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HomeMy WebLinkAboutBuilding Permit # 4/22/2015 t%ORTl� ® BUILDING PERMIT 0'C.'I.ED Ib�tio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ®Ie- Permit No##:_ Date Received ED Aoa �EKw,pa�R ��SSACHHSE� Date: Issi aed: C__ IMPORTANT: Applicant must complete all items on this page L: CATION d� I h qlc5h, Print PF OPERTY OWNER l Print 100 Year Structure yes o M'aP PARCEL ZONING DISTRICT: Historic District yes no Machine Shop Village yes no rTYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family C�'Addition ❑Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other . � a A?I& .e � DESCRIPTION OF WORK TO BE PERFORMED: - A el U o�e! `he a d V e I— P c Ary,0'. lentificatioPlease Type or Print Clearly OWNER: Name: di G n Phone: 7 S- -�- Address -o l ZIP/C) Contractor Name: Phone: 6 03°-- Email: AD)-U 0a , 7 Address: S-4 een 0 .07 A9 Supervisor's Construction License: o'I Exp. Date: Z _ � Home Improvement License: VL—r19-103 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED $925.00 PER S.F. Total Project Cost: $ �' 6 00 FEE: $ Check No. Receipt No. NOTE: Perso s contracting with unregistered contractors do not have access to the gu ranty fun F v"yml' ✓�.i.t �;l,,�,,. I{i/,.%I J fl 90MINIX///i a,'i�i1O'., ��i� /I /i�` ///�.r�n, %T %/�' i..jlNA!/`P"� //U,v/r.�[ili�7✓/i p17 n Uo i;Vlt ,!lluP(9115A'i/I/ 1' I ✓�'m/��WI�,`���11'IG�O/�yl�����rl���IIIL Y( NO No.r •.. J! r • • Page# of pages (Io,,s4\,q-., afu� C) �R­DPOSAFSHUI-BM-ITVITo: "-­"" E j6B—# -­—------ ADDRESSJOB RAI- 54-no �ov —........... BT—EZ4O F.t. k ...... ..........WONE# \ FAX# CHFFECT Me hereby submit specifications and estimates for: ------ Z ov j/C eoq,A� 0 4 C 0 A 0 Lt��l ......... 'via . .......... ................. ------- ........... --------- ..........------------------------- ............ . .....===.=� ............ -------------- ................... .................. ......... ............................ ------- ........................ .............. . ...............-........................ ............. ........... ............................ ----------II..........--........... --......... .................... '(I propose xj I t j (list] atom erial wrd labor-cpW e in accordance with the above specificafions for the suis of: 51M 1- L ... Dollars ............. ....... with payments to be rnade as follows: ... Any alteration o r deviation from above specifications invo M ig extra coifs Respectfully wi I I be exer.0 led only upon Wr iffen order,and will become mi exfp a ct targ e submitted ---------- --------- over and above the estimate. All agreements contingent upoastr*es, accidents,cr delays 1leyvm9 aur control H(114te----fts Pr opo I may be withdrawn by It if not accbpted within .................days. -------------- "U'Creptance of - T The above prices,specifications and conditions are--Safisfactory and are hereby accepted. You are authorized to do tho work as specified. Payments will be made as outlined above. Signature------- Date of Acceptance Signature............. ---------- =—= . . ......... .-:::::::._....__ax...:_.:__._-__.......- -. ........ ...... X-NC3819/T-W5o 09-11 #1 construct new addition on left rear of house #2 addition to be 8'x 8'one level includes framirrg siding windows roof exterior finish interior demo-one wall to open to house_ ctran rielino a V #3 construct new doghouse bulkhead on right rear of house #4 addition to be doghouse bulkhead(to be size of bulk head) includes framing iding roof exterior finish strap cieling before Addition z v j J i 1� y f, t _ s t j pR0p05G-(D L � � T of re Addition Floor Plan t3 s Z7 C:iose Window Niew sedio+m JL04.-Sq.lf P P .132 iq.ft 132 g1t: u*a:3.s/FujFN4:[9 z2 2z 1674-Sq.ft 27' 27 ft 94 q:ft ft '-FY'on t fJL)nY 0 PLAAJ i do�hous-e hcrl�<h� =� Ex s 1 Neuf Po 0 h-, pPoPOS t REAP E (E UAT IOA) Z$ !o r Roo rA t EA,Si(v { -v-- LoOP, M I AI(� P/AA/ I r 1 br j .., x 40 w�/-hurt i co r-e c f APs ri �X`s�`� GQ n 0 h,) Z -fix r@ RooF AM1 /V�7 PLA A/ 6 �pR PLA ABL MORTGAGE INSPECFLA INSPECTION N y. REGISTERED LAND SURVEYORS NAME AMY YAN LU P.O.Box 70702 Quin$igamond VWW Station UNDER WORCESTER,(P 01607 LOCATION 32-34 STONINGTON STREET 508-752-8050(PHONE) ( 508-752-8004(FAX) NORTH ANDOVER, MA A Division of H. S. & T. Group, Inc. REGISTRY ESSEX NORTH SCALE 1 = 30 DATE 02-24-15 �I MOM UP +° r WOM ��ooK/WACE 12465/57 � °Fvummamm as WtAM eoo�c/WLAM X265 vMmmomw Ania OF QFn DANOR o �j �p� J WE COMff IW 7W UNW4M ASE Wr+W M nM mumm O w *i� s'�At FLOW rM1 AWL aEE FOI1 YAW: oF, I�i�c I ENHER oo 4 209 F me 07-03-12 N E Vt Lam 20"m lHO mw LMS C"m R at o Eam Fm%lMJ W Bffowco FM RM HaANO nW WS tlfOM MONOM K$GALE AFD AGIW711 UMOER YAiWG QX.7gLE 1!L CYYL Oft SM 7 W" 13 MOT l if At7GURk{g UMti OEflitNE WlAti3 ANE lgiM O S w well Oi MOM-liIAMW NAE. /bR A WOOL COMRC{ $tlRV6Y R HA#E AlOf1E.0 ANE IIIAOE MH17ME WNOY!!OM'HYO' O1SUm K MA At4y P000 E'O L4 ACCUMN AM MW 7W msvR►£- Mm"m PQlFONI�p,WNL FAE�wOlOfbj WOW OEOt7O0� "mpg"L�AiOCtW*UW LOCOW w N W M 7o 7FE I V� 1 O/IM LAIN"M OF SNA E =ASU, P.C: >�1HT tRiNZ Cman Hrt The Commonwealth of Massachusetts ' Department oflndustrialAceldents { tl 1 Congress Sheet, Suite 100 F Boston,MA.02114-2017 www.mass.gov1dza Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE I+'ILED WITH TEE PERMITTING AUTRORITI'. Applicant Information /p Please Print Le 'bI Name (Business/Organization/Indivadnal): Q A nT75 oe l S ( d R.Sr tl C r Address: rU City/State/Zip: r G l9 /�/� Phone#: Are you an employer?Check t appropriate box: Type of project(required): L[41 am,a employer with + employees(full and/or part-time).* 7. ❑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. F1 Demolition 3.F1I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.E]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 If.E]Electrical repairs or additions proprietors with no employees. 12.O Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ l 13,[]Roof repairs • These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its offrcers have exercised their right of exemption per MGI c. 14.EJ Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] , *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. Iain an employer than is pi ovidhig lvorlcers'compensation insu ran ceyor nay employees.'Below is the policy and job site information. Insurance Company Name: E' Policy#or Self-ins,Lie.#: LUC600? :Z.'7.tom ' Expiration Date: P /O Job Site Address: ? J 1 f1/AG 1pA ( City/State/Zip: /ItG d Attach a copy of the workers'ebuipensation 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under hepains anadnaltles ofperjury that the information provided ahoy is true nd correct. Signature: Date: Phone# Official use only. Do not write in this area,to be completed by city or town offacial., City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACaCERTIFICATE OF LIABILITY INSURANCE DAT4/14/DIYYYY) 04/14/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu Of such endorsement(s). PRODUCER CoA NT CT AL MATTHEWS MATTHEWS INSURANCE AGENCY PA1CNNo Ext: 8 - 2- AIC No: 781-872-1813 182 PARKER ST E-MAIL ADDRESS: LAWRENCE,MA INSURER($)AFFORDING COVERAGE NAIC# 01843 wsURERA: MERCHANTS 23329 INSURED ALL IS WELLS CONSTRUCTION INSURER B: LIBERT MUTUAL 19624 288 NO END BLVD INSURERC: SALI S B U RY,MA INSURERD: 01952 INSURER E: INSURERF: 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. rA TYPE OF INSURANCE D S BR POLICY NUMBER MMIDDIYYW CY EFF MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY I(' PREMISES Ea occurrence $ 1,000.000 CLAIMS-MADE I OCCUR ` MED EXP(Any one person) $ 15 000 BOP1047700 04/14/2015 04/14/2016 PERSONAL&ADV INJURY $ INCLUDED GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 17 POLICY PR O LOC $ AUTOMOBILE LIABILITY Ea accident COMBINEDSING E ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIREDAUTOS AUTOS (P NON-OWNED P PROPERTY DE $ UMBRELLA LIAR OCCUR r EACH OCCURRENCE $ EXCESS LIAB F—ICLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y� WC00035222065 02/10/2015 02/10/2016 E.L.EACH ACCIDENT $ _100,000,,,,_ OFFICE/MEMBEREXCLUDED9 N NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 I I OPERATIONS w DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) GENERAL CARPENTRY CERTIFICATE HOLDER CANCELLATION TOWN OF NO ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 OSGOOD ST ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING 20,SUITE2035 AUTH054ED REPRESE TIVF NO ANDOVER,MA 01845 \ ©1988-2010 AC CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACCIRIV r s -^_. _ +-�a•.,,�s ..� . -.._........._-_.._� X11—�e�a.��.. �.r�---��v.:_.....,. .^ :�..._.sy,maZ..�........... . ...... Office of.Consumer Affairs` ...£ siness Regulation 10 Park Plaza . S�aue5>170 Boston,Mass et6'02116 Home Improvement °or Registration ` Regialratlon: 125503 DBA WIND©WS 8Y WELLS M Wration: 1 /08/201 Cno 293210 RANDALL WELLS' • - a 1 M.MAST RD. w EPPING, NH 0304 < Urate Addren and return Mrd.Mark xapr+for cbsigo. Addrew Renewal Rip e Commonwealth of Massachusetts Department of Labor standard. Heather E Rowe,Director Deleader Supervisor Massachusetts -Department of Public Safety RANDY Ci.,WELLSBoard of Building Regulations and Standards , Eff.Date 02/11!15 �iy✓�i �f p/ Construction 5uliervisor "`� License: CS-078048 Exp.Date 02/10/16 f OS06078316 � 4 �, tvbmberof CA.N.E.S.T. Randall G Wells r ._ w HV-RENEW PO Boa 246 Salem NH 03079 r IN 111111111111 )I 1t0 Expiration 09/08/2016 Commissioner