HomeMy WebLinkAboutBuilding Permit # 3/6/2015Permit No#: Date Issued: j BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Date Received IMPORTANT: Applican v must complete all items on this page 11.AM'1/4/11' f4ti*,711//fi°11 1 flaiP zsl . , V 410 A . 0r° ' I,'" f rill Faoteti , 10 I 114 iic/1/ ,eall«IPAP IMP k '00 0 (?)/0a4, 044 , offild„ offi0-4y,y1 soSplaiv, pi a' gel uf.LYy357,1t/i '0 71 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential Li New Building El Addition 111 Alteration 0 One family 0 Two or more family No. of units: [i] Industrial 0 Commercial Eli Repair, replacement 0 Demolition 0 Assessory Bldg 0 Others: ' ,,0 , li Other r /7 ,/, ) //r, /„ / '0 4 ft ' pocIpl/ain „0 Air etlan s 0% , i f„ 46/41Wrilifif ,0Septiovi „ DESCRIPTION OF WORK TO BE PERFORMED: 97-45[INJ (Y cl Identification - Please Type or Print Clearly OWNER: Name: iv). Px-90-1iAf 077'/( Phone013)667-7?0C Address: 3S1 LLJ)i• Abl#7 Nefk;k,f111 PlOn& Ayd,i,,,,mibokoAardo 4 tillfGe 01' wfvorwt() xid /1,1f ARCHITECT/ENGINEER Phone: Reg. No, Address: FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER Total Project Cost: $ /04)— , FEE,: ,S0 Check No.: 6) (p TX) Receipt No,: - NOTE: Persons contracting with unregistered contractors do not have access to the guaranty find Signature of Agent/Ownerft iSignature,of„cantractor6,N 7TTJ!T' T ' Plans Submitted Plans Waived — Certified Plot Plan Stamped Plans TyPF.5F SEWERAGE DISPOSAL POlic Sewer — Well — Private (septic tank, etc. I Tanning/Massage/Body Art Tobacco Sales Permanent Dumpster on Site [ 1 E Swimming Pools ❑ ❑ Food Packaging/Sales THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) No Coe o r_ s c1j vJ a ,c I ✓i e -D,T A/P 7-42,0e7 --- Aft, (0 ❑ Notified for pickup Call Email Date Doc.Building Permit Revised 2014 Time Contact Name co -c O 1< N n 0 CD Zv CD O $ C. 7 O O ® cD CD '< O Cr su CD O CD CU w O CD � CCD I - v y O 'a Z n 0CD 0 70 : cD 3 0 cD map of pagn 210133dSNI JNIa1Il8 3fl I1SN03 SS31Nf1 m m 0) 0 7v = cn VIOLATION of the Zoning or Building Regulations Voids this Permit. oo O `a O" O O -w; o C O• CD n CCD O O a Cq' Cn O w rt "D o' O O - Q W C N p • CD C D CD 0: 111 in' N O O N o. O O D = 110rt�� S CD CD ,a 'a p CO O N • 5. 0 to CD s ra CD Cn Z 0 O 0 0 CD 9 O n1 CCZ CD 5 L O CA CD fv < O. O CD CD rN gu �cD c CD off. - G CO a o8- CD CD =- � 0 -I o �, iftwompi 1VHl S31M30 SIH. EYJ i ran cr) The Commonwealth of Massachusetts Department of Industrial Accidents 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 Name (Business/Organization/Individual): Address: 3 ;\"}�\\K 0 V\ V City/State/Zip: NOi'1 li (1kVeIMkhone #: 67g)6 gq`W0 Please Print Legibly Are you an employer? Check the appropriate box: 1.0 I am a employer with employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 proprietors with no employees. 5.E1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6 �We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ['Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14:�✓ Other �e� *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 that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 3$' D LA-,1 / i4 it1 , irl7 JoveY City/State/Zip: /14 I C os-- Attach a copy of the workers' compensation olicy 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 pedury that the information provided above is true 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 #: OP ID: DC QCCIOR� ..- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/05/2015 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(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 Platinum Insurance Agency 418 Massachusetts Ave Arlington, MA 02474 Niru Bhatia Yadav CONTACT PHONE FAX (NC. No. Extl: (A/C, No): E-MAIL ADDRESS: PRODUCER BOLLY-2 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED Bollywood Grill Inc. Malkiat Gill 350 Winthrop Ave North Andover, MA 01845 INSURER A: Safety Indemnity Insurance Co. INSURER B : Peerless lnsurnace 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, 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 INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY1 LIMITS B GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR BKS55786233 10/01/2014 10/01/2015 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 , CLAIMS -MADE MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: —I PRODUCTS - COMP/OP AGG $ 1,000,000 POLICY PRO - JECT $ A A A A AUTOMOBILE AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BBDM21 08/20/2014 08/20/2015 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (PER ACCIDENT) $ X X $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N/A WCSTATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ below EL. DISEASE - POLICY LIMIT $ B Liquor Liability BSK55786233 10/01/2014 10/01/2015 Liquor 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Liquor liability is included $1,000,000 limit CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Niru Bhatia Yadav ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD