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HomeMy WebLinkAboutBuilding Permit # 6/4/2015 ..................... BUILDING PERMIT t%ORTII + TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#, Date Received area Ssac 141JS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 5 1 P. int PROPERTY OWNER 'VDZ_6_11_10 7'> //-_ Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District :yes no Machine Shop Village ye -no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 11 One family [I Addition 11 Two or more family [I Industrial El Alteration No. of units: El Commercial [I Repair, replacement El Assessory Bldg El Others: El Demolition El Other F5,,o" ,i-vv- DESCRIPTION OF WORK TO BE PERFORMED": entification- ease 'y e or Print Clearly Phone: OWNER: Name: /(1�11. Address: _7)e" Phone: Contractor Name: Email: Address: Supervisor's Construction License: Exp. Date: !!S- Home Improvement License:_p Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. — FEE SCHEDULE;BULDING PERMIT:$12.00 PER$1000-00 OF THE TOTAL ESTIMATED COST BASED ON$125.00PER S.F. Total Project Cost: $ Z FEE: $ Z_ Check No.: Receipt No.: NOTE: Person contracting with unregistered contractors do not have access to the guaranty fund rlwlSORT H town of IT,, ndover ® ' 0% ® ® T ver, ass, O LAKE ' / COC NIC K@W1CN ��� 04 S � BOARD OF HEALTH Food/Kitchen PEr% M !T T D Septic System THIS CERTIFIES THATBUILDING INSPECTOR .......................... ........... .............. ..................................... ........... ® Foundation has permission to erect .......................... buildings on ..... .. . .. ..�......... ....... ........... ........... ® Rough A. tobe occupied as ...... ........... ...... .......... ........ ................................................................ 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. PLUMBING INSPECTOR Rough !VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT ELECTRICAL INSPECTOR UNLESS117 T Rough 000 Service ...... .... ..... ..... ......................... o...................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired t® Occupy Building Rough Display in a Conspicuous Place on the Premises D® Not Remove Final No Lathing or Dry Wall To e'Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. K General Construction Work to be Performed At 35 Ruth Ave 49 Church St Dracut, A. 01826 North Andover, MA 01845 Tel: (978) 815-4544 617 — 407 - 2483 HIC #129474 MA License #091242 We hereby propose to finish the materials and perform the labor necessary for the completion of the job. 1. Provide all necessary permits and Insurance Certificates to perform work legally 2. Properly protect building and grounds during construction 3. Remove 1 layer of shingle roof 4. Install new drip edge 5. Install 15 pound of felt paper 6. Apply lead around chimney 7. Install 30 year shingles 8. Notify owner of any rotten wood. $35 per 4' x 81 board to replace 9. Use 1 1/a inch nails for nail gun to install shingles 10. Clean up all debris 11. Dumpste"r-will-b6'supplied by contractor 12. 5 years labor warranty 13. Should it become necessary for the Firm to file suit for the collection of any sums due to the firm from the Client under this agreement, the client shall pay in addition to the fees, costs, and/or expenses due under this agreement an amount for reasonable attorney's fee equivalent to 25% of the amount due 14. All accounts are due when they are presented. Those accounts not paid within 30 days from the date of presentation shall accrue interest at 18% per year on the unpaid balance Total Cost for This Project $8,500 Deposit $4,500 Finish $4,000 Contractor Signature, Customer Signature, The Commonwealth of Massachusetts Department of IndustrialAccidents a l 1 Congress Street,Suite 100 Boston,MA 02114-2017 , www.mass.gov/dia O.IM yV�V Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ib1 Nance(Business/Organization/Individual): Address: S '°� Phone#: City/State/Zip: fG�' Are you n employer?Check the appropriate box: Type of project(required): I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 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.❑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.F1 Electrical repairs or additions proprietors with no employees. 12..Q Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs 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#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 is providing workers'compensation insurance fog'my employees. Below is the policy and job site I information. Insurance Company Name: Policy#or Self-ins.Lie.#: S`f Expiration Date: City/State/Zip: Job Site Address: 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 WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify under the pains and penalties of peijujy that the information provided above is true and correct= Date: Si nature: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: %N 05-14-' 15 13; 00 FROM-Byam BrosMahony Inc 978-937-0745 T-807 P0001/0001 F-503 ■�'��R®. © �/ p DATE(tdM/DD/YYYV) CERTIFICATE OF LIABILITY 1 IN URANCE 05/14/2015 ■ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the term$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). - CMTPRODUCER Phone;978 454-2926 NAMEACT ByaFax;978-837-0745 m Bros Mahoney Ins.Agency PHONE FAA E 191 Pawtucket Blvd IFit): No: Lowell,MA 01854 EMAIL Byam Bros INSURER S AFFORDING COVERAGE NAIC N INSURER A:WeStern World Ins.Co. INSURED Peter N4,J'eth dba K-N Construcst INSURER B: 115 Amesbury St INSURER G: Dracut, MA 01826 INSURER D INSURER r: INSURE 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, DDL SUB POLICY EFF POLI E IN TYPE OF INSURANCE POLICY NUMBER Mld! DIYYYY MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000 A X COMMERGIAL GENERAL LIABILITY NPP9237331 11/2012014 71/20/2015PREA r y 100,00 CLAIMS-MADE R OCCUR MED EXP(Any one parson $ 5,00 PERSONAL E ADV INJURY $ 300,000 GENERAL AGGREGATE 8 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 300,000 POLICY PR LOC $ AUTOMOBILE LIABILITY COMBINED erill D SINGLE LIMIT S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODIGV INJURY(Per uccidenq $ AUTOS AUTOS OOWNED PROPERTY DAMAGENON- $ HIRED AUTOS AUTOS var $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCE:$$LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WOaKERS COMPENSATION ARV I i iT 0TH- AND EMPLOYER5'LIABII.ITY ANY PROPMETORIPARTNER/EXECUTIVE Y/N_ N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (MandalorylANH) E,L.DISEASE-EA EMPLOYEE $ II yes dOSGrIGO Vnder DESGIRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OP OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Ramarka Schedule,If more apace Is roqulrecl CERTIFICATE HOLDER CANCELLATION NOANDOV SHOULD ANY OF THE A9 VE pESCRIBE P LED BEFORE THE E � LIVeRED IN Town of North Andover ACCO �4 LICY PROVISI �. Bldg 20 Suite 2035 +. 1600 Osgood St AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Byam Bros I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I aTet•,, oewt..e" v 5tanciards ,gip, vlassacnus� oQyulations an 1 Board of Butwing Conrtru,-tion S,--�Periisor license. Gq_0g1242 „ .. Y pETERNGETH ;- '} 35 RUTH A� Dracut MA 01826 p510512016 a/ e✓��ayrac�uaeGZ.t CJ Ze �Oomu�eo rzusea1 Office of Consumer Affairs&c Business legulahea f OME IMPROVEMENT CONTRACTOR egistration- 129,474 Tyke: -'Expiratwn:_ 9/9/2015- DBA Kork Ngeth Remodeling Contactor PETER NGETH' 35 Ruth•Ave. Dracut,MA 01826 Undersecretary i