HomeMy WebLinkAboutBuilding Permit # 4/16/2015 i
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BUILDING PERMIT
TOWN OF NORTH ANDOVER � �
APPLICATION FOR PLAN EXAMINATION _
Permit No#: �� Date ReceivedAr
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Date Issued:
PORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
A Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
hfifCl'Se tic" ❑Well r CI%Floo,c! Iain r ❑Wetlandsf r ` F❑ Watershed District
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SCR PTIO� OF BEP RFQRMED:
'1'VlC1(l� �� S IVL0C� WORK Ti�1:< IQ fitN(A 119y ' �, I ✓1 �`}
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Id ntification- Please Type or Print Clearly
OWNER: Name: nul) Phone:
Address:
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ARCHITECT/ENGINEER Phone:
Address: `A 14 Reg. No. Jz
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 3i oc o FEE: $
Check No.: !> Receipt No.: �_�
NOTE: Persons contracting with unregistered contractors do not have access to the ty fund
Y
Si nature ofA ent/Owner' ` Si nature"of contracto
o ,
& FORTH
Town of
A- ndover
2 4_E. ._
0 0
® s
n h ver, Mass, IQ
T O LAKE
COCNICHEWICK.V
OtOATEV 01?
S U
BOARD OF HEALTH
Food/Kitchen
rwERMIT T L �u Septic System
THIS CERTIFIES THAT ................ . .... . ........... .. .".�..a........ ............. .. ..... J..............................
BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings on ... .... . ........
Rough
to be occupied as ,,,,,,...
......... .. .. ... .... ......q..5.j. .izT..............�1.�� .....�Jl.��. Chimney
provided that the person accepting th ermit shall in eve respect conform to the terms of the a lication
p g � p pp 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
IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STS 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 To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
PPW M 4654
Express Asset Management Work Type: Bid Approval
Work Order Information Assignment/Due Dates
Client Company: 78569
Customer:251 Recei fed Date:April 1, 2015
Loan #: XXXXXX9032 Loan ue Date:April 7,2015
Type: Ass gned To: Elkin Gomez
Address: 392 MASSACHUSETTS AVE
NORTH ANDOVER, MA
01845
Lot Size: 145 x145=21025
Comments
PERMIT MUST BE PULLED-THIS MUST BE STARTED ASAP
Work Order Details Qty Price Total
PHOTO-PHOTOS 0
PHOTOS DOCUMENTING INTERIOR AND EXTERIOR PROPERTY CONDITION, DAMAGES, BIDS,
SUPPORTING BEFORE, DURING(TO SHOW PROGRESS)AND AFTER OF WORK COMPLETED.
PROPERTY CONDITION -COMPLETE A PROPERTY CONDITION REPORT 0
REPORT CURRENT PROPERTY STATUS INCLUDING UTILITY INFORMATION. CONFIRM PRESENCE OF
SUMP PUMP AND VERIFY IF OPERATIONAL. IF NO VISIBLE SUMP PUMP IDENTIFY IF CROCK IS
PRESENT.
COMPLETE A PROPERTY DAMAGE REPORT 0
PROVIDE DETAILED DESCRIPTIONS OF DAMAGES INCLUDING LOCATION, PHOTOS AND BIDS TO
REPAIR. EYEBALL ESTIMATE IS NECESSARY WHEN DAMAGES ARE PRESENT.
PROPERTY CONDITION OTHER 0
IF REPORTING A PROPERTY AS OCCUPIED, PLEASE INDICATE REASON FOR REPORTING
OCCUPANCY, NAME, RELATIONSHIP&CONTACT INFORMATION OF PERSON PROVIDING
VERIFICATION, OTHER METHODS USED TO VERIFY OCCUPANCY. PERSONAL PROPERTY IS NOT A
JUSTIFIABLE CAUSE TO REPORT THE PROPERTY OCCUPIED, UNLESS YOU ARE IN A MUST EVICT
PERSONAL PROPERTY STATE. IF THIS IS A MOBILE HOME ADVIS OF MANUFACTURER, MAKE,
MODEL, SERIAL#,VIN#AND HUD TAG VS.ADVISE IF IT IS A SINGLE, DOUBLE WIDE OR TRIPLE WIDE.
ADVISE IF THE AXLES,WHEELS OR TONGUES HAVE BEEN REMOVED. PROVIDE THE LENGTH AND
WIDTH OF THE MOBILE HOME. PLEASE PROVIDE CLEAR PHOTO OF VIN#AND HUD TAGS.
BID APPROVAL-REPAIR/REPLACE ROOF- 0
PLEASE COMPLETE THE FOLLOWING FROM BID#(2599673)ON WORK ORDER#(1046626970).
SECURING- REPLACE- REPLACE ROOF—REMOVE MAIN ROOF-ASPHALT SHINGLE-DOUBLE
LAYER. REPLACE ASPHALT SHINGLE-BASIC 3 TAB (25-40)YEAR.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
e 1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information r Please Print Le ibl
Name(Business/Organization/Individual): / I��I �/ � vwr)
Address: rV) Is
City/State/Zip: AtckKbf l m� 71&3 Phone#: 1-0 _J`O
Are you an employer?Check the appropriate box: Type of project(required):
1.P I am a employer with employees(full and/or part-time).* 7. E]New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.F]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 []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.
12.0 Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roofbing re
These sub-contractors have employees and have workers'comp.insurance.$
repairs
6.Q 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.]
*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.
$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 insurancefor my employees. Below is thepolicy and job site
information. /
Insurance Company Name: 1 rA
Policy#or Self-ins.Lie.#: Expiration Date: Q
Job Site Address: :3y"), rm z 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. 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 thepains andpenalties ofperjuiy that the information provided above is true and correct.
Signature: 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#:
DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 06/11/2014
ACORD,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 lNSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. les must be endorsI ed. if SUBROGATION IS WAIVED,subject to
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy( }
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). ANDRE SILVA
NAME' 508-875-5885
PRODUCER PHONE 50g_875-5600 (AIC,No):
Rap. 8. 7epsen Financial and Insurance Services Luc No Ert:
1103 Commonwealth Ave aoDREss:
INSURER(5)AFFORDING COVERAGE NAIC#
Boston, MA 02215 INSURER A AMGUARD INSURANCE CO
,NSUi2ED NOLBERTO RMFING AND SIDING INC INSURER B
INSURER C
f 8 BACON SLEEP _
APT 1 INSURER D
MILFORD, MA 01757 INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER:RT MANAGEMENT
REVISION NUMBER:
THIS IS TO CEROTIFYTP i::flffE POLICIES 01:THSTANDING ANY REQUIREMOLICY PERIOD
ISUENT,TERM OR CONDITION ISTED VOFBANY CEEN ONTRACTT OR OTHER DOCUMENT WITH RESPECT ALL
HE TERMHICH THIS
INDICATED. N
CERTIFICATE NS RAND CONIS
DSTIONS OF SUCHEPRTAIN,THE OAN THEI
LICIES.LIMIT M TSRSH WN AFFORDED
ORDA VE VE BEENEREDUICED BY PAIDICLAIMS.
ED REIN IS SUBJECT TO ALL THE TERM -
EXCLUSIO LIMITS _
IN TYPE
=IN =
INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY►
LTR EACH OCCURRENCE $
GENERAL LIABILITY $
PREMISES(Ea occurrence)
COMMERCIAL GENERAL LIABILITY MED EXP(Any one Person) $
CLAIMS-MADE �OCCUR PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS-COMPIOP AGG S
GEN'L AGGREGATE LIMIT APPLIES PER: $
PRO-
POLICY I i JECT (Ea accident) S
AUTOMOBILE LIABILITY I BODILY INJURY(Per person) I$
i
� I ANY AUTO BODILY INJURY(Per accident) $
ALLOWNED SCHEDULED
AUTOS- AUTOS $
NON-OWNED (Per accident)
HIREDAUTOS AUTOS $
EACH OCCURRENCE $
UM13RELLALIAB OCCUR 1 $AGGREGATE
EXCESS LIAB CLAIMS-tAADE I S
DED RETENTION SYyu
7AY11- 7H-I
WORKERS COMPENSATION TBA 06/0612014 06/06/2015 X 10 Lill ITS ER
I AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT S 1,000,000
1 4 ANY PROPRIETORIPARTNERIEXECUi� N I A
f A OFFICE RIMEMB ER EXCLUDED? N E.L.DISEASE-EA EMPLOYEE S 1,000,000
fl if yes,describe under E.L DISEASE-POLICY LIMIT $ 1,U00,00U
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE D CRIBED CIES ANCELL EFORE
THE EXPIRATION DATE TH_<E F,NOTICE WIL E LI ERED I
ACCORDANCE WITH THE POLI PROVISIONS.
RT MANAGEMENT AUTHORIZED REPRESENTATIVE
ROODY@RTREMODEL.COM =
120 MAY ST
NORTH CHELMSFORD, MA 01863
O 1988-2010 ACGRiTCORPORATION. All rights reserved.
AGORD 25(2010105) The ACORD name and logo are registered marks of ACORD
RPMAN-1 OP ID:SW
CERTIFICATE LIABILITYI DATE(MMIDDIYYYY)
04/15/2015
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($), 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:732-842-2012 NAk1ERC-T
York-Jersey Underwriters,Inc. Fax:732-530-7080 PHONE FAX
185 Newman Springs Road arc No Ext: AfC No):
PO BOX 810 E-MAIL
Red Bank, NJ 07701 ADDRESS:
Johnnie Rumbaugh INSURER(S)AFFORDING COVERAGE NAIC a
INSURER A:Underwriters at Lloyd's,London
INSURED RP Management INSURER B:
Valias R Herold Jr
120 Main St INSURERC:
N Chelmsford,MA 01863 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
!NSR TYpE OF INSURANCE POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MMIDD!'('(Y MMIDD/YYYY
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A X COMMERCIALGENERAL LIABILITY 15NAMB0408 02/23/2015 02123/2016 DAIv1AGE ccur
RENT o
PRE
Ee orence s' 50,000
X CLAIMS-MADE ❑OCCUR MED EXP(Any one person) s 5,000 '..
X $2500 Ded PERSONAL&ADV 114JURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A.GG S 2,000,000
POLICY JECT LOC S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea ecadent S
ANY AUTO BODILY INJURY(Per person) $ '..
ALL OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS AUTOS '..
HIRED AUTOS NON-O'NNED PROPERTY DAMAGE S
AUTOS (Per accident
S
UMBRELLA LIABOCCUR EACH OCCURR6VCE 5
EXCESS LIAB HCLAIMS-MADE AGGREGATE S
DED I I RETENTION S S
WORKERS COMPENSATION WCSTATU- OTH-
AND EMPLOYERS'LIABILITY YIN TO I .i S FP
ANY PROPRIETORIPARTNERIEaECU11VE ❑ NIA E.L.EACH ACCIDENT S
OFrICERAIEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S
If yes,describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT I S
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required)
Mortgage Field Services - Errors & Omissions $1,000,000 (claims-made) $2500
deductible. Extended Property Damage $50,000 occurrence/$100,000 aggregate
CERTIFICATE HOLDER CANCELLATION
MILFORT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Milford ACCORDANCE WITH THE POLICY PROVISIONS.
52 Main Street
Milford,MA 01757 AUTHORIZEDREPRESENTATIVE
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
r4rd Rr.,Y' , ^ary a L4`6 e,?�V:•'� �°n, !✓ r"ter. "-',.�-��"C Ye�:'c.�'"e":�``L'•..�
Office of Consumer Affairs and Business Regulation
f ±"' 10 Park Plaza.- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 169638
Type: Corporation
Expiration: 7/13/2015 Tr# 242537
ROODY PROPERTY INC.
VALIAS HEROLD JR.
120 MAIN ST.
CHELMSFORD, MA 01863
Update Address and return card.Mark reason for change.
SCA 1 0) 20*05/11
Address r] Renewal r] Employment n Lost Card
,r
r*%
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
NOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
iRegisttation 169838 Type; Office of Consumer Affairs and Business Regulation.f Expiration: 7/13/2015 Corporation 10 Park Plaza-Suite 5170
,Boston,MA 02116
RODDY PROPERTY INC. f
VALIAS HEROLD JR.
120 MAIN ST. % _moo
CHELMSFORD,MA 01863 Undersecretary Not valid wit t signature
s
!owl k ..iuIYdl rt
CS^106968
VALIAS R HEROLD JR
120 MAIN STREET
North Chelmsford'MA 01863
;�aor7r r� .r5:ver�;r' 01/02/2017
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