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Home My WebLink AboutBuilding Permit # 6/4/2015 txORTH BUILDING PERMIT TOWN OF NORTH ANDOVER to APPLICATION FOR PLAN EXAMINATION Permit Whzo K Date Received 101 SS ACHUS Date Issued: 6L IMPORTANT: Applicant must complete all items on this page -,LO"CC I' o"p, u FS 0,11 -a/l/ ........../"' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building lik6ne family 11 Addition 11 Two or more family El Industrial 11 Alteration No. of units: [I Commercial wAepair, replacement Li Assessory Bldg El Others: El Demolition 11 Other 91 P b"'W" Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: '�u ARCH ITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST SED ON$125.00 PER S.F. Total Project Cost: FEE: $ II CheckNo.- 16(d, Receipt No.: N', fE: Persons%Xretracting with unregistered contractors do not have access to the guaranty hnd $'ig 0 atu'i 6,,,"'f"A J-VO 0' ure df contracto, Town of Andover 0 No. q26 - 195 _ �AKE ver, ass, CoCNICMEWICK ' A°RATED P� 7 S U BOARD OF HEALTH ff—I r RMI 'T IF LD Food/Kitchen Septic System THIS CERTIFIES THAT ......... .. . .... BUILDING INSPECTOR has permission to erect .......................... buildings on Z4 8 (i .. Foundation ... ... ,� I.�.: ............. .. Rough tobe occupied as ......`. ....... ............... . ...... ............................................................. Chimney provided that the person accepting this permit shall In kejy 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESST RTS Rough Service —�—� ......... .... ............................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall 1'o Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Woo�dland Home-Works 10 1, Middlesex Ave. Wilmington, 01887' Cell (978) 804-0374 Office(978) 604-6455 June 28,2014 Paul Miller 37 Bucklin Rd N Andover lila 01845 Price of roof : $6,500.00 1/2 due prior to start 1/2 due upon completion Pricc includes Stock,Labor,Dumpster and Permit Strip entire roof down to boards.Lay six feet of Grace ice&water shield from fascia up remaining boards will be covered with synthetic underlayment.Run 8"drip edge and starter shingle around entire perimeter. Install ccrtaintced architect roof'shingle(color of choice). Shinglcvcnt 11 ridge vent over entire ridge all pipe boots will be replaced. If there are roof boards found loose,ratted or broken you will be notified and they will be replaced or rc-nailed at a cost of$40.00 per man-hour labor only.house will be fully tatpcd white being stripped yard will be cleaned and magnetized for any nails at the end of each work day. Job will take two days depending on weather. If you have any questions please feel free to call anytime 978-804-0374. 10 year warranty on all workmanship Thank you, Donald R. Woodland Owner Licensed/Insured Hic H 151655 CS SL 099489 6/4a 11 The Commonwealth of Massachusetts Department oflndustrialAceidents I Congress Street,Suite 100 Boston,MA 02114-2017 . .J'. www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIIIITTING AUTHORITY. Avylicant Information Please Print Legib Name(Business/Organization/Individual): Y3( {mac Q,� K)0 15-J 1\ Address: e'sey NVc '04-ACity/State/Zip: ,_\m',' (Yi" O VO Phone#: (>7a-- 0'04- Are re you an employer?Check the appropriate box: Type of project(required): 1. ' I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8, E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.F1 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E:]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 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. 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 ant a71 employer tliat isproviding workers'compensation irrsurcalce for my employees. Below is the policy and job site infinwiation. Insurance Company Name: ` 1 �'t l S o(`0 q C.-C Policy#or Self-ins.Lic.#: " a -S ` 7 1-7LI `0 VL1 Expiration Date: t� S Job Site Address: - ��G��/l�bv "C� City/State/Zip: N) ikt1 c.3 Q—e( M, 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 un ewe pains and penalties of perjuvy that the information provided above is true and correct. Signature: �-' . -'�} Date: Phone#' 7 L'1' 0 7 Li Official use only. DO not iw ite in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACc> R ® CERTIFICATE OF LIABILI INSURANCE FDA-MlVM wnrM 03/30/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NCaATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED IBV 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 cenlflcate holder is an ADDITIONAL INSURED,the Poilcy(Ies)muet be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy.certain Policies may require an endorsement. A statement on thls certificate does not confer rights to the carthIcate holder In lieu of such endoreemen a. PRODUCER Brown son Insurance Agency CONTACT Maureen Poliman 939 Albion St. vnoNE (781)245-2292 FAT( (781)245-3826 P.O.Box 349 mal AppsEft Wakefield MA 01880 mo@brownsonlnsurance.com REA AFF C tf Northland Insurance Company INSURED Commerce Insurance CO. Donald Woodland JEEL— Woodland Home Works .LM Insurance Corporation 101 Middlesex Av Wilmington MA 01887-2712 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. INBR TYPE OF INSURANCE ADDL SUER POLICY OPF POLICY r7rP A X C01l8AERCUtL GENtcRAt LUIBHJIY LINi's W8236124 12/12/2014 1211212015 9,000,000 CLAIMS-MADE ®OCCUR DAMAGE TO RENTED 100,000 Bod.inj.B Prop.Dmg PR A(EsomimancA) 14 Dad.$500 Per Claim MED�' one 51000 PERSONAL k ADV M 1.000,000 GEN'LAGGq UMITAPPLIES PER: G ACiOREGATE 2,000,000 FiPOLICY1JECT 0 LOC l UCTB-COMPIOPAG 2,000,000 E $ AUTOMOBILE LUIBRIfY BDTCWZ 9 DJ17/2014 10/17/2015 COM D BINDLE LIMIT 8 ALL OrO BODILY INJURY tPer Imm ei S 100,000 Al60WNED � Sl`XIEOVLED AUTO AUTOS BODILY INJURY(P&acemm) S 300,000 HIRED AUTOS NON-OWNED AUTOS PROPERTY GE s 100,000 '.... UNINs/UNDERINS s 20140 UNBRELt,q LutaHrt QCC11R EACH O, CE EXCEegtJAB Atu&MADE AGGR C AND EMPLOYERS, VERS, SAIION AsILrF WC5.318-367174.014 9/28/2014 8/28/2015 X PER OT)L AND EMPLOYERS'LIABILRY ANY PROPRIETORIPARTNERIE)IECUTIVE FOR INFORMATION ONLY E.L.EA H CIDENr 100,000 OFFICEtUMEMBER EXCLUDED? N I A (Mandatwy In HH) Ir de=vrooundar E.LDISEA9E-eAEMP YF E S 500,00 EL DIMA -LQUCY LIMIT 100.000 DEBCRIPTIONOFOPPJWT►ON$ILOCATIONS IVEHICLFS (ACORO101LAdditionalRemukeBch&",nmyrbeatUchWNmoreePRM gyyf�d Is► } Carpentry Operations, Liberty Mutual will issue the Certtlieale for Workers`Compensation coverae. / gI&r.Jab: 20 Wolcott St, MA 01878. CMIFICA,Te HOLDER CANCMJLATION Al 095'766 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE 10MI eED W ACCORDANCE WITH THE POLICYPROVISIONs. AUTHORIZED REFREBENTATME L Fox:(978)64{3.4434 ®19682014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 'registration: 151655 Type: / Office of Consumer Affairs and Business Regulation Expiration: . 6/20%2016 DBA 10 Park Plaza-Suite 5170 WO•'O" DLAND HOME-WORKS ''�='-'� Boston,MA 02116 : i DONALD WOODLAND 101 MIDDLESEX AVE WILMINGTON,MA 01887 Undersecretary --" — Not valid without signature Massacnusaft -Depirimerrt o; ttl clic 430a*"d Of Suildlny Reequla_ior:s -ind r '�'u;�st.`urti��u �uperritor.'�pe�•ia1i;,• . License:CSSL-099489 DONALD R WOODLAND 101 MIDDLESEX.AVENUE WILMYNGTON MA 01887 ✓,,.�..�Bey ,ei� ii r.�� "•rte.'.. ,:�ir�•cio:� C01711-1ussioner 10/27@045