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HomeMy WebLinkAboutBuilding Permit #1230-16 - 2 STACY DRIVE 5/24/2016 s NORTfJ 6. BUILDING PERMIT , ,6 q'�o r.. 46 .. 3 TOWN OF NORTH ANDOVER €;.. a- A ii APPLICATION FOR PLAN EXAMINATIQ'h[ ... M Permit No#: 2 W ! Date Received �• - - �'qs qATeo SgCHUS Date Issued: ey IMP RTANT: Applicant must complete all item�rdii#gage LOCATION ✓ Print PROPERTY OWNER �!`eSG�f� �!(a P int 100 Year'StMcture yes no MAPPARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition ❑Two or more family ❑ Industria! ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other t•.a> �=' w'd wA9' �'^�a`Y''�r s.,r ke ^s�y� ept c e I' f Food a b ® etland IS -Ad� w a e s ed I#J'dG-tqRq4` < DESCRIPTION OF WORK TO BE PERFORMED: +nLL� bBon Identification- Please Type or Print Clearly � OWNER: Name: rscct* S oc. Phone: Address: Contractor Name: 111v1 vt s G` Phone- Email: n i 1 r Address: Supervisor's Construction License: (' 0 M311 Exp.'Date: ZL`t� I'� Home Improvement License: t Lk 0 3f7(0 Exp: Date'.::::, Z� ARCHITECT/ENGINEER Phone: Address: Reg..-.1\.(0. FEE SCHEDULE:BULDING P�ERfMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COS F` WiMFOR4125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: 17 r�3 Receipt Ng:. : �5`?.I NOTE: Persons contracting with unregistered contractors do not ha WON. � ve=aees. tix;tFi guaran fund t. �'�`� r 1 NORTH - y _ _ ow , : c ver 0 . . � No. 1 a3b - .261 W. h , ver, Mass, 4 coc...'.rW1c« 1. s TE D U ` BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System (� F ...,..... ...... BUILDING INSPECTORTHIS CERTIFIES THAT ..... .......�........CQ!,1.Wpj............................................. nn Foundation has permission to erect .......................... buildings on ...l7L.� �... ... ./.:�.v .............................. / Rough to be occupied as ......... /.Y.S. ./ ..fa z'..'n4�.a..': .... r .................................................. 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 CONSTRUCTION S ARTS Rough Service ................... ........... .. ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. The Commonwealth ofMassachusetts Department of IndustrialAceldents " - X Congress Street,Suite 100 ' Boston,PM 02114-2017 , www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Elgctlicians/Plumbers. TO BE FILED WITH THE PERMn'MG AUTHORITY. Applicant Information Please Print Le •bl fi ' Inc Name(Business/Organizatiou&dividual): % P11n Address: City/State/Zip: Add�efdh /j'l�1 Q�9 K 9 Phone#: 77Y Areyou an employer?Checkttie appropriate box: Type()f project( @gnired): 1.�I am a employer with_[_employees(full andlor part time).* 7. [l New construction 2.[j lam a sola proprietor or partnership and have no employees working forme in 8. [j Remodeling i any capacity.(No workers'comp.insurance required.] 9, D Demolition In lam a homeowner doing all work myself(No workers'comp.insurance required.]t 10[]Building addition e J 4.Q I am a homeowner and will be hiring contractors to conduct all work on my prop rly. Iwill ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proirrictors with no employees. 12.[]Plumbing repairs or additions j .5.F1 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# 6.0 We are a corporsAgn pnd its gffigers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and Nye have no,employees.[No workers'comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who subniif this affidavit indicating they are doing all work and then hire outside contractors Must submit a new affidavit indicating such. $Contractors 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. Ifthe sub•c6n6,,[urs wive employees,they must provide their workers'comp.policy number. .T airs wz employer that is providing workers'compensation insurance for'my employees.'Pelow is thepolicy andjob site information. ( Insurance Company Name: Policy#or Self-ins, Lie.#: ( 7 I .3 J Expiration Date: 02 0�0 ��� AI Al W ` Job Site Address: '02 ?— n vlf. City/State/Zip:L c ��``�` Attach a copy of the workers'kompepsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o.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 form ofa,STOP WORK.ORDER and a fine of up to$250.00 a day against the violator.•A copy of this statement may be forwarded to the Office of Investigations of the DTA.for insurance coverage verification. X do hereby cern under thepai�ainpps��andpenalties ofpe4futy that the informationprovidedabove is hue and conect. lam"' r Si afore: Date: Phone# Official use only. Do not iw ite in this area,to be completed by city or totpn official. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ® CERTIFICATE OF LIABILITY INSURANCE12-/11/2016 DATEIMM/DDMlYY) ACORO THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy((es)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COW E: McSweeney&Ricci Insurance Agency,Inc. PHONE RIC.No; 420 Washington Street E-MAIL s Braintree MA 02185 INSURER($)AFFORDING COVERAGE NATO A INSURER A INSURED UNI-P-1 INSURER B: Uni-Ply Roofing Inc INSURERC: 3 Forms Way INSURER D: Middleton MA 01949 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:688057472 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. !NSR LTR TYpg OF INSURANCEAWL POLICY NUMBER MMILDIDY EFF MO pCDY EXP LIMITS A GENERAL LIABILITY CPA0074606 2/15/2016 2/15/2017 EACH OCCURRENCE $1,000,000 X DAMAGE COMMERCIAL GENERAL LIABILITY E S e RENTED u c 5260 000 CLAIMS-MADE OCCUR MED EXP A one pore $5,000 PERSONAL 6 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGG $2,000,000 INED SINGLE LIMIT POLICY X PRO- LOC S A AUTOMOBILE LIABILITY MAA0074476 2/16/2016 2/1b12017 Ee a dent) 1000 000 ANY AUTO BODILY INJURY(Per person) S ALL OWNED Fv7 SCHEDULED BODILY INJURY(Per aaldant) $ AUTOS NON-OWNEDPROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Pe aecWent S i A UMBRELLA LIAR X OCCUR CUAGO74507 2/15/2018 2/15/2017 EACH OCCURRENCE $1,000,000 FX EXCESS LIAR CLAIMS MADE AGGREGATE $1,000,000 DED X RETENTIONSO 5 B WORKERS COMPENSATION WC0719336 2/26/2016 2/26/2017 7X [. STATU- 0TH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE a NIA E.L.EACH ACCIDENT $500,000 OFFICE BER F�CCLUDED7 (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE $500,00D If yyes describe under E.L.DISEASE-POLICY LIMIT $500,000 DESRI (ON OF OPERA ONS below i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,AddRlonal Remarks Schedule,If more space Is required) 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. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD -� Commonwealth of Massachusetts Massachusetts-Department of Public SafetyDepartment of Public Safety Board of Building Regulations and Standards !F Construction Stipercisor License: HE-076413 ' Hoisting Engineer License: CS-084282 ' *� I{EVIlv A CAll4P S KEVIN A CAMPONESCKI , Imo: 3 NORMAN ROAD 3 Norman Road 'READING MA 01867 Reading MA 01867 * T Expiration Expiration: 'Commissioner 02/0412017 tCommissioner 02104/2018 i �A. ) f(n/JrR1011W(•ps, i License or registration valid for individul use only 1 ;i\. Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: /r HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation ! Registration: 140376 Type' 10 Park Plaza-Suite 5170 Expiration: 10/28/2017 Individual Boston,MA 02116 KEVIN A CAMPONESCKI I KEVIN CAMPONESCKI 3 NORMAN RD10 I READING,MA 01867 Undersecretary 4Not valid without ' nature j s 1 i • i 1 AEDIALE:aA11N[t'SCERTIFICATL ---- _ — ----- 'ILnNyCOatl�nttunhed /�T.t•+ r%•••t."^t't' h tavrdute with utlwtnlAleter brie.i.l: I RMLllvetl�CpR591AtJF1Af)udwllhttvwkd d1bedd bidvttm,19ad Ok peneP hgtaUfied,ad,lfappttmbk,ulT whet -- wndet tel Mkt Let _ OdrltlatwlOh anerespl hln<N,ttae(NCFIINIAT) [+.ti+�—„[�1- p�t�—ptE" ...p Ea prtronptatrdh,-ti*b Pet CFRIeC..hnbn CeNDeatt(SPE) _ r �RT.,S R(tlyEp�p 13-'­g e •�bF; waWMntmpttna O9vaGMd h,aptnlbe ef4PC/R U1.d1 r°rr LICENSE- . - yUSA ipa hfsmef:nlh eepro.lded teptdhplhD pL,tlnl wnklalleAhmt udeenplelw Atvnpkteeumbnllve femwRbnyafUtbmtetembW11U, IIA fi.dhtt nwpltltyand mnnly,evdbvn Rl<Iete,vOltt. MLDIGLETE NAMW[R TELEPHONE 4d MWDER ! •1 ,1 ZSS DAGIII9II6 '• ���F NONE ,vS. - a R7(A,i1WER+s NAME(PRIt7f) �/ .' AD 130"nam 0Aj.,<d P. ke HnSt VV4 , —3-008— 41 TAN P1 �f'I'!1/tj n� OPh)11<b.MtDbnl 0Olber Mttllbn<r 04A.975 r AIEDICALE%AXtINMISLICENSEUR NATIONALREGISTDYNO.0 CEIITIFI4ATENOIISWING STATE i tssac,M# tsNdt509 u (, ; rts — vse •. ,... �y. t•^ - I SIGHATliIEOFDRIVER INTRASTATEOM CDL DRIYER'S tES IlCCNSEND. STATE MCC 11 {ted,' ONo ANO TOREN �,gy�a �L ADT)"M OTO ER I IJL /f,•.tt..J. i�It L�IJLi� READING,MA 01867.27111 J Y ''1. IAILDICAI.[ERTIFlGTION CA•IRATION DATE JIII�I II6 •5-DD02.06•2013ROVOI-15-2000 • L.-- I I L