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HomeMy WebLinkAboutBuilding Permit # 3/3/2015 BUILDING PERMIT NORTH TOWN OF NORTH ANDOVER /PPLICATION FOR PLAN EXAMINATION Iva- ii hermit No##: Date Received DSA °°~°~�w D a,. . Q TED Date Issued: �SpcHusE I P RTANT Applicant must complete all items on,this.page Y / ( /r i / //✓1 "VI (/J / 1(! 1 (r " 1 r l l�, ����II , � I' ,�,� f �,���1,�f r r>����//>✓� �� /��1�I� l� ��� /, ,��%h'UI11��,��IIr�II� ,,� ,�I ����., .,,r,'. I '�l!! 1,�� �i rpt>I..:Gl. P �� Ir �(.���f l /J��ID J / � >/� !,'/�/���/. J;✓� ;;.'�"r�r I���,.. E Ir, ll 1 1 ,�rr ,>"•.../� / ����� Il �?rlll ����i r r r I r r 11 v / l / , / «tri it a!;✓arWr ,,f��, �� 1 // � ,'r � � /��/ /��1,r) Bei=c; /ilr%!a; ,. /G d��N/",Ji��V1. ���„�(� ,� UrfJu,Yrv9r,i .�, ,r ,J rr }� r; es�%-.,l`?� ,,. / ✓� ' ✓ r r � 1, / J r ,� r/ �� �.� , ����/��� �,///i/�i��l!/., /���////O%/�i%'�'i,/�i4r� a„�,�il,lcr �irr/i,�io•.1]�%V,///�r i,�m,�,rr�/��>�Jir iiivr/,. /�, 1�r���r10/�j/,,.... TYPE OF IMPROVEMENT PROPOSED USE r 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 riri„gi i r a/ / r, 1 r / ✓i r r r/ r Se fc /❑UUeI , �,�' ,,// frl, � /r , r/ � , r , / r,,.. / //� � ,,. / / ❑,Food ,, �, /r , � r, ,, ./ r 1a�n / . , / / r � ❑We / ,r / / ON// r � � pr r /f hdD, tris t r«rl r4�, , .. / it 1 l f DESCRIPTION OF WORK TO DE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: J , r r ✓/ r r r r r r rI r / r « � r%/����H In< �i �,, r,, /, /�/ , , / G /��- /�//i,� ,d,,, ✓ r �>rl o' /✓ !,, ,,, J/c,,, /,r�i / „r//�, t'//�lr,�,� rr,, r/�rr,� / �, r1/,c.,. ,% ,��/, / I, .. �r/��11 r - �r 1 �l� /J r� , �✓', 1 r r.r,/ , �!� /. , ./ / ,, �% r r///l/,,.,,f e��.�,/�r.., �r ...a�r�+rlOf,a d� a rarcY,m a BGua,✓rfN}., _ / L ,a .. / �v`. ri✓ii, O /,; ARCHITECT/ENGINEER Phone:_, : ”�` Address: Reg.,No FEE SCHEDULE.BULDING PERMIT:$12,00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBA,sED ON$925.00 PER S. r-- Total Project Cost: $ 1` .-100 FEE: $ `` Check No.: ( Receipt.No.:. NOTE: Persons contracting with unregistered contr ctors,do not have,access to the guarantyjc]5�ind r Signature of Agent/Owne ! - ' Sig natureM,of contractors° F NORTFI Town of .1 E. ...'A,, No. Andover _ ...................... LAKE y ver, Mass, COCKICMEWICK ��• 0R'l`TED /, ,�5 S U BOARD OF HEALTH PERMIT T LD t Food/Kitchen Septic System C— e�r�' BUILDING INSPECTOR THIS CERTIFIES THAT .............................................. ...... ....vim............................................... has permission to erect .......................... buildings on I. �....... - S, ck J�--e. �� Foundation ..... .... ................................................. Rough to be occupied as9 � .......................................................................... 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 STAT 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. a 1gZ2 C Ri Nei I< r' g L 1`la , Nn0uear- W1 The Commonwealth of Massaehusetts Department of Industrial Accidents 0 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 7�\?Dob Address: u S_ Sytrt-k 517 City/State/Zip:71�T��Mk 0 kq ZZ Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.F-1 I am a employer with employees(full and/or part-time).* 7. E]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.] �3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition �4.4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.F-1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we 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. I 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 am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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 pef jury that the information provided above is true and correct. Signature: " I--. Date: 3 1 20 15- Phone#: -716k - —A % `v Official 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#: .. '. v � �(.'a�3r�)tortirerrf�rir?�j�tfJrrf�ttrt�fs Office of Consumer Affairs&Business Regula6aY[ GME IMPRO1/EMENT CONTRACTOR 77, egistration 138657 Type i 'Expiration:` 5/1/2015 ' Individual I BOB KR18KO ROBERT KRISKO 45 SOUTH ST. 4 � � rII� BYFIE,LD;.MA,oi 022 Unopm eretary I- fl „ Massachusetts -Department of Public Safety Board of Building Regulations and Standards -7BTi'-"500 Y {, "nstructior,Sut a r License. CS-068967 ; IS ROBERT P IPSO 45 SOUTH ST o2 x BYFrELD MA Expiration 11/08/2016 commissioner i From:Arthur S Page Insurance 978 462 0890 02/27/2015 11 :17 #359 P.003/004 KRISK-1 DATE(MMODP�ID: KQ CERTIFICATE OF LIABILITY INSURANCE 02/27(2015 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 endorsement(s). PRODUCER CONNAME CT None Arthur S Page Insurance Agency PHONE g78- 5-5301 57 State St. 46 C No Ext): , ): 978-4 Newburyport, MA 01950 E-MAIL AIC No62-0890 _ None ADDRESS: — INSURER S(AFFORDING COVERAGE r NAIC N INSURER A:Commerce Insurance 134754 INSURED Robert Krisko INSURER B 45 South St. ---- - ----...- -------- ... ..... - _._.. Byfield,MA 01922 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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, TERMOR 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: I DDL SUB ---`—POIICY EFF •POLICY EXP LTR; TYPE OF INSURANCE 'INSD D I POLICY NUMBER POLICY (MMIDDIYYYY) LIMITS A COMMERCIAL GENERAL LIABILITY I i EACH OCCURRENCE __ s 1_,_000,000 CLAIMS-MADE �l OCCUR BGGRCC 04/21/2014!04/21/2015�MIBES�a occur-Nnce 5 _-_ 100,000 _ ) i X Business Owners I MED EXP(Any one person) •$ - 5,000 i PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE ' S 2,000,000 i—I POLICY PRO- ECT LOC I ! i I----- .—....-----!— -----•----- ---. — I I l �PRODUCTS-CDMPIOP AGG 'E 2,000 00 OTHER. S AUTOMOBILE LIABILITY i I 'COMBINED SINGLE LIMIT .S L ANY AUTO _ BODILY INJURY(Per person) ;$ •ALL OWNED SCHEDULED I •-----••�-------•—_-_-_.. AUTOS AUTOWNED AUTOS SaODILY INJURY(Per accident)'S NON•OPROPERTY DgMgGE $_ HIRED AUTOS I I I I PeraccidenD --,_----.----_ '',... s I UMBRELLA LIAR OCCUR •--.( :—_.f , EACH OCCURRENCE ?S !EXCESS LIAR i 'CLAIMS-MADEI ' 1 --�------- --- 'AGGREGATL= g I DED RETENTIONS I $ 'WORKERS COMPENSATION -I : PER (AND EMPLOYERS'LIABILITY YIN i I I I !5TA1'lll'E ___.•LR 11— _— •-_ _ _ iANY PROPRIETORIPARTNER/EXECUTIVE ; ;E.L.EAC __"..._._- H ACCIDENT S .OFFICERIMEMBER EXCLUDED? I N/A I , _..---._;____•.-.---- .-.._. _..... (Mandatory in It yes,describe ander I ! ' i—l_E.—.pISEASE-EA EMPLOYEE'$ I under � � I _—...__..__...., DESCRIPTION OF OPERATIONS below 'E.L.DISEASE-POLICY LIMIT;$ (PROPERTY 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addltlonal Remarks Schedule,may be attached It more space is required) :ARPENTER 'ERTIFICATE HOLDER CANCELLATION TOWNN-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept. 1600 Osgood St AUTHORIZED REPRESENTATIVE North Andover,MA 01845 #A �- ©1988-2014 ACORD CORPORATION. All rights reserved. kCORD 25(2014/01) The ACORD name and logo are registered marks of ACORD