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HomeMy WebLinkAboutBuilding Permit # 3/4/2015 w W." %AORTH °9 BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION - Permit NO: 0 Date Received Date Issued: r� �9ss�cwus�$�y IMPORTANT: Applicant must complete all items on this page r r r / // r .✓ r,v /r /ii/ /r,,. r/ r/ // 1 r ✓/i/ r i/ r r r�r)} ! /!///rr/... /. /// /i "IV(AP NCS ,r,;f PARCEL„r :;1ZO�lING DISTRIC y;�1'%,!/, ,/,,,,Historic D strict ,r / ' , es r; / Me,, , no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: _- emolition El Other D Septic1 Well ❑ Flaodplam ❑�llfetlands Q Watershed District r� W`4 r 2En/-PAJW6 AfeW—a 2 o A-6 LfG- Identification Please Type or Print Clearly) i OWNER: Name: Phone: Address: ,, / ..,, r r ri ./ ./.r, / / ,/ -r� rri:c,/f/// //�/.rir/,�/� li ►�,�� �.r r p /i:, // , „ %//iil �i//�c,, / /,� r, r / r.. r „t i. r r r ✓ / r / / r / / r // r r , rr �c r� ,ir //�,�,r.�, ,//„/.,/rf r/, e �� r, .„ /,r �,/� r f l / i.. ,,� �, it/, //// ///r//✓/ .i/ r / r /i� i ,, ,, r r i //r .✓ r r /i / r, ✓ r r r r ,: /r 1..,,,,.rr ,/ �rry .,r/ /, ri/ r,/ ,. / it r // / / r „,. ,.r r r ✓' ,.r/„/ r rr I ::; rrr�r :.. ✓,fir, //,. /r/ , / / / / i / / / /, �, /r r // , ,//, // , ,.. // r % `/. � / ,,,,i.�r, „ ✓../ it li// � r „r � r, r%�///,/,r rr_,r. ,, ,r. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST RASED ON$125.00 PER S.F. Total Project Cost- �� FEE: $ Check No.: ( Receipt No.: 5•-t NOTE: Persons contracting wit nregistered contractors do not have access to the guaranty fund Signature of Agent/gwn Sgnature;of;eontrac#or ,;, Dimension Number of Stories: Total square feet of floor area, basdd on:Ext6rior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service dro.p�requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine ; NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 _own 0 _ �� Andover O ® ' ]/ h � " ver, Mass, 3 O� COC"Ic"twK,[ �• -�--p-� �.95 R•i7E D P,I? U BOARD OF HEALTH Food/Kitchen PF: RMIT T E 0 Septic System �� THIS CERTIFIES THAT 5 U! �v%1'x L 111111110�'L �.. 01-1BUILDINGINSPECTOR ....................................................... has permission to erect I �'�4I1. Foundation p ............�v�.... buildings on ...... .. .... ..............�...."........................... .. . ........ - '. Rough tobe occupied as ........ .......................�............ .................v.`�........................................ �� � ••••.•••• Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final 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 TSRough Service .......... ...................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place 'on the Premises — ®o Not Remove Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 r Boston,MA 02H4-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information s Please Print Legibly Name (Business/Organization/Individual): (1 I! CP4J Address: 2 t ��l6 w ��, .,f , 'CA City/State/Zip: Phone# 2— S-0 Are you an employer?Check the appropriate box: Type of project(required): I.[J I am a employer with2_0 employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. emodeling any capacity.[No workers'comp,insurance required.] 3.®I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. emolition ❑4.4.F1I 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.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[—]Roof repairs These sub-contractors have employees and have workers'comp.insurance3 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Ot11er /f C. 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. 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 am an employer titat is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: , Policy#or Self-ins.Lic.#: i Expiration Date: / Job Site Address:,/ N D '� City/State/Zip:,Adra A,awxee 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 a 152,§25A is a criminal violation punishable by a fine tip 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 certi er t ains and penalties ofpeijuiy that the information provided ab ve is rue and correct. Si nature: Date: /�- Phone . 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#: - - ""�^ -_ 2CIIG'Clt`���• elation; Affairs&Business Reg Office osumVE ►VIENCONTRACTOR Type, I ' MEIMPROr;1A919h 4 egistration• Individual 121212015 piratlon � JASON ROY JASON ROY g Ap NTERN LP NE Undersecretary g NASHUA,NH 03062 ` Massachusetts -Departrrent of?a iic Safety 1 Regulations and Standards Board of Building Construction Superyisor License: CS-C80495 fl. MASON C ROY �` 9 LANTERN LN- � NASHUA NH 03662 I =Apiration �. cJ f1f" 0712812015 Commissioner ACC)R oma® CERTIFICATE OF LIABILITY INSURANCE 7/14/2014 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 Rose S Munoz NAME: EA Stevens Company, Inc. PHONE ('781)322-2324 FAX No:(781)397-7672 389 Main St. E.DDA)L P. 0. BOX 188 INSURERS AFFORDING COVERAGE NAIC# Malden MA 02148 INSURER A-Admiral Insurance Com an INSURED _!NSURERB:Safety Indemnity Company 3618 '.. Alpine Environmental, Inc. INSURERC:Central Mutual Insurance 21 Progress Avenue, Unit 1 INSURERD:Travelers Indemnit INSURER E: Chelmsford MA 01824 INSURERF: COVERAGES CERTIFICATE NUMBER:2014-2015 Master 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER DDNYYY1 (MMIDDIYYYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 50 000 E SES Ea occurrence $ r A CLAIMS-MADE Fx_1 OCCUR ro Be Assigned /18/2014 /18/2015 MED EXP(Any one person $ 5,000 Includes Pollution Liab PERSONAL&ADV INJURY $ 1,000,000 1,000,000 Per Occurence GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 Aggregate PRODUCTS-COMPIOPAGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ 1,000,000 B ALLOWNED X SCHEDULED 6224004 /18/2014 /18/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNX HIRED AUTOS X AUTOS ED Peer acciden DAMAGE $ Uninsured motorist BI split limit $ UMBRELLA LIAB [I OCCUREACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION o Be Assigned /18/2014 /18/2015 $ WORKERS COMPENSATION WC STATU- X 0TH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE PJUB-5B98513-8 /14/2014 /14/2015 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N I A D (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 '.. If yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 500,000 C Contractors Equipment CLP 9178326 /18/2014 /18/2015 $1,000 Deductible $124,848 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sample Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE '.. Thomas Cares, Jr/RS ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 onirns)M Tho Arr)Pn nnmo nnrl Innn nro ronic+ororl mnrka of hrrwn