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HomeMy WebLinkAboutBuilding Permit # 4/21/2015 BUILDING PERMIT t%ORTH ' TOWN OF NORTH ANDOVER 6 00 APPLICATION FOR PLAN EXAMINATION 47 Permit No#- Date Received VSS C US Date Issued: t /IMPORTANT: Applicant must complete all items on this page "I'll"Y"', ol"S �W? 'mm pan 112" -w P CO O NEWON rrr ON rr. E W 4 _hMAP ARC IF TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential Li New Building O'bne family Li Addition Li Two or more family Li Industrial Ci-Alteration No. of units: 11 Commercial Li Repair, replacement 11 Assessory Bldg [I Others: 11 Demolition Li Other DESCRIPTION OF WORK TO BE PERFORMED: V'2- MOV SA 6- Identification- Please Type or Print Clearly OWNER: Name: C_o�w i ce. Phone: 9 SSS e&-s Address: Sv IVO--f 71' .Y l 0 0 2 Le A` "mr1Q, 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: $ 0 FEE: $ 622 67 Check No.: Receipt No.: r— NOTE: Per ons ontracting with unregistered contractors do not have access to the guaranty fund Si natureof Agent/Owri ,p, Signature FORTH ndover town of A. ® »' OA No. L.K. h ver, ass, r COCHIC"t WICK ��• A°RATED ST ►P� ,�`� U BOARD OF HEALTH PERMIT T L Food/Kitchen Septic System THIS CERTIFIES THAT �y; BUILDING INSPECTOR •... ........... .. .. . ... t Rough K4.+ ii to be occupied as ... 4 I ..1.... l ...... .. .. .. ..... .Z.. .....'.... . 'e......... 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 1&9wl 6 T- PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final -� PERMITEXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTIO ST TS Rough Service ...... ........ ..... ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Puildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts X Department of IndustrialAceldents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH THE PERINITTING AUTHORITY. Applicant Information Please Print LeaiblY Name (Business/Organization/Iudividual): ��{y�(� ` � �5 � � `� /� (�,LP� ue Address: /%S' 0 City/State/Zip: t "Vet_ ' 1U6Lylgt 23 Phone#: Are you an employer?Check tine appropriate box: Type of project()required): 1. am•aemployerwith_�. employees(fulland/orpart-time).* 7. ❑New construction 2•[J I am a sole proprietor or partnership and have no employees working for me in 8. r]Remodeling any capacity.No workers'comp.insurance required.] 3.F1 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 10 E]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. ' f 12.❑Plumbing repairs or additions 5. I am a general contractor and I haye hired the sub-contractors listed on the attached sheet. ❑ � 13.FJ Roof repairs These sub-contractors have employees and have workers'comp.insrrance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[_ Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] -m *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 fiave employees,lhey must provide their workers'comp.policy number.• Iain an employer trial is providhig workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: 5CZ-��tp Gtl'�t�Gr Policy#or Self-ins,Lie.#: Expiration Date: ���� �/ Job Site Address: 147 W� City/State/Zip:,/Z/�,_/-t?�r,14V-eY O(X Attach a copy of the workers' comp ,sation 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 her ehy certify under thepains andpenatties ofperjury that the information provided above is true and correct. Signature: Date: -f 2-/ Phone#• Official use only. Do not write in this area,to be completed by city or town official.. City or Town: PermitA cense# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: EDDIE-1 OP ID:DR �c er p CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNM) 04122J2015 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 pollcy(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 John J Doyle Insurance Agency NAME: $5 Constitution Lane Ste 2H PHONE Fax Danvers,MA 01923 E,rnAINi ExtI, AIC No Sean P Doyle ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURERA:Safe Insurance 394554 INSURED Eddie Mac's Home Improvements 115 Sylvan St INSURER B: Danvers,MA 01923 INSURER C: 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. INSRAbft sue POLICY EFF POLICY EXP LTR TYPE OF INSURANCEINSR POLICY NUMBER MM/DDlYYYY MMIDD/Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000100 A COMMERCIAL GENERAL LIABILITY BMA001177D 03/06/2015 03/06/2016 DAMAGE EMI ES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP Any one parson) S 10,00 PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JFrT F-1 PRO- LOC fife le a S 100,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accldent $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS PER ACCIDENT $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAO CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y/N E.L.EACH LIMITS NT $ ER OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH)estlescribe E.L.DISEASE-EA EMPLOYEE $ If y , under DESCRIPTION OF OPERATIONS below_—T E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Scheduts,lrmors apace,Is roqulred) CERTIFICATE HOLDER CANCELLATION NORTHII SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BRIAN LEATHE ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD ST AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 Sean P Doyle ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD 1 U/ae�poo���2aa2uecc�ifa o�UI�LaJJac�culef Office of Consumer Affairs&Business Regulation WepisME IMPROVEMENT CONTRACTOR t ration: T65633 Type: iratio.n: 3/10/2016 LLC EDDIE MAC'S HOME IMPROVEMENT"LLC EDWARD MACFARLANE 115 SYLVAN ST DANVERS, MA 01923 Undersecretary I Massachusetts -Department of Public Safety. Board of Building Rcgulations and Standard.- Construction tandardsConstruction Supervisor License: CS-101276 EDWARD L MAC ;- 115 SYLVAN ST DANVERS MA (F1923 r,. 1 Expiration Commissioner 06/20/2016 I .