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HomeMy WebLinkAboutBuilding Permit # 4/8/2015 (2) i I -, NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER ; APPLICATION FOR PLAN EXAMINATION n Permit NO: Date Received ,. Date Issued: Nt �9SSACHUS���y IMPORTANT: A2plicant must complete all items on this page LQC/�TION'� / .: � � :yZir PROPERT0INIVER , '7 MAP NO PARCEL: ZONING,dISTRICT: Historic District :' yes Machine Shop Village',; yes,, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family a Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement C]Assessory Bldg ❑ Others: 1 Demolition ❑ Other I Se tip ; EA Well, ❑,Flogdplain o Wetlands ElWatershed:District,, �' � at6r/Sew6r : : . .47 C—f x ;Z6 Identification Please Type or Print Clearly) OWNER: Name: �`° Phone 4n) W Address: CONTRACTOR .Name Address; t. g Supervisor's Consilrb` n License : Expk Date: Home Improuemertt License 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 Cost: $ FEE: $ Check No.: Receipt No.: Q PL, NOTE: Per ons co tra ling with unregistered contractors do not have access to the guaranty fund Signature of Agent/Own —Signature of contrac M'. "I FORTH Town ` E ..•h' ®ver to ® �( , Y O LAKE h ver, Mass, COC KICKEWrCK ��• AOR,qTE D A?�,`'�5 S U - BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ........,, .G. .... . .. ............. .. .... . . .. .. .. . ..... .. .. .. . BUILDING INSPECTOR .... ....... ............. ....... Foundation has permission to erect .......................... buildings on ..�.�..� . :/:�. ..h... .............`.::ti..:..G..`... Rough to be occupied as �.d�.�� .... ......... .. .D ............... ................................................................ Chimney provided that the person accepting this permit 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 and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION T RTS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® 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. Proposal HIC#174377 Damp ousse Roofing LL A trusted name since 1938 Roofing • Siding ®Windows 87 Belmont Street • North Andover, MA 01845 P: 978-683-45888 ® F: 978-685-7446 NAME OF OWNERZ--21-1 � /,✓ " f ADRESS OF JOB . � —;� TEL. G�� DATE: � We will remove all roof shingles off total roof area, up to two layers. Replace any boards or sheathing at additional cost. A new 8"white aluminum drip edge applied on all edges. Approx. Eft of ice and water membrane applied on eaves, aft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. A - architectural roof shingle installed. Install new vent pipe boot flashings. Waterproof existing chimney flashing and remove debris. Shingle Color: Ridge Vent Upgrade$8.00 per ft. Wood Sheathing Repair .per ft. ,r C 0 oe%Al Z�&'/— We Propose herby to furnish material and labor-complete in accords ce with above specifications,for the sum of: dollars($ �-✓ )�." Payment o be made as follows / r ?4) " Authorized Signature NOTE:This proposal may be withdrawn b us if not accept/with in/ days P P Y Y Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are herby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Signature ! Date of Acceptance: 1-2-2— J-� Signature The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual : Address:2 i� t J �r City/Stafe/Zip: ��03�Ci�'!�.� 1 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. t I am a employer with 4. ❑ lam a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.? �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9 El Building addition [No workers' comp.insurance 5. [J We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Pl bing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12. oofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑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 Lire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workerscompensation insurance for rriy employees. Below is thepolicy and job site information. ] Insurance Company Name:- " Policy#or S elf-ins.Lic.#: ^ y z} ems{�j/� ,f Expiration Date: Job Site AddresCity/State/Zip: 1�11AI�12Z Attach a copy of the workers'coin nsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cerci itniler the pains andpenalties ofperjury that the information provided abo e is true and correct. Si:riiature: .2��. �"-�/� 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#: Client#:14415 DAMPHOUSSE ACORD- CERTIFICATE OF LIABILITY INSURANCE 0DATE(MWD 5/07/2014 rn PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.80x 1965 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Elm Street Andover,MA 01810 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Alain Specialty Insurance Compa Damphousse Roofing LLP INSURER B: 87 Belmont St INSURER C: North Andover,MA 01845 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR affl TYPE OF INSURANCE POLICY NUMBER PAC CTiV POL CTE imWDORY) Are )RATION LIMBS A GENERALLIASILITY CIP16938701 04/12/14 04/12/15 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE MSFTO RENTED 5100 000 CLAIMS MADE Q OCCUR MED EXP(Anyone person) S5,000 X PERSONAL s ADV INJURY S11,000,000 GENERAL AGGREGATE s2.000.000 GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGG s2,000,000 X POLICY PRO LOC AUTOMOBILE LIABILITY COMBLYED SINGLE LIMIT S ANY AUTO (Ea acodent) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per aaidant) $ PROPERTY DAMAGE S (Peracadenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO EA ACC S OTHERTHAN AUTOONLY: AGG $ EXCES&UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR D CLAIMS MADE AGGREGATE S S DEDUCTIBLE $ RETENTION S S WORKERS COMPENSATION AND V/C STATU- OTII FR EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETORIPARTNEFLEXECUTIVE OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE S II yes.descnbe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I S OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Covering operations usual to Damphousse Roofing LLP... CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO NIAIL In DAYS WRITTEN 1600 Osgood Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO oo So SHALL North Andover,MA 01645 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED ATIVE ACORD 25(2001/08)1 of 2 #S30466/M30465 DML U 0 ACORD CORPORATION 1988 Hca 0 CERTIFICATE OF LIABILITY INSURANCE DAT5/07/2DIYYYY) 05/07!2014 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). ACT PRODUCER 00474-001 NAME: Doherty Insurance Agency Inc PAHiCONNo.Ext): (978)475-0260 A1C.No.: PO Box 1985 EMAIL Andover,MA 01810 ADDRESs: INSURER(SI AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 26158 INSURED INSURER B: Damphousse Roofing LLP INSURER C: 87 Belmont Street INSURER D: North Andover,MA 01846 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. ILTR TYPE OF INSURANCE ANSR SWVp POLICY NUMBER POLICY EFF MMIDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PRt�NISES Ea occurrence CLAIMS-MADE []OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ ENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ OLICY ECT OC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ '.. NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ '.. UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMSMADE AGGREGATE $ yypRKDEERDg pry ERNETENTIOIJ $ $ AfJD EMPLOYERS LIA" 191 X TORY LIMITS OER OFyIC UgJUERIEXECUTIVE YIN N E.L.EACH ACCIDENT $ 500,000.00 A F Eory in NH) EXCLUDED? � NIA AWC-100-7028774-2014A 4/17/2014 4/17/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000.00 If yyes describe under E.L.DISEASE-POLICY LIMIT $ 500 000.00 DESt APTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) No partners are covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION Town of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE G� ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ti Office of nsumer Affairs&B sines Regulation HOME IMPROVEMENT CONTRACTOR a Registration 174377 Type: Expiration: 2/4/2017 LLP D4' OUSSE ROOFING LLP' SHAUN TWOMEY 87 BELMONT ST N.ANDOVER,MA 01845 Undersecretary 9 Massachusetts ..Department of Prabhc Safety Board of Buy l ing ReguAatpcans and Standards (:"mistral cion Super)isor IJcense: CS-067560 SHAUN M TWOMEY 61 PATROIT ST .w N ANDOVER MA 018,x% r r , J. . ai PVrafVrt a"N Commr ssioner 10/25/2015