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HomeMy WebLinkAboutBuilding Permit # 5/4/2015 T BUILDING PERMIT t%ORORTF► TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ h Z. Permit No#: Date Received ° Argo RM SSACHUS� Date Issued: P ANT: Applicant must complete all items on this page LOCATION [ )�4 z Print PROPERTY OWNER t Se-�W_r - Print 100 Year Structure yes no MAP PARCELD ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other X l ❑ Se tic ❑1/Uel1 DFlood lanj >❑U1(etlandsr/' t3 ❑, Aide ',,W'6 Distract { �'� ,:; - :. , ✓1 eF" v-rr. xzs�r,°, xr c. � ,;�r�€ �/=��"... � r.rf� �.r �. .x. �� � �^�a 1 x�r ,.uty� ���`�rmyy r .�".r: DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name:�i �- Phone: Address: 1 a. 62 rx Contractor Name: (qt -,q ' Phone: Email J Address: Supervisor's Construction License: I0 5'cf I Exp. Date: 3&0s— Home Improvement License: ____L-70 7Exp. 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 --I Project Cost: $- -- r FEE. $ Check No.: �, � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access ar ty f d i "'a tkORTH Andover -Town of 0 7 � E 1 ' 11 INSPECTOR.41 BOARD OF HEALTH PERMIT T LD Septic System BUILDING 01r.A Foundation has permission to - buildings on Rough to be occupied as ► Final • a • •• •. • - •' • •- t• a • • • . • • • Roughon 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 INSPECTORVIOLATION of the Zoning or Building Regulations Voids this Permit. Final ELECTRICAL PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCT S TS Rough Service iu r INSPECTORBUILDING INSPECTORGAS Occupancy Permit Required to Occupy Bu Rough Displain • • • - on 1 • Not Remove Final FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Until Inspected and Approved by - Building Inspector. Street No. Smoke The Commonwealth of Massachusetts Department of Industrial Accidents M r 1 Congress Street,Suite 100 . __----___..............__.._..._._......_...._...._.._...__........_._...__......_....__.........__......._.__.....__.._- www.mass.gov/dia Sy+V Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le ibl A licant Information Cl �► � Name(Business/Organizationllnd(i"v�id42 I Address: 7 ''� City/State/Zip: Phone#: Type of project(required): Are you an employer?Check the appropriate box: full and/or art-time * 7. F1 New Construction ---------,employees 1.0 I am a employer with ( P )' 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. [1 Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4. 1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.Q Plumbing repairs or additions 5. am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs wf These sub-contractors have employees and have workers'comp.insurance.t 14.Q Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. I 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. lam an employer tliat is providing workers'compensation insurance for my employees. Belolv is the policy and job site information. Insurance Company Name: AR Policy#or Self-ins.Lie.#: /„�,.� tt 1, ,, Expiration Date:/ C Job Site Address: l � City/State/Zip: A?_ , ub- Attach a copy of the workers' coulpenhation 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 WORD 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 certi rrri r•th ains ndpenalties of perjury that the information provided above is true and correct. Date: Signature: Phone#: Official use only. Do notwritein 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 0 ® I DATE(MM/DD/YYYY) i® LITY CERTFICATE OF LIABINSURANCE 4/23/15 THIS CERTIFICATE IS ISSUED AS A (NATTER 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 _..._........ _.._.cerlificaeh©7er7n" euof"sucTi"er�c7®rsement( ........._------_--------_--------------------------------..._......_.__......_..__.....__._......._.__...__._......______.__..._..... ------------_._.........__._.._.___._..._.__...__......._.._...__...._..........._._.__....._. _....._._r PRODUCER CONTACT NAME: Angela Westen Insurance Agency PHONE 9781 735-4094 Fax No: (978) 735-4095 557 Central Street E-MAIL ADDRESS: anqela@awesten.com Lowell, MA 01852 INSURE S AFFORDING COVERAGE NAIC# INSURERA:ATLANTIC CASUALTY INSURANCE CO INSURED INSURER B:HARTFORD UNDERWRITERS INS COMP F 0 CONSTRUCTION corporation INSURER C: 119 FARMLAND RD . APT 1 INSURER D LOWELL, MA 01850 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 AML SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER M/DD/Y MIM Dry YYY LIMITS A GENERAL LIABILITY L021008696 3/18/15 3/18/16 EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTED $ 100,000 X COMMERCIAL GENE PAL LIABILITY MI�� a occurrence) CLAIMS-MADE D OCCUR MED EXP(Arty one person) $ 5 000 PERSONAL&ADV INJURY $ 1,006,000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 1,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMB IcNEEDISINGLE LIMIT(Eaac $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTYAMAGE D $ HIREDAUTOS AUTOS eracEnt UMBRELLA LIAR F OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ H WORKERS COMPENSATION 2E112068 3/30/15 3/30/16 WCSTATU- AND EMPLOYERS'LIABILITYI. ANY PROPRIETOR/PARTNER/EXECU' YN/A E.L.EACH ACCIDENi $ 100,000 OFFICERIMEMBER EXCLUDED? (Mandatary In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN LARRY AND NANCY HOPP ACCORDANCE WITH THE POLICY PROVISIONS. 16 AVALON ROAD STONEHAM, MA AUTHORIZED RE PRESENTATIVE O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: (781) 665-7740 Fax: E-Mail: -Office oPConsumer�Af , � � ��. Affairs�t Business Regulation f ME IMPROVEMENT CONTRACTOR .............._�...__..._..._.............. ..._.._._.._......__..._..................._..._......__._. ._.__.._.__. � a 705`�5__.._......._..__..___....__.___""Type...__......._._.__.__.._._._...._.....___..___.._..__...__.__..._-------_._._----___._ ..._._.. Zpiratian: 11/10/2015 DBA W CD ROOFING VINCENT COLANGELO' 3 HODGSON ST i o TEWKSBURY, MA 01876 �— Undersecretary 1 w ' CSSL-105943 'VINCENT COLANGELO 3 HODGSON STREET Tewksbury MA 01876 9-�, -� 03/09/2016