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HomeMy WebLinkAboutBuilding Permit # 6/4/2015Permit NO: Date Issued: BUILDING PER IT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received MPORTANT: Ap Ivo'. pow 1,6,40/ dd 740 fe mogoggg," icant St complete all items on this age 070 Nfoipspi410440Avloptiob.4 V00 0 104004 t" TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential Fl New Building Li Addition 0 Alteration 0 One family Cl Two or more family No, of units: 0 Industrial Li Commercial 0 Repair, replacement El Demolition 0 Assessory Bldg El— Others: 0 Other 1Li12'(' 46 )4 , 14444 ,f '' 0/: , or, vow, 4 , i to .gp, Vw y,,,i ,,,,o, ,w (0,6 t 4 'P, rA. '49) e.01 vrel ,„"› pf,,) d'0,';'^ , 1, 9 GP, 4.) p07„: 4 4994 1411 1 OWNER: Name: Address: Identification Please Type or Print Clearly) of 4, Li 4 m 04/ itr'l= Phone: p44pPW 00's,(00,1^4 d „ ^Ps? ,4400. , ARCHITECT/ENGINEER AM/ 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. TotarPro act Cost: $ /5" FEE: $ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Check No.: (;)-v ,r,w5.7m,g:K,FFFP>7y3Kf,,,yo;,RR;ph4fdiz:6:iaf:6.6:h,f.iwa:f,", CD CD a O. CC. CD CDCO W C CD MEM Q. ig CQ CD Cl) CD 0 0 5' 0 cn 0 C) 4) A) ci CD 0 CD 3 cn eD 0 0 CD CD n 210103dSNI ON101If18 00 SS31Nf1 I S2ZIIdX31I1/11N3d VIOLATION of the Zoning or Building Regulations Voids this Permit. Gi O -S �D O. O 0 n. 0 o a ▪ � C 6. O O - O. W n fD Ci Cv O' O O CO O. (1), O1. fl1 s • S C) CD p <• CQ O 0 ▪ Cn -h CA 'O ® -h a O W O O 0- • O 7.1 O O CD W - `< CD Cn O � CD N rt CAD n O O 8 ® O ,. srt CD o rt Cn 99) 0 D) n o 0 a A� CD'ZS 72 • n' su ®' O, pen of uolssluaaad set! C CO CA O 1tlH1 S3Id112130 SIHI FI LIPJVIPPEPLIPPLPLIEOPLIOTOPLPLIOPEINEPLEEPTEIMPPLEO frrr?PrJEIVPLPriardPLPLIElfE?fgVIEPLIEEPLPLIEPLPL_PLPLTEPLPLPLJIPJVIEPL1 Li Li 0. -in • (D ca cD M co 5 1, a 0. 6 0 tr) (r) CD O a CD = Z 0 CCI CD 7) 11 0 Cr CD -I. a 1/4< eAR Go Go ofl < Zm HH < c m o N x c, m cr) CD 0 HO D.' CD rp • (I) g 9 ti) U) (7, CD o — n C) 0 5 &) U) a. D.) 0 6- 0 0. a, -‹ )1) DJ -0 0 - = .a 0 n- ▪ ns' M - •0 a) g 0 `--1 CD ▪ (1) a) ft) C7 a -c7 cr) n• - to a < ti) EL Di, 0 W 5 w (1) CD 0 (1 •-+ Q0 0 03 C - 0 LflM e!u.1 (7; M M CO --`1 CD ° -/ CD c/)rncnci > Cl) Z 0 --I Z O 7) z > 0 cn H 0 Fri rn cr CD to a 2 a 5 CD 0) U) (7) a U) CD 0- pel.ee,211.ueplelaJi-eweH, ueaq cthe 4— 0 4— t2 Co Co i.uawd! kao rJ 5 , OPEEPLPLP c_PE_Pr_P r_PLTOP EFEEPLIP_PLFOPLEIDSOPLEEPLIVIEFET0101 El The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly PETERSON PARTY CENTER Name (Business/Organization/Individual): Address: 36 CABOT RD City/State/Zip: WOBURN, MA 01801 Phone #: 781-729-4000 Are you an employer? Check the appropriate box: 1. Ni I am a employer with 200 employees (full and/or part-time).* 2. ri I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. El I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 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.] Type of project (required): 6. New construction 7. ri Remodeling 8. Demolition 9. Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13, TENT OtherTEMP. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. T 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Wolin allOH. Insurance Company Name:A I M MUTUAL INS CO Policy # or Self -ins. Lie. 14: WMZ8006586 Job Site Address: OS C crziel7 Expiration Date: 1 °/9/15 City/State/Zip: / /frie' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fme 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. Be advised that 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 perjury that the information provided above is true and correct. SiEmature: „ft 4/4' „,A. Phone #: 781-729-4000 Date: 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 #: �1 ® C R �, �� CEIFI T I IITY I DATE (MMIDD/YYYY)9/28/2014 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 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 Bonacorso Insurance Agency, Inc. 10 Cedar Street Unit # 32 Woburn MA 01801 CONTACT Michael Bonacorso NAME: lac°."No. Ext): (781)937-3200 FAX No):(781)937-3202 E-MAIL mi ADDRESS: chael@bonacorsoins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Acadia Insurance Co. INSURED PETERSON PARTY CENTER INC. TABLE TOPPERS OF NEWTON 36 Cabot Road Woburn MA 01801 INSURERB:AIM Mutual Insurance Co. INSURER C : INSURER D : INSURERE: INSURER F : ES CERTIFICATE NUMBER:2014 Master Certificate 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 LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CPA5061026-12 10/9/2014 10/9/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 250, OOO MED EXP (Any one person) $ 5,000 CLAIMS -MADE X OCCUR PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE -I POLICY X LIMIT APPLIES FJESROT PER: LOC $ A AUTOMOBILECOMBINED X LIABILITY ANY AUTO ALL OWNED x x SCHEDULED AUTOS NON -OWNED AUTOS MAA 5063173 12 10/9/2014 10/9/2015 SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ UM/UIM $ 1,000,000 A X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE TBD 10/9/2014 10/9/2015 EACH OCCURRENCE $ 10, 000, 000 AGGREGATE $ 10,000,000 $ DED RETENTION$ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y N N/A WMZ8008006586 10/9/2014 10/9/2015 X WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Michael J. Bonacorso ACORD 25 (2010/05) INS095 mmnner m ©1988-2010 ACORD CORPORATION. All rights reserved. Th. ACnRn nem. and Innn era rnnictarnrl mark. n4 ACnRn ,achUSef Y .. ww c k ►c a ety Board of Building Regulations and Standards aF'damaroi Fvo,&" License: CS-060219 Mark Traina 33 Hanford Road w' Stoneham MA 0-A8 Commis " P num���r;s 1k�1 Expiration 04/27/2017