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HomeMy WebLinkAboutBuilding Permit #060-16 - 534 SOUTH BRADFORD STREET 7/14/2015 01It NORTIf q ttbtD 6��Q < BUILDING PERMIT 3� ^:• ` �'• o� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received V � � w0*AToP Date Issued: 9SS�cHU I ORTANT:Applicant must complete all items on this page LOCATION__: 5 3 4 6vr h 6641 94r- Print 4Print PROPERTY OWNER .�o � b.-jpc( Print MAP NO: �PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building -o-One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial @-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic 0, Well 0 Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer R��[�' Kc�77YT! T�Z�+M q h� S1 Df alf Cr Identification Please Type or Print Clearly) OWNER: Name: 'ToSePh AC--6•o Phone: cTIu E OG (PU- - Address: 534 ,4Q Sr. CONTRACTOR Name: Phone: Q-7$ $C,S Q((, N43c-, Address: Supervisor's Construction License: Exp. Date: Lei it.o, I Ito Home Improvement License: Exp. Date: V 3'1 5S,2\ It zw 140 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cos : 5'00— FEE: $_ q J Check No.: Receipt No.: NOTE: Persons contrac ng 'th unregistered contractors do not have ace s to the guaranty fund ignature of Agent/Owner 4,. T—gqature of contractors NORTH own o n over o " h Mass, 1 2015 CO ver, cocHicHew.c.c �►• �d A�R�T1E S V BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT t 11.0JVBUILDING INSPECTOR has permission to erect ............... buildings on ..... � � �... Foundation ........... .... .................. . Rough to be occupied as ...... ............�.�.� ......... .......... ... . . ........ .. ........................... 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 M T S ELECTRICAL INSPECTOR UNLESS CONSTRUCI RTS 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 of Massachusetts ;Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricions/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Leeibly Name(BusinesslOrganization/Individual): IV A 3 C-, Address: o dflk 17Z City/State/Zip: AevCxo,..er ti[vl otb��Phone#: q)-7b 6-09 96'!C Are you an employer?Check the appropriate box: Type of project(required): Lamm a employer with employees(full and/or part-time).' 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing al I work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S.Q I am a general contractor and 1 have hired the subcontractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t n ^ i2l� OF 6.0 We are a corporation and its officers have exercised their right of-exemption per MGL c. 14. her I 152,§1(4),and we have no employees.[No workers'comp.insurance required.] D✓A-j6- •Any applicant that checks box#I must also fill out the section below showing then workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I I am an employer that is providing workers'compensation insurance far my employees. Belmp is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: &tG Expiration Date: 1)Ilk �D Job Site Address: `, st�u'h CitY/State/Zip Attach a copy of the workers'compensation oticYdeclaration page the policy number and expiration date) . i Failure to secure coverage as required under MGL c. 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 of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sianature: Date: Phone#: b,e'�iUq 9ln((.o Offlclal use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: /2014 3 : i6 :55 PM 8740 0 02/02 m `ter DA7f=ItalalilBIm �` lril5 Ce-1 TIF[CAt IS ISSUED AS A Pa-ti or-WORt1MON ONLYMD COMERS NO lumms UPON TIME CE zt CATO HOLDEP•. TMS 09PITIFICAYE DS NIST AFFRW*-1 llis(-Y OP IGSATIMY ANW,SND,QR ALiM TIDE C91 M APFQP.DLID BY-em poLf(;ES BELOW. THIS ClI'i'�ICATE OF I'nlSumdom boss imr adm T,HE A CQi t t�I�I;'llla tM TIE I95U : t�1G IN�j,A€tTI$OI;I��E9 P�EI�P,ESC-tl!F'AYiItE�! F O DUCIrr 4.411 lII THE M P1CiA3E HOLLF)E., IMPOP,T Ali!A l the cer ba-lee hBlde:is an A FsMU&MUM,Ma poft its)rA 1 bs enti Md. If SUBROGA i ON IS VdMDI SubPect,to fete°ems anlf coI=.mans flf file POP,;certain Pames to y mgtaran endofS�Ienz A ddement on:Itis C�e.�lflea'te seas trot eonW Slghis two the cett-i€fcats€colder�iters cifai b eAflorl;Saettf f* F,zoQIlx 04963-ODI cr ItiM Inounince ASsoolateS LX iAl6 o.25I 7979)GM-8700 FAl�R� t9'18I 8Bti-S7R'1 1320 Osgooditeet iTIOA MdGVer,MA 0104 n�n 'nom•. — m GS Iia IkSttRrs7 res a• A.I.M.NI{rYttel Insurance Co pq II'ONZ and=ev Su;llding Cora U s- a0 901; iia ' C: :tpr8tl Aftdpva:, �A.41885 •WOMB: OOL�.Afa1E$ T a tyl=f`�t rt'rI�A:�nitFlln$El?: - RSI®It]Atlilt'IE�• me IS TO CERIVY TrIAT Tris POLICIES OF 0$SUIiK ME LISTED BELOW HAVE BEEN ISSUED TG�A�lSlIREF?NA15Et3 pB01/c F04 171E POLICY F?.IOD INDICAMED. NOTLMiZ'ISTANDING ANY REQ,=pVR If'TOM OR CONDf77OH OF/M1Y{�RF[RAOi'OR�7I IER Q dpi i 1ftRTH t3E5FECT To WrtICIi iY0 r-CL FlCAte MAY BE ISSUED OR MAY CIj PiL1i W. iilE OLSU pfi t 7g ED S%?THE POLICIES DESCRIBED HEREN IS SUBJECT i�ALL 7He TSM. EXCLUSIO,\B Rh1fI CO,YdrPIONS OFSUCH FOLiCIES.LIRSIT3 SH01'i$CRY HAVE 3EEt4 REDiJCFt}BYFRtD CLAIMS IL—PS 0FC%wwwICEr D FOLtc1'I:U6,7ia4 Yyyf D Lli l GEie"@ALLYt6ltCtY EACHOCctIRfl�f� $ COIt•E��ICtAI.GS�'EKUAMftY OAiSAGE f� s ( CWfuL�'.ti?3'� �C�JR IslG3FXi'{iR/oAsF35��j S Fid* P1RLSADVIDIJURY is G! AGGRESA-Te (S rs�lrlGGP,-�rskTEUIJFi FiRFl1E5� I � pgpp►(py'$-COMROPfSiG 5 L iOLi03{L3LUl5t ny A LOa^ TOSLLOUI�tPlUCHA31ULID emLyVJURYiFt�N JS FURm AU-0S r�IFBu�L$ aotsLY tNJttRY tom:z�ttmp(S Aeras P AthFi _. E A d d n s s UIdt�3s'fc.LA t.WS OCCtJei f EACH O=W%MC= Is excam WAS CL,It,fSLfADE AGGRWiTz Is kN.D 109 OM"Ra U.rPY v tI 31(. C �-•-��5--- 71131 Urxrldatotl+in IiH) ��C-,09-res 232BY•�0 t..... i�JRil?0':€ i71i�.124�5i00,{IDD.i?t7 it, - q v; tat MS3R—M-E4E'a mYEE s 100:Q00.QQ ,ttaysWar.. l � EL aLs�,s-P?IctrtlSTJf s b00,DII8.Q0 i I DSCRIa,Ilaral .ailotrsrcOc4rrorsr ' I V IICL':SilunbAcowlef.AtldUrotg3Rcr�ac/s dW�ffu�orespac3rst frU j 13-ri lINCA I e IIOL,331=, '!CELi�'iOj I I WOULD AW OF rM A3QVE DFaCP.I3®PQLICM 0 CANTTCELLED SEFM 110.. EXPIRATION DATE i7�Ib7'Z-o 1401703 4M.LL IIE 0RX=-RM ,Ri CGAP.Dk�lGE?�tt'i rI TRE POLICY PRO'UiSfOASS :+w_Ono REArC-'=�fiAIV= -k- rr L .CORD 28201018& ©• fl 01JAO�I��I��a€I;iATI4t�. ria#SfeseltT�i. ( I' 's?te�1GflI�f3 Warne alts!ago are zOlsbarzO marls of A004D i r .J•�".�3;'Tiiii_lif pj fa,t(7i!(:`1i;"•sGi',: �` [3oarci of ivtuilctJic i'?e illavoil$ (.'iinsrs•uctien',,tepr!•i•isrh• l.icens�: CS-982,316 JOHN R LPKF+11 AK jn 76 iPII![.,LoN II OAb n�IIiL'P'�N l� 8D2�66 i~if„urd•:�;rt,+s:�•r 0611612016 .. I. t Office of Consumer.Affairs and Busine �� �� ss Regulation ` 10 Park Plaza .. Suite 5170 Boston, Massachusetts 02116 Rome Improve>!ment Contractor Registration Registration: 137552 TVPe: Private corporation NORTH ANDOVER BUILDING CORP. Expiration: 11/26/2016 Td/ 260459 JOHN LEEMAN P.O. BOX 132 N. ANDOVER, MA 01845 _...... _,.... .._ _._.... ._.........___................ __........ ._......_.._..._......._... Update(address and return card.Win,*reason Col.change. scn t r, 2oM•owtt /address f:::l C::;l Renewal f"..f gillpioyment Lost Card Location No.6 C��"+�©��o Date 7 /L . - TOWN OF NORTH ANDOVER 1, Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ � TEax TOTAL $ t i Check# J Building Inspector