contractor ` JAMES R LUONGO 198 STOW ROAD STOW ME 04037 r-"-jzC CA— Expiration: I' Commissioner 04122/2018