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HomeMy WebLinkAboutBuilding Permit # 5/6/2015 ,40aTH BUILDING PERMIT ° A4`"° �r gd r TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit Date Received '� °� s........ ,> M— 3's crews� Date Issued: --- � IMPORTANT: Applicant must complete all items on this page LOCATION Prin PROPERTY OWNER Print MAP NO: LL PARCEL. ONING CIISTRICT: Historic District yes no Machine Shap Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑One family ❑Addition fwfwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other ❑Septic, ❑Well ❑ Floodplain o Wetlands ❑ Watershed District +4_ ❑Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: � '� l Phone: j Address: � - �? ( "V-'0 i Vvwiii CONTRACTOR Name. Phone: KCA la_� Address: 0fl + C' Supervisor's Construction License: Exp, Date: Horne Improvement License: �� Exp. Date: r � I ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: b o Receipt No.: NOTE: Persons contracting with unregistered contractors do not have ac ess to the guaranty,j`und Signature of Age nt/4wner - signature of contractor l'44- tk®RTH Uf Ail uly, V ® No. mum � C 0CP• dA1411 h VeY'y Mass, S L) BOARD OF HEALTH Food/Kitchen PER NT TV&A L mumml" Septic System THIS CERTIFIES THAT ...... ..5 ... ...... ....... ^ ` ,,., BUILDING INSPECTOR ............ ....... ......................................... ....... ...... has permission to erect .......................... buildings on . . .•..... .4...... "...'.�. �Lj .................... Foundation Rough to be occupied as ......... .6k ........... ��. ...... too ! �............................ Chimney provided that the person accepting this permit shall in every respect confor 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 IT EXPIRESELECTRICAL INSPECTOR LES T A Rough Service 00e ........ ....................................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required t® Occupy Bulldln 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 the Building Inspector. Burner Street No. Smoke Det. CONTRACT ROBERT BOHONDONEY CONSTRUCTION CO. 12 HALL STREET METHUEN, MA 01844 978-685-0970 (office) / 978-685-8262 (fax) Fully Insured Construction Supervisor License #979 Exp 4/21/2016 Home Improvement Contractor #114238 Exp 8/16/2015 Customer Name: Russell Hertrich Property Address: 44-46 Ashland St, North Andover, MA 01845 Contract Type: Roof Repair Date: May 4, 2015 Scope of Services: Roof Repair 1. Supply local building permit. 2. Supply and install new %2" recovery board over existing roof and install new EDPM .060 rubber membrane roofing. 3. Remove all construction debris from site and dispose and provide job site clean-up and safe work zone. TOTAL CONTRACT AMOUNT: $6,000.00 CUSTOMER SIGNATURE: �� DATE: CONTRACTOR SIGNATURE: DATE: Page 1 of 1 The Commonwealth of Massachusetts Department of IndustrialAccidents ' I Congress Street,Suite 100 l Boston,MA 02114-2017 www.mass.govli is Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Ul Address: � �Aau City/State/Zip: 1 ft WN Phone#: q Are you an employer?Check the appropriate box: Type of project(required): 1.004"am a employer with k5 mployees(full and/or part-time).* 7. E]New construction 2.M 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. ❑Demolition 3.®l am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q 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 1 l.n Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13, f repairs These sub-contractors have employees and have workers'comp.insurance.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.] *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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: [VV Policy#or Self-ins.Lic.#: x a q `7 Expiration Date: `1 Job Site Address: ' "I45k(a City/State/Zip: f" �l t5`t 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 tine 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE "f1"` 5415 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERrIFlCATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If ths certl cats holder Is an ADDITIONAL INSURED,the policypee must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemen s. PRODUCER ME. Bates Insurance Agency Inc. 1 E 396-4 8 . (781) 395-9454 92 High Street, Suite Bi e . Andrea@Bateslns.com Medford, MA 02155 INSURE!q3I AFFORDINSCOVERAGE NAICR INsuRet :RCA-Essex Ins Co INSURED INsuneRe:A.I M. Mutual Ins. Co. Robert Bohondoney INSURER C: Bohondoney Construction I 12 Hall St E: Methuen, MA 01844 INSURER ; COVERAGE$ CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES 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. IN TYPE OF INSURANCE wVn POUCY NUNBER EFTUMTS A GENERALLIABMY 2CI47759_15 2/3/15 2/3/16 EACH OCCURRENCE s1,000,90 DA GET REN ED 9 O O X COMMERCIAL GENE RAL LIABWTY CLAIMS-MADE ©OCCUR MED EXP(Ariy one Person) $ 5 000 PER80NALSADV INJURY $ i 00 GENERAL AGGREGATE $ 1,000,000 GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS-OOMplOPAGG S 1 O OO POLICY P LOC ; AUTOMOBILE LUIBUTY a e der0 S BODILY INJURY(Per person) S ANY AUTO AUTOS ALLOWNED AUTOS LED BODILY INJURY(Per Wddent) $ NON-OWNED E HIREDAUTOS _AUTOS ere i UMBRELLALUIB OCCUR EACH OCCURRENCE $ EXCESS LIAO CLAIM8 RADE AGGREGATE $ DED FTENT WORKERSOMFE }3 WORKERSNSAtfON AyQC40070243322014 e/9/14 8/9/15 wcsrAMTS Tu- orH- AND EMPLOYERWUABILITv .L.EACH ODENr 1 500,000 ANY PROPRIEMRIPARTNERIEXECUTNE Y� N/A OFFICERMEKeER EXCLUDED? _�_L L. EAS -EA S 500,000 "Swatory IONH) DEesG�RlPll Nu eOPERATiON3 beb E.L.DIS POLICY LIMIT $00,000 DESCRIPTION OFOPERATIONS 1 LOCATIONS I VEHICLES(Aftwh ACORD 1(1,AdMfonsl ReMdo Sdmduis,Rmae spsos Ir rsgdred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOAM REPRESENTATIVE 0 1988-20104fiCORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: Massachusetts - Department of Public Safety Board of Building Regulations and Standards ('mwi-urtion Super"i�u License: CS-000979 _" 1 i, /, ROBERT A BOHONDONEY_. 12 HALL ST WTHUSNNU 01844 \ Expiration Commissioner 04/21/2016 514/2015 Office of Consumer Affairs&Business Regulation-Mass.Gov The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation Flony- Consumer Rights and Resources Horre 9aproveTKint Contractirg HIC Registration Complaints Registration # 114238 IgpL(p jffi[Lrr� -j'A Contractor g rrLL"--- Registrant ROBERT BOHONDONEY CONST CO Name ROBERT BOHONDONEY Address 12 HALL ST City, State METHUEN, MA 01844 Zip Expiration 08/16/2015 Date Complaints Details 110 ci�wnpWnts fbi.ind for ths registrant. You can also view arbiLrafion and Qumran ly ELgId ti to Back To Search 2012 Commonw eafth of Massachusetts. Mass.Gov@ is a registered service mark of the Commonwealth of Massachusetts. http://ser\Aces.oca.state.nia.us/hicBicdeta7ils.aspx?bdSearchLN=14200