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HomeMy WebLinkAboutBuilding Permit # 4/3/2015 BUILDING PERMIT NoRrH qq". O`�.�LED ;b q•Y� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �0 cn by»1 y' /® Date Received �QA0RgTEo Permit IVo#: �SS•aCFW-��� Date Issued: I PORTANT:Applicant must complete all items on this page C s 'C °aCr ' N� DST I � ,� r. �Hsore ��rsrc es o f� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 91 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other . ��,Fl „ u,�r:. Wye „i �,,,-",,✓' -/�"r��, ,oi i�e�m✓ui ,oi �nf.ww, rr i u�. v¢i'J !"�"Pf�!rti'V'tidy dry ,;_.�, �F, I-, � � - / __Ham r�wrNl h'�l�r�� N r f I� We , �I i�/�tellrueWG'II r DESCRIPTION OF WORK TO BE PERFORMED: LIZ 16 lr fir= Identification- Please T e or Print Clearly �_, . OWNER: Name: � ilaG Ikrr 1�k'tsT*t/ zzcl. &J Phone: Tl � Address: am � o e t ns. �, E�xr tae a �hvInrni wuw�rrcwrmrMzalurrramm _.._ i wN �i ,...,. -.. ......._, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92,00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ _.... FEE: $ LI I Check No. ° ell Receipt No: NOTE:—-Persons-co tracting with unregistered contractors do not have access to the aranty f`incl r t �e „cnlG^% n / 6 rNi au p ��w NORTH Town of I E :. Z, Andover 0 - 55 I __. n IL �AK. h ver, Mass, A- cocMic„tw�cK y1. 7d ADRATED 7S U BOARD OF HEALTH Food/Kitchen RMIT LD Septic System THIS CERTIFIES THAT .......... e"W.L.0000.54W....... .......I... . . ......... BUILDING INSPECTOR Foundation has permission to erect.......................... buildings on .. !�.. .. ........� _�►.....��'�!!�■,� Rough tobe occupied as ...... . ... ................. ......... ... ........ .... ............................................. Chimney provided that the person accept) this permit shall in every respect confto 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough MONTHS PERMIT IR I 6 MONTHS ELECTRICAL INSPECTOR ® UNLESS CONSTRUCT ARTS Rough Service ........ .... . .......................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall T® Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. WAYNE ROOFING SYSTEMS, LL(--.'. 65 E Belcher Road TELEPHONE (774)215-5338 Foxboro,MA 02035 FAX (774)215-0421 This proposal is contingent upon strikes, fires, accidents, or other causes beyond our control, and is not a contract until signed by an officer of this company, and is subject to acceptant within 30 days from the date of this proposal. Our workers are fully covered by We rkmen's Compensation Insurance. Payment Terms: 1/3 due upon commencement of work 2/3 due upon completion Interest of 1112%per month will he charged on all accounts over 30 days f ACCEPTED BY TITLE DATE By: S Com Edward Coyle,Managing Member 2 i WAYNE ROOFING SYSTEMS, LL � 6,CIldcl—Fund TELEPHONE (774)215-5338 FnOnm,MA 02035 FAX (774)2 1 5-0421 I PROPOSAL I'o: Mr. Brian Rittershaus Date: April 2,2015 123 Mass Avenue North Andover,MA 1 RF,: Roofing p123 Mass Ave.,North Andover,MA We propose to Furnish all necessary labor, material and equipment (except as noted b aow) to perlbrnl the following work in a first class workman like manner: i SCOPE Off WORK* - • Co over existing,shingles with new shingles • Clean jobsite of all work related debris For the sum of: $8,000.00(Eight Thousand and 001100 Dollars) 1 i 1 The Commonwealth of j lassach usetts Department of Industrial Accidents 4 Office of In vestigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Elects icians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Wayne Roofing Systems LLC Address:65 E Belcher Road City/State/Zip:Foxboro, MA 02035 Phone#:774-215-5338 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 20 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub'.-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8• ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. $insurance comp.insurance. , required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ t am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption;per MGL 12.[M Roof repairs insurance required.] f c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box fl I must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire'outside contractors must submit a new affidavit indicatingsuch. tContracton;that check this box must attached an additional sheet showing the name of the sub-contractors and state whcgrer or not those entities have employees. If the sub-contractors have employees,they must provide dreir workers'comp_policy number. lain(in employer that ivproviding workers'compensation insurance for n:y employees. Below is the policy and job site intoPlnation. Insurance Company Name:CNA Policy#or Self-ins. Lie./t:4024977222 Expiration Date:6/18/2015 Job Site Address: 123 Mass Ave. City/State/Gip: North Andover, MA 01845 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby certify rimier the pains and penalties of perjury that the information provided above is true and correct. Si nature: `% Z Date:4/2/2015 / Phone#: 857-753-546 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#: WAYNROO-01 MMCNAB CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4/2/2015 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 CONTACT NAME: Deland,Gibson Insurance Associates,Inc. PHONE 781 237-1515 FAX 36 Washington Street (AIC,No,Ext):( ) I(Arc,No)e(781)237-1808 Wellesley ills,MA 02481 EMAIL ' info deland ibson.com ADDRESS: � g INSURER(S)AFFORDING COVERAGE NAIC 0 INSUREf{A•Continental Casualty Company 20443 INSURED INSURER 13:Safety Insurance Company ,39454 Wayne Roofing Systems,LLC INSURER c:National Union Fire Ins.Co.of Pittsburg,PA - 65 E.Belcher Road INSURER D:Transportation Insurance Company 2049.4 Foxboro,MA 02035 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 IADOL'SUBR1- - - 1!POLICY EFF I POLICY EXP I LIMITS (NSD:WVD POLICY NUMBER 1(MMIODIYYYY)i(MMIDO(YYYY)j A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 _DAMAGETORENTED CLAIMS-MADE X OCCUR I 14024977219 06!1812014 06/18/2015.PREMISES(Ea occumence) 15 100,000 j I MED EXP(Any one person) S 5,000 I i PERSONAL B ADVINJURYj 5 1,000,000 __ _ GEN'L AGGREGATE LIMIT APPLIES PER: I I GENERAL AGGREGATE S 2,000,000 PRC- POLICY, X ECT I LOC I PRODUCTS-COMPIOP AGG S 2,000,000 ---____LOTHER: AUTOMOBILE LIABILITY u —�COMBINED SINGLE LIMIT + (Ea accident) S 1,000,000 BANY AUTO ' 15058830 06/18/2014.06/18/2015 BODILY INJURY(Per person) ''$ ALL OWNED X 'SCHEDULEDBODILY Per accident $ AUTOS AUTOS ; ( ) i IIIREDAUTOS NON-0VvNED PROPERTY DAMAGE AUTOS I (Peraccidenl) S X UMBRELLA LIA6 1X OCCUR EACH OCCURRENCE $ - 9,000,00 C EXCESS LIAR CLAIMS-MADE' IBE080850833 06/18/2014 10611812015 AGGREGATES 9,000,000 ;DED X I RETENTIONS ,00010 - - .WORKERS COMPENSATION —' PER '-TT 3 AND EMPLOYERS'LIABILITY X I STATUTE ER D ANY PROPRIETORIPARTNERIEXECUTIVE Y I N 024977222 06/18/2014 1 06/18/2015 E.L.EACH ACCIDENT 1$ 1,000,000 OFFICERWEMBER EXCLUI L , NIA -.. (Mandad,ryIn NHI) E.LDISEASE-EA EMPLOYEE-$ 1,000,000 l( es,do afl a under - - - I.D SCRIPTION OF OPERATIONS below � _ 1 I E.L,DISEASE-POLICY LIMIT is 1,000,000 A ',Equipment Floater 4024977219 06!18/2014 06/18/2015 Ishort term rentals 165,000 A .Installation Floater 14024977219 06/18/2014 06/•18/2015 Special Form 300,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mere space is required) Project:1 23Mass Ave.,North Andover CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street,Building 20,Suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i I } CS-090495 EDWARD COYLE 53 Summer Street West Roxbury MA 02132 07131/2016 I i i j III -