HomeMy WebLinkAboutBuilding Permit #920-2016 - 59 ELM STREET 2/26/2016%AORTH
AaM -�DUV�'
BUILDING PERMIT
TOWN OF NORTH ANDOVER
00
APPLICATION FOR PLAN EXAMINATION
PermitNo#: Date Received
,CHU
Date lssued:2—�-Z-(,:,tt�o
I IWORTANT: Applicant must complete all items on this page
LOCATION -S-2 1�71Z-14
Print
PROPERTYOWNER Arj1k,,,0- ( e- v e -
I Print 100 Year Structure yes no
MAP PARCEL: &/9 ZONING DISTRICT: Historic District yes no
0
Machine Shop Village yes (0
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
11 Addition
41fwo or more family
0 Industrial
11 Alteration
No. of units:
0 Commercial
0 Repair, replacement
0 Assessory Bldg
0 Others:
OlDemolition
0 Other
11 Septic 0 Well,
El Floodplain 0 Wetlands
0 Watershed Di.8tri
11 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
—/,o ex ,&-%A /3, r -E, y
�v
Identification - Please Type or Print Clearly 9-z�
OWNER: Name: kr�kvr m, -.c u -e- Phone:
Address: (o 6 u vt r, 1) e te &L V,
Contractor Name: X-yx-(� =vie Phone:
Address: S S ' Lc&ncc.)4�xr S 1�- 9 CWL,--�Vtt AA 0.
Supervisor's Construction License: 0 F65') 5-- Exp. Date: 71-Z 1 �17
Home ImDrovement License: Id FS -b
Date: �// 1/ 16
ARCH ITECT/ENGI NEER 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. $ FEE: $
Check No.: � %I CS&
NOTE: Persons contracting with unregistered
Receipt No.: :�3ZO6� Z—
do not have access to the guarantyfund
Plans Submitted [I Plans Waived 11 Certified Plot Plan 11 Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools El
well El
Tobacco Sales
Food Packaging/Sales El
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On Signature'.
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
. Conservation Decision:
Comments
Comments
Water & Sewer ConnectionlSignature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 USgood 6treet
F-IRE-jQE-PARTMENT -.Tb'mp)DumpA�er,.qn,�,5�Tf�.IY"�PSL�� —LL ;J!00,
(:Ldd-0f.e- -at',12',41" -�, ti' -i
01. WintS.ree
COMMENTS -
Location
No.
Check#'
Date ' 11 - � -. 1, (.f�
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$-
Building/Frame Permit Fee
sLz--�—
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
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_-Proposal
(J*Nok—
HIC # 108503
All Types of Home Improvement
38-40 Lancaster Street - Haverhill, MA 01830
Haverhill, MA:
(978) 372-4088 Nashua, NH: (603) 595-2272
Andover, MA:
(978) 475-3723 Portsmouth, NH: (603) 433-1811
Woburn, MA:
(781) 937-4212 Manchester, NH: (603) 666-5502
Natick, MA:
(508) 653-2200 Dover, NH: (603) 740-3099
Boston, MA:
(617) 423-3559 Rochester, NH Lakes Region: (603) 335-0068
Toll Free Nationwide: (800) 966-9238
Fax: (978) 372-0360
www.jnrgutters.com
PROPOSAL SUBMITTED TO PHONE DATE
STREET JOBNAME
CITY, STATE and ZIP CODE JOB LOCATION
We jJrXIVOSe hereby to furnish material and labor - complete in accordance with specifications below, for the su-m of.
dollars ($
Payment to e made as follows:
i
C
Authorized, Note: this proposal may be
Signature withdrawn by us if not accepted within days.
We hereby submit specifications and estimates for:
-7�
CO.
L' 7,
Te-
E.C17
0 L� 7
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tc I
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6
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'�Arreptanr-e of JJraposal - The prices, specifications and Do not sign this contract
conditions listed above and on the back of this form are satisfactory and are if there are any blank spaces:
hereby accepted. You are authorized to do the work as specified. Payment will
be made as outlined above.
Three day cancellation rights under section forty-eight of chapter ninety three, sec-
tion fourteen of chapter two hundred and fifty five, D or section ten of chapter one Signature
hundred and forty D as may be applicable.
Ae commonwealth Of Hassa'�huseas
Department ofindustrialAccidents
I Congress Street, Suite 100
Boston, 1IL4 02-114�2017
www-mass.govldla
Wovkers, Compensation Insurance Affidavit: BuffdersIContractors/Elqctflclansffltumbers-
TO BE MED -VUTH TM ]?FPMTTMG AUTROMY Please Print LeghlY
A cant fnformation,
Name (Biigi-aessloxganizationftdividual):
Ad -dress:
city/statelzip;
,.Pl.y,r? app*r'oprj�ta box'.
Are you an
NY ) 1) Mono #: -7
fig
i.Ofam.aemployervith '7,- 61"Ploy"s ( andlorpart-fta)'*
I am a sole proprietor or Parfner8MP andhayo no e"PlQYe0s'Wo'kffig forYAG M
any calacity. [No workers, comp. insurance requived.1
9111 am a homeomner doing 4 woEkniyBeM [No -,vorkers, pomp. insurance required.] t
I am a homeowner anct-will ba hiring contractors to conduct all w -&on my Property- Ival
4-Elonsuro that all contractors e S010
,iff,,r have wolkere compensation insurance Or are
S.E] I am a general contraot?r andl hayeaedtho sub-coidractors Ested onthe attached sheet.
these oes and have worke& com
S�Ib_contractoj OY
p. Insuranco.T
6.[:] We are a corporation and its offiqRrs have exercised their right of exemption per MGL c.
n� a -Ye�g. [
No worIcars, comp. insurance required.]
152- § IM. an� -we ha
Type of project (T*jxed):
7. New construction
8. Remodelffig
9. El Demolition
10 F] Bacyng addition
II.E] Electrical repairs or additions
13. Ej Roofiepairs
14. El Otlfbr-----�
I must also M, ont&tWhO Sectionbelowy, sh—ol>heirwOrkers' rompensationpolicyMou-nation.
indicating they are doing alUt -work andthea hire outside contractors must 34bmit a now affidavit indicating such.
sheet showing the
. name of the, sub -c ontractors and state whether or jio� thos a entities h�Lvo
ZZYNII: V;orkirsl comp. policy numbar.
y an djoD 81te
�rNrv' compensation insurancefor, my emplbyees.' BeIOV is thepolic
information. -e
ThsUranco CompallyName, _r 2-01
Ct Lj 2— ExpirationDa
C, o 0_
policy 9- or 8 olf-ins, LiG.
fob Site Address -
Attach a COPY Of the ;�Orj&32 cbmpopsation poMy declaration page (showingthe POJicynumber and expiYation date).
Failure to se=a coverage as required under MGIL o. 152, §25A is a r le 5 .
,ximinal violation punishab byafM0-apt0$I 0000
and/or one-year imprisonment, as WOR as civil penalties in the form ofa STOP WORK ORDER and a fine of up to $250.0 0 a
day against the violator. A copy offbis statement may be for-ffarded to the Of:fice of luvestigati6ns ofthe DIA for insurance
coverage verification. yormationprovided above is true and correct
�dojije�rebyeer�gf
.y unJer —Mepalrs andpenaldes ofPejjUU Mat the in Date
Phone j. Y
g, ? �,,7
offleial use onty. Do not -write in this area, tO be comPleted by city or to" offlcial'
City or Town:
permitILICense
Issuing Authority (eircle one): i cle& 4.Mectricalluspector 5.Plumbing1aspector
I.Board of E(ealth 2.)gaffdjug)Uepartmeut 3. City/Town
6. Other
Contact Person:
Phone
--le
AC40RV CERTIFICATE OF LIABILITY INSURANCE
ill.�
DATE (MMIDDNYYY)
1 2/3/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsoment(s).
PRODUCER
Cross Insurance -Peabody
139 Lynnfield Street
Peabody MA 01960
CONT CT Glendaly Gomez
,AME�
PHONE (978)532-5445 (978)532-2217
No Ext)* Nol:
-(AIC-
E-MAIL
ADDRESS:ggomez@crossagency.com
INSURER(S) AFFORDING COVERAGE NAIC 0
INSURER A -Berkley Regional Specialty Ins.
INSURED
JNR Gutters, Inc.
38-40 Lancaster Street
Haverhill MA 01830
INSURER 8 Merchants Mutual Ins Co 23329
INSURER C.Graniter State Insurance Company
INSURER D:
INSURERE:
FINSURERF:
f'nV=DAf'_l=4Z rF:RTIFIrATI= NIHIMIPIPRCL159249284 RF-VISIUN NUMk:$L--K:
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.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR
POLICY NUMBER
POLICY EFF
POLICY EXP
LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED nce) $ 100,000
PREMISES (Ea occu
A
__1 CLAIMS-MADEFx
-1 OCCUR
MED EXP (Any one person) $ 5,000
CGL0050174
7/20/2015
7/20/2016
PERSONAL & ADV INJURY $ 1,000,000
L AGGREGATE LIMIT APPLIES PER:
GENERAL AGG EGATE $ 2,000,000
PRODUCTS - COMPIOP AGG $ 2,000,000
POLICY [:] PRO- F LOC
JECT
M'OTHER:
— $
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
130DILY INJURY (Per person) $
B
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
X NON -OWNED
HIRED AUTOS AUTOS
MCA7015134
6/21/2015
6/21/2016
BODILY INJURY (Per accidenQ $
PROPERTY DAMAGE $
(Per accident)
pip -Basic $ 8,000
X
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $ 51000,000
AGGREGATE $
A
EXCESS LIAB
HCLAIMS-MADE
_.DEDT1
RETENTION$
$
CU0050684
7/20/2015
7/20/2016
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNEREXECUTIVE
OTH
ER
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYEE $ 500,000
C
OFFICERIMEMBER EXCLUDED? E
(Mandatory In NMI
NIA
WC009774192
9/20/2015
9/20/2016
E.L. DISEASE - POLICY LIMIT $ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addttfonal Remarks Schedule, may be affached If mom space Is required)
1%0M'r1C11%A'rC Uf%l r%C0 rANr.Fl LATION
19 1 VtI7J-ZU14 Al,;UKILI UUKtUKA I IUN. Ali rigms reserveo.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 1`701401)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
For Insureds Purpose
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WTH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Glendaly Gomez/MD1 ALMJAW-
19 1 VtI7J-ZU14 Al,;UKILI UUKtUKA I IUN. Ali rigms reserveo.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 1`701401)
Massachusetts DepaittnentDf Public Safety
'86ard of Building. Re.gu'16tions and Standards
License: CS -080515,r
construction Supervisor
KEVIN M FRANCI&
33 LAYFAYETTE,ST)r —i
HAVERHILL MA; -;018
Expiration:
Commissioner 07/21/2017
Offi-e o VbAl
f Consumer Affairs & Business Aegulatioll..
ME IMPROVEMENT CONTRACTOR,
-egistration: 108503 Type:
xPiration: .8/19/20,16 Private Corporatk� 1 !
J N R GUTTERS, INC.
Jonathon Raymond
36-4
. 0 LANCASTER ST
Haverhili, MA 01830
us