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HomeMy WebLinkAboutBuilding Permit #627-2017 - 8 STACY DRIVE 12/9/2016A (� BUILDING PERMIT Lli TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received a -Q - X 11 Date Issued: I a - 9 - 01-V t IMPORTANT:A v'm LOCATfON; v u it PROPETY- 8M P" MAP NO41 71,rott PARC La, "ut Zt must complete all items on this TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family CONTRACTOR Name ❑,4ddition ❑ Two or more family ❑ Industrial VAlteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other [-Septic ❑ UVell , ., < ❑ Floodplain , elands C� atershed 1�s " t ❑ Wai or/Sewer.. %�f IS` A �� r tP C� l� Y1on 1�A6-r1 nc,, w �e l) Ir �'ltfalt -ra l A 1<t- 1-- 19 kn -e a- w e'A l I Le a 1.., c. ✓ dam -.�-e. k QJ n4 w--- 1 l in l h -1k- Cj &f -r' q -�e- -L 1"� k, 4C Identification Please Type or Print Clearly) OWNER: Name: Phone: A ddress: clr r--e— CONTRACTOR Name Pf�one�3`"C r Address f f�^� r Supervisors Construction License,l Exp Date x� 77, , r I� Home �ripfo�teentt'Llcettse y ,, r Ex x; ,r f� y F.: rx ,,,� rf> .�. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST/BIASED ON $125.00 PER S.F. Total Project Cost: $ `, o - o o FEE: $ Check No.: a' 1 a (f / Receipt No.: X31 ? l C� NOTE: Persons contracting with unregistered contractors do not have access tothe guaranty fund i nature of A ent/Owner Signature of contractor 4 � i Plans Submitted❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ 'i'YPSOF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swi"n ning 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Sianature COMMENTS HEALTH COMMENTS i Reviewed on Zoning Board of Appeals: Variance, Petition No: Plani%iing Board Decision: Comments_ Conservation Decision: Comments Water & Sewer Connection/Signature & Date DPW Town Engineer: Signature: Sianature ning Decision/receipt submitted yes Permit Locatea Jb4 usgooa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date r COMMENTS r limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop.requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy f H.I.C. And/ C.S.L. Licenses El of Contrac ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan • Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) • Copy of Contract tr act • Mass check Energy Compliance Report o Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location 19 5-7 A ( (I �1. No. -7 -Iol 7 Date 0 -q - d 016 A - TOWN OF NORTH ANDOVER Certificate of Occupancy $— Building/Frame Permit Fee s—/ Foundation Permit Fee Other Permit Fee TOTAL Check # Building inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 15X0.00 m $ - $ 180.00 Plumbing Fee $ 22.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.50 Total fees collected $ 325.00 8 Stacy Drive 627-2017 on 12/9/2016 remodel ®� om V O_ r, CL i•r M (r a� *JE o � �:Nv S� n d 0 cm o c r Q h cn CL E N o** 3C i m w IEo-a > (.a C t s o • � � goo = CL0) O O O �;�•0 c am 2c'>0 �2� nd .� r ,tog)m L ' � ' v 0 — o a� co N = r_ = as Q.�•� N Tor F- O Na v m d UJ '0_ O O � � d cc O o %M9 wN V r� V O W 0 N = L F- • U m o -a Q o L- C O 0 s . a 0 Ci > o U W :a z Z O 0 O F• m TCl) i Z O �o Z V W OC Z z JV w0 U w O �W W a z W LLJ N (A = N Z Z W LL Z d Q O C7 Q Z w O Z Z U p N o LLI O u o: m D LL N m C d W +% O Y T N O Z N Con O O_ 7 7 L C C C O C � � LL O d' LL O d' (n LL or LL m N N LL {n LL ®� om V O_ r, CL i•r M (r a� *JE o � �:Nv S� n d 0 cm o c r Q h cn CL E N o** 3C i m w IEo-a > (.a C t s o • � � goo = CL0) O O O �;�•0 c am 2c'>0 �2� nd .� r ,tog)m L ' � ' v 0 — o a� co N = r_ = as Q.�•� N Tor F- O Na v m d UJ '0_ O O � � d cc O o %M9 wN V r� V O W 0 N = L F- • U m o -a Q o L- C O 0 s . a 0 Ci > ,a w s o U W :a z Z 0 m TCl) i Z O �o Z V W OC CL z w0 �W a z M ,a w s AUTHORIZATION TO PERFORM SERVICES INSURCOMM CONSTRUCTION, INC 3510 Lafayette Road, Suite 4 Portsmouth, NH 03801 <603-430-7, 01 6h3-373-6214 Fax J LJC� "Customer," authorizes Insurcomm "INSURCOMM" property at: _ �J _ , herein referred to as Construction, Inc., herein referred to as to perform any and all necessary restoration services on Customer's \ 1�e 'CL V 10 r -T -k Customer authorizes I- ``i 9^r A Insurance Company, herein referred to as "Insurance Company", to pay INSURCOMM solely and directly. Customer requests Insurcc�nm to finalize all resation costs on and estimate and submit a copy to b r�ter5 -6 t"�-'-,-+(Insurance Company's Adjuster for agreement. Once the Insurance Company and Insurcomm agree on a figure for restorations, the Customer will be notified of the agreed amount and a date will be set for repairs to begin. It is fully understood that Customer and it agents, successors, assigns and heirs are personally responsible for any and all deductibles, depreciation, or any costs not covered by insurance. Any and all costs for services not reimbursed by the Insurance Company are the responsibility of the Customer and are to be paid upon completion of work. However, additional work will not be performed unless approved by the customer. The liability of INSURCOMM is expressly limited to the total amount of the services authorized herein. Insurcomm agrees to acquire all necessary demolition and construction permits as needed and to have all necessary inspections completed before any walls are closed in. Property is to be restored to its former state, allowing for modern construction techniques and current building codes. If INSURCOMM submits this account for collection, Customer agrees to pay interest at 1.5% per month or at the highest rate allowed by law, court costs, reasonable attorney fees and all costs of collection. Customer agrees that INSURCOMM is working for the Customer and not the Insurance Company or agent/adjuster. Remarks: z/ til' Customer Sign ure Date Printed Name Insurcomm Signature Printed Name 00 c a� U -�4 ,,8 ,6 t I TE - 9 ACORO0 `� CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDNYYY) 12/8/2016 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(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 endorsement(s). PRODUCER CONTACT Emma Panke NAME: y PHONE FAX WCNo Ext : A/C Nol: Kane Insurance E-MAIL emm ADORE a@kaneins.com SS: 242 State Street INSURERS AFFORDING COVERAGE NAIC # INSURERAOhio Security Insurance Company 24082 Portsmouth NH 03801 INSURED INSURER B :Peerless Insurance Co 24198 INSURERC:The Ohio Casualty Insurance Co 24074 Insurcomm Inc., First Response Cleaning And Restora INSURER D Netherlands Insurance Co 24171 290 Heritage Ave Ste 1 INSURER E: 1 INSURER F : Portsmouth NH 03801 COVERAGES CERTIFICATE NUMBER:CL1612815160 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE FxI OCCUR DAMAGE TO RENTED300,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 15,000 BKS56439740 11/7/2016 11/7/2017 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 1 PRC JECT F—]LOC PRODUCTS - COMP/OP AGG $ 2,000,000 Owners or Lessees $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS BA8999676 11/7/2016 11/7/2017 BODILY INJURY (Per accident) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE ccident $ Per accident) Individual Employee Extension $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 C EXCESS LIAB CLAIMS -MADE DED X RETENTION$ 10,000 $ US056439740 11/7/2016 11/7/2017 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN X PER OTH- STATUTE I JER D ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? FNIA (Mandatory in NH) If yes, describe under WC8999776 11/7/2016 11/7/2017 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYE $ 500,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Activities usual and customary to fire, water, and mold remediation and restoration with construction build back. For work to be done at, Prescott Crossings, 8 Stacy Dr, No. Andover, MA. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) INS025ooiwi) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of North Andover MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main St ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Chad Hancock/CHAD ACORD 25 (2014/01) INS025ooiwi) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD O 4.1 ca O L N 0 O CD C T N Cl) 0 0 O C: ++ Cat = C N co ca CV .CU (IO CO C Qy-2E L_ (D EC) 02 CL CO -r- TE a m O N U_ E O 0 n' W iF 0 c C'- 0 T T U ♦♦� CO U) CO O 0 CZ 4- O O O i = N O OO C N I - C 0 d C � � L N O d d d Y N N � O O C m 7 O C a = M 13 c amu) LQO 0 O •. O E N r > C.N ' p C N O NQ OY N L 41 Cc O m otEa c m 0 V- M C 0 d U C o t0 N C ~ � N Q W N 4 V 03 u) o ui M Lu o CL cm 0 o L r- E` CC ULWO (L.O cCL r U 7' W O I Ci C O00T T O 2 cnco 0 c = U Z mw Ea CcOD E0 :3 L - N 'a� O SZNa a CD '° C