Loading...
HomeMy WebLinkAboutBuilding Permit # 4/1/2015 p►ORTw BUILDING PERMIT 0* ED ,b�•yo TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: MPORTANT: Applicant must complete all items on this page f w TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition N-Two or more family ❑ Industrial 14 Alteration No. of units: Z ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other w u„r� u, V ,a �6ar f dl�'WI ,r{IIAV� I;,11In”` 11 c� elf ��� m t- i ,i,.r.. -,it �..i.� ��, .. i�•,I, lo'!lk'r?d/0�� ��� .1(..ry YiJ>l�'.�,A,��'nttfrfrl��e f.. �0 sYf,� ,.�����1� DESCRIPTION OF WORK TO BE PERFORMED: �e, o Identification- Please Type or Print Clearly OWNER: Name: 1AA/ -1LQZV C=am Phone: '17860 e0 Address: d � i � ,� N 9 nm hMNhIfSr ln(fPl{VY ull ��l vi�Krram ro W11vtll�luikm��01 U a . �,.. . r�r, i�hvvlli J(lunl ert�a.' �: �� , l % 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: $ Z5', ( FEE: $ .w� P Check No.: Receipt No.: NOTE: Person contracting with unregistered contractors do not have cess t lie `Zzr / ty and p !ii'7T.�a �',�a;v, r „;:. ` '; r r ,,?�///%%�/ /r JZ ri/ r ///,' J/,e;,;,"� f Ti/0 ,,. �,�✓ � /,�,J,rr//!%/ rp ri "/ r . t®O '7 Town of Andover ® I No. jqj. 1,5 '91 �o LAKE ver' Mass, COCHICM@WICK S U BOARD OF HEALTH Food/Kitchen RM T T L D Septic System THIS CERTIFIES THAT .......A-Y-A .. . ... . ,�.l.4�.v - BUILDING INSPECTOR d ...... ... ............................................................. Foundation has permission to erect .......................... buildings on .. ..�......6 ".... 1. ...G1..� ... ........... �-- n Rough to be occupied as ......v ... .../I.......�.... ..3 ,,,�G®l� }...... .Gw... 6`�'� .. .. T... ...� .. Y.a°.� ' Chimney provided that the person accepting this permit sha(I 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. and mw W ottoA)� t 'g�-b 0 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 2W. PERMIT E I E IN 6 MONTHS ELECTRICAL INSPECTOR LESS CIO S Rough Service ............................. . ............................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy .Permit Required to Occupy Ruildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final ® Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 2 PAL L WAY 6Vt5 !/'x B eDRZo M �vti�ny r.3'-6 " rr IL Co��H EST.1941 ,42 Do Of ►Z' ' E5T.1941 The Commonwealth of Massachusetts Department of IndustrialAceidents -- I 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). Sc TC I m PA o V c—m[N T,5 ,IyL Address: 3 2- M A-elv 6r-AC--e7-7- City/State/Zip: r-At=e7-7-City/State/Zip: .5AtE/1A j A/H 03077 Phone#: (`l7 S) &06-10-50 Are you an employer?Check the appropriate box: Type of project(required): 1�I am a employer with 5 employees(full and/or part-time).* 7. 0 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.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 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 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑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.insurance., 6. We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] IL *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. #Contractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. ,. Insurance Company Name: UZAw VV _3 Policy#or Self-ins.Lic.M W VO g 4107 /qExpiration Date: y Job Site Address:' 1,-, S--&-7 8F—LM �/ZE City/State/Zip: A/, A/v D® ts�,72 ,M A ' 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 cavi peva ' s in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. c y of this statement ma be forwarded to the Office of Investigations of the DIA.for insurance coverage verificatio . I do hereby cert'y and i ndpeaAwlycp fjur that the information provided above is true and correct. Signature: Date: Phone#: L,97F3 6 f O 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#: SITEI-2 OP ID:SR ACORO°y CERTIFICATE OF LIABILITY INSURANCE 7OT4/011201 E(MM/DD/YYYY) 5 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). CONTAPRODUCER NAME: Lawrence R.Michaud,CIC Michaud,Rowe And Ruscak Ins. PHONE 978 688 8829 Nc No): 978 557 2130 P.O.Box 188 A/c No Ext: North Andover,MA 01845 ADDRESS:lmichaud@mrrinsurance.com Lawrence R.Michaud,CIC INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Harleysville Insurance Company 26182 INSURED Site Improvements,Inc. INSURER B:Hanover Insurance Company 22292 Anthony Finocchiaro INSURERC:Wesco Insurance Company P O Box 1145 Andover, MA 01810 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 ADDL SUB POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR SPP79814L 02/06/2015 02/06/2016 pREMISEs Ea ocMAGE-TO cur encs $ MED EXP(Any one person) $ 100,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident B ANY AUTO ADN0749277-07 06/22/2014 06/22/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS X X Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE CMB79863L 02/06/2015 02/06/2016 AGGREGATE $ 1,000,000 DED TTETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N/A WWC3094079 07/11/2014 07/11/2015 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Grading of Land,Site preparation for paved areas Office CERTIFICATE HOLDER CANCELLATION NORTHA9 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. Attn.: Building Department 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 4!�!Lzl2�d�— ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD