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HomeMy WebLinkAboutBuilding Permit # 3/24/2015 i # NORTH BUILDING - -_ BUILDING PERMIT - �°`� yam by°hot TOWN OF NORTH ANDOVER ° A s� APPLICATION FOR PLAN EXAMINATION " Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Pr��t PROPERrY orNER e r f MAP NOi�. ��. p�RCEL� � � �zO�fING [�IS�"RICT Ffrstonc Drstr�ct yes TYPE OF IMPROVEMENT PROPOSED USE j Residential Non- Residential ❑ New Building 9 One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial X Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other o Sept% D Well Flootlplain r Wetlands ❑ lied1-77 Q�st"rict qWafei`/Sewer , ; p M©ue- aft ( n oc 1,V `l orM c( IAS U Ict (9 P. In area5 a ice Identification Please Type or Print Clearly) OWNER: Name: KWA Phone: Address: Z o�ccf�u ln�- h C�vet- CONTRACTOR Name Pho es4 , Address < r , � Z �rrlu at` e� � tI fit ' Superulsor's ons, NDate 1 Horne (m�ro�reme�rfi Llcert�e` � 3�� Exp Date � �� �� , 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'dost: $ Ll �� FEE: $ Check No.. �� Receipt No.: Z -5 xz, NOTE: Persons contra ing with unregistered contractors do not have access to the gu a ty fund Signature of Agent/Own Signature'of contractor. z�f a=ll � NOIR T� Town of ndover ® - 0 No. I -� - C% ver, Mass, T O LAKE COC MICMEWICK V AD4ATED S BOARD OF HEALTH Food/Kitchen PEIRMIT T D Septic System THIS CERTIFIES THAT ......... �.. !4 Cr 1 IIn ................................................................... BUILDING INSPECTOR has permission to erect buildings on AM �� 44 Foundation .......................... ........... .. ........... ........ .... ...... �y� n ... Rough to be occupied as - � ` . 1 .'.�.� .`.' C Chimney p' ....... ............. .... .... .... provided that the person acceptin this perm t 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 anc� Construction of Buildings in the Town of North Andover. J�'�� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S ARTS 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. BB Carpentry Service, Inc. 122 Gorham Street carpentry work Chelmsford, MA 01824 DATE ESTIMATE # 978.454.1819 / 978.479.0970 Bruce J. Baker , Pres. 3/8/2015 640 E Customer Joy Duncan 247A Farnum Rd. No. Andover, Ma. 01845 978-701-2039 ITEM DESCRIPTION AMOUNT carp 7 Remove damaged drywall materials on the walls and ceiling and 4,500.00 replace with new blueboard and plaster veneer coat, prime and paint to match existing. Remove and replace wall and ceiling insulation in the affected areas and remove and replace the roof gutter system across the front of the master bedroom. Areas affected include the 1st floor kitchen back side wall, the 2nd floor laundry room wall as well as the 2nd floor game room wall and the master bedroom front wall and ceiling. I t Thank You for using BB Carpentry Service Inc.! Total 4,500.00 The Continonivealth of 11?ossnehtuetfs Depmi tinent of Industrial A celdents 1 Congress Street,Suite 100 .Boston,MA 02.114-2017 wivw.ntasv.gov/din Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. 'TO BE FILED WITH THE P13,RMITTING AurHORI':rv. Applicant Information Please Print Legibly Name(13usines/Organization/Indivklual): / rhe 1 C .[/�` �/ ,t A eer Address: /ZZ 6��`�—O&K­577- C'iq,/State/Zip:_C4�,)/mS hP/'(X„ _B/�d _ Phone#:�91 Are you an employer?Check the appropriate box: �. "Type of project(required): I.[]I am a employer with ,employees(full and/or part-time).* 7, []New construction 2,E]I Din a sole proprietor or partnership and have no employees working for me in S, ki Remodeling any capacity,lNo workers'comp.insurance required.) 9, El Demolition 3.❑I run a homeowner doing all work myself.(No workers'comp.insurance required.)t 10 F]Building addition 4.Q i am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or arc sole I Ln Electrical repairs or additions proprietors with no employees. 12,[:]Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13, hoof repairs These sub-contractors have employees and have workers'comp.insurance.t p (,'R We are a corporation and its officers have exercised their right of exemption per MGL o, 1.4,Q Other 152,§1(4),and we have no employees.[No workers'comp,insurance required.) *Anyapplicant that checks box/it 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, lContractors 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 ant an employer that is prodding workers'compensation insurancefor n{h employees. Below is the policy and job site information. insurance Company Name: Policy It or Self-ins,Lic,II _ _ _ _._ . 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, 1.52,§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 DTA for insurance coverage verification. Ido hereby arcer-n'y tinder the pains a d penalties of perjury thrit the infor»cation provided above is trice and correct Sinttue:_ < . .�_� �. __ _.. _�iJale:_ 3_.,2y..�5,._..__—_-_-- ._/ Phone k: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License It Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector G.Other Contact Person: Phone It: From:Mara Lage FaxID: Page Z of-z Uate:tSrzr2U14 uz:zts Pnn rage:z of BBCAR-2 OP ID: L1 CERTIFICATE OF LIABILITY INSURANCE DAT06102DNYYY) 06102/14 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 Phone:508-422-9277 NAME:CONTACT 133 Milford Hickey Agency Fax:508-422-9914 AIC N Ext): FAX No): Medway,MA 02053 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC INSURER A: INSURED BB Carpentry Services Inc. INSURER B: Bruce Baker 122 Gorham St INSURER C: Chelmsford, MA 01824 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF c P LIMITS LTR 5 POLICY NUMBER MMIDDlYYY MMIDDlYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY CPS28386 05/10/14 05/10/15D AGETO E T 50,000 PREMISES Ea occurrence)S CLAIMSMADE D OCCUR MED EXP(Any one person) S 5,00 PERSONAL&ADV INJURY S 1,000,00 GENERAL AGGREGATE S 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,00 POLICY JECT F-]PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED Per acciPROPERTY DAMAGE S HIRED AUTOS AUTOS dent S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION WCSTATU- 0TH- AND EMPLOYERS'LIABILITY YIN S ER TORY LIMIT ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS belmv E.L.DISEASE-POLICY LIMIT S ommercial Applica DESCRIPTION OF OPERATIONS!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 Sample Certificate THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /lY'C 70-. M O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 112380 Type: Private Corporation Expiration: 3/11/2017 Tr# 236971 B B CARPENTRY SERVICE BRUCE BAKER 122 GORHAM ST. CHELMSFORD, MA 01824 Update Address and return card.Mark reason for change. SCA 1 CS 20M-05/11 Address Renewal Employment F] Lost Card Massachusetts -Department of Public safety Board of Building Regulations and standards Construction Supervisor AWN License: CS-042055 BRUCE J BAKER-` 122 GORHAM Sy4gw 46,(. s Chelmsford MA 61824 > , " j41 Expiration Commissioner 03/06/2016