HomeMy WebLinkAboutBuilding Permit # 3/12/2015 oT 6�No
BUILDING PERMIT
TOWN OF NORTH ANDOVER to
APPLICATION FOR PLAN EXAMINATI N
Permit NO: ! Date Received .04
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Date Issued: � '
IMPORTANT Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑ Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: ❑ Commercial
Repair, replacement ElAssessory Bldg [I Others:
❑ Demolition ❑ Other
/% rSe tic!//❑Well r ' Wetlands / ❑ rNatershed Drstnct ,r
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Identification Please Type or Print Clearly)
OWNER: Name: 141C r m 0/,/fc � 9 C21 Phone: �� ...) /
Address: '' =� � ✓ ��' { � / /�
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ARCHITECT/ENGINEER 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: $
Receipt . "ICheck No.: \1 � t No.: ,p
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Sigrtafiur of ggent/pwner ignattare of contractor'
Certified Plot Plan IT Stamped Plans ❑
TYPF.OF SEWERAGE DISPOSAL
pl,blic Sewer ❑
Tanning/Massage/Body Art ❑
Swuiuning Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
Reviewed on
COMMENTS
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:
r Located 384 Osgood Street
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The Commonwealth of Massaeliusetts
Department oflndustrialAceidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
'° ~v.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual):
Address: a 2 l Akt� ak A <�) -
City/State/Zip: �,� ��iC� / / /7� Phone #: 1�?9 3^ C!54 ���(� D
Are you an employer? Check the appropriate box:
�I am a employer with VC) 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. ❑ 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.❑ 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.E] Other
*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 tliat is providing ivorlcers' compensation ir:surance for lny employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: G{� gxpiration Date:
G
Job Site Address: ` �lur U"M �} ` ' O ity/State/Zip:
Attach a copy of the workers' conipensation 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 rinder the pains andgullies of perjury that the information provided above is true and correct1..
Signature: I�'1� ""1 ��� � /Date: 3I i � � / S
Phone #: ��� ( <;+-910/_0
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 Cleric 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone M
VDAC
R,"FORD WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S60UB-2E62448-0-14)
NEW -14
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE: 10456
1.
INSURED: PRODUCER:
PIMENTEL CONSTRUCTION CO INC EDWARD F SENNOTT INS
231 ANDOVER STREET PO BOX 457
WILMINGTON MA 01887 TOPSFIELD MA 01983
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 12-20-14 to 12-20-15 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GA
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 01 -13-15 AK
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: EDWARD F SENNOTT INS
2562B
ST ASSIGN: MA
ee .
\9 msmhu:eb=.Dep:R mee of Puh c S:D%
Bo «u Q � :%ng R:g % % »n:znd y and »d:
cmumma yyn«« ���
License: CS -012453
.
ANTHONY JPMNT91
>e
« Spencer Court-'
\�
Andover MA 01810 )
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