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Home My WebLink AboutBuilding Permit #124 - 234 BRIDGES LANE 8/12/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 0- Date Received Date Issued: - �_ t- IMPORTANT: Applicant must complete all items on this page LOCATION /Z r Co( L., Print PROPERTY OWNER Lp�vnv�� v%. r/ ! Print MAP NO: _t � PARCEL: tT 6 ZONING DISTRICT: 'Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement ✓ Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: L,vli/(-I vil C Dov Phone: C1 ? Address: `3 ��t t �L L�/, N� �C3 VL-;,t CONTRACTOR Name: �t G /Y2 C`7 Phone: 9 "7? G e2 ` 0/0 Address: 104- ) �rf'L15- 097741-'- L-A./ t't'l ��-• e^�/-�f Supervisor's Construction License: Q d jc� Exp. Date: f`( j'Xa-& Home Improvement License:_ f v� Exp. Date: At - 1 1 ti ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ C, coo FEE: $ Check No.: �� d" ��— Receipt No.: �' NOTE: - ofPersons contracting with unrd contractors do not have access to the guaran and Si natA entlOwner T g _ . - Signature of contracto ure Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS - HEALTH Reviewed on Signature a COMMENTS Zoning Board of Appeals: Variance, Petition No: zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location 3 &, 4--r-A N o. Date I 40RTk4 TOWN OF NORTH ANDOVER f R . A }�a Certificate of Occupancy $ CNUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ c TOTAL $ Check # 2261 Building Inspector "Ie Comrnorrweaft ofMassachusetts DePartmemf of Industrial Accidents i t ice of Investigations 600 Washington Street ti„' Boston, MA 02111 t 7 wu�w mQss.goU/dia workers' Compensation Insurance.Affidavit~ Builders/Coatracfors/EiecfriciansiPinmb A 'cant IaformatiDR. ers . . . Please Print LeQibi Name (Businrss/ l brgeoizadrnr/individuof): � � �--� 7I Addms r, 7 CC, t/. City/Stat~/:VL/L.1 6�1M4 O q� Li Phone#: . �' 7 7C11 U Arerilmim as employer?Cbeek.the appropriate box: I:E� a employer with c�--- 4. ❑ I am a Q T�of pro! (regni*: =,emeral contractor end I 2.Demployees(fun and/or part-time).* neve hired the sub-co�aetcn 6. D New construcdon I am.a sole proprietor.or partnw. listed on the attached sheet 3 ship and have no em f ees 7• ❑Rtsrrtodeimg P oY Tbese stnl�-eontractors have working far me in any capacity. workers' comp.insurance. 8' D Demolition [No workers'comp,iasruance S. Q We are a corporation and its 9. ❑Binding addition req�d.] aff+cers have exercised their 10.0.Electrical repairs or additions 3.D I am a homeowner doing ail work right of exemption por MOL IL myself[NO-WorkD Plumbing repairs or additions insurance ?red. �, 'c' �?' §1(4j,'and•we have no -required.] .employees.[No workers' 12•[]Roof repairs *Amy apptice„c ri,er comp• insurnn=inquired_] I 3.0.ether checks boZ f€!must also fin out the section below showing&eirworkad aompanse$ou policy mfonmfion. t HomeownerT who submit this affidavit indicating they am doing ail worts _ ICoufta ors that check this box mustarteoh rn add.�tiaasl A- 4- Mand then hire ouraide cenMtctors must submit anew afrtdavit indi WhM ttte nw.o£tir sub. ca*such. f tF�. contractors and tom' worm¢'rc. �e'�ioper that isyor»+od"uagwor�.�•'�, erzs `� 'w�•FcFic;:mon. fo> flor_ at�tn iirauranrefor my.=W&v a,., B", ly t .*.1sePiilicy Gndyob site lnstaancc Company Name: Policy#or Self-ins.Lic.#• q'� �—� 3�b �t1� Expiration Ewe.Y Job site Amt;: 3Y citylStBterLtp: fir Attach a copy of the workers' coin °4 N� �— peumfioc Poky a�aratiion page(showiag the G Failure to se^trre covers a as Policy number and expiration date} . g required under rnentn s w of MOL c. 152 cart lead to the imposition of criatinal penalties of a fine up to 50.00a d and/or one-year imprisonment;as well tis civil penalties in the form of a S717P WQi m al pna and a free Of up to$250.00 a day aping.the violator. Be advised that a copy of this statement may be forwarded to the Investigations of the DIA for insurance coverage verification. Office of I do hereby certify un and cdiuY Bleat the cnfoTmagoa provided above is[rice ¢orrecx Si Q Date: Phone#: O O J O,f�iciQl use only, do not write wx this area,to be c»mple�ed bj'�J'or town ofjrciol City or Towtr Permit/l.i,caase# Issuing Authority(circle one): 1. Board of Health 2 Buildin;DePwIr aeut 3.City/Towu Clerk 4. Electrical Inspector 5. Plumbing Inspector (.Other Confect Person: Phone#: i OP ID DATE(MMIDOIYTYY1 ACORD� CERTIFICATE OF LIABILITY INSURANCE rLIIBT-1 08 12 09 PRODUCER ONLY AND CONFERS NO RIG U ON THE CERTIFICATEION Segreve & Hall Ineuz.Assoc.ZnC HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 305 D1ott]� Main S t. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Andover MA 01810 NAIC11 Phons:978-975-1300 8ax:978-975-7596 INSURERS AFFORDING COVERAGE 41360 INSURED INSURER A: ACL+lil■ Protection TAA• ea. INBU •• Zneuxaa ce Co. 3,1754 INSURER e. Cotttirterce ,. .. Richard Fluet Contracting IDe. KWqU ER C: 102 Bridle Patth44Lane RDMethuen MA 01R E: COVERAGES T POLICY PERIOD INDICATED.NOTWITHSTANDING T THE INSURED NAMED ABDYE FOR HE THE PpLX lE5 OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 0 TO W NICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT,TERMOR CONDTrION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT AMY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE I.IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMBER DATE MIDD DA7 MMIDDIYY LIMITS TR NSR TYPE OF INSURANCE EACH OCCURRENCE 51000000 GENERAL I.JOILTTYb 100000 A X COMMEROALGENERALLIABILITY 8500034727 06/12/(19 06/12/10 pREAIiSEs(Eaeeelmnde) CLAIMS MAGE [X]OCCUR MED EXP(Any one perm) s 50 0 0 PERSONAL AAOV INJURY S 1000000 GENERAL AGGREGATE S 20 00 0 0 0 - -- PRODUCT$•COMPIOPAGG %2000000 GEwL AGGREGATE LIMIT APPLIES PER, POLICY PRET I LOC FOM013U LIABILITY CDMBINED SINGLE LIMIT b (EA Accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ 100000 12/01 09 12/01/09 (Peroerson) $ YX SCHEDULED AUTOS 7CV14 fi 0 / •• - ' HIREDALROS 90DILYINJURY S300000 (Prr accident) NON-OWNED AUTOS PROPERTY DAMAGE $100000 (Per sccWenl) AUTO ONLY-EA ACCIDENT S GARAGE LIABILITY ANY AUTO OTHER T14AN EA ACC S AUTO ONLY: AGG S E ACHOCCURRENCE b EXCEM MIBRELLA LIABILITY OCCUR I J CLAIMS MADE EGATE b g DEDUCTIBLE S RETENTION S WORKERb COMPENSATION AND ORY LIMITS ER A EMPLOYERS Lu►BIIITY 910434 03/31/ ACHACCIDENT s500000 ANYPROPRIETORJPARTNERIEXECUTIVE ISEASE,EAEMPLOYE $500000 OFFICER/MEMBER EXCLUDED? ,de�eribe underISEASE•PpucY L?MIT S 50001 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I%TmICLE91 EXCLUSIONS AOM BY ENDORSEMENT I SPECIAL PROVISIONS I CERTIFICATE HOLDER CANCELLATION 7]DATE HOULD ANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE THE EXPIRATION Town of North Andover THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN Attention Brian Leathe OTICE To THE CERTIFlCATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL 1600 Osgood Street MPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,RS AGENTS OR Building 20 EPRESENTATIVES. North Andover MIL 02845 0 R A„r T� "��(•�- ®ACORD CORPORATION 1958 ACORD 25(2001 FOS) I