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Home My WebLink AboutBuilding Permit # 6/9/2015 I' BUILDING PERMIT of NORTH q °(,LHU /bq NO TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1K Permit No#: Date Received gSSAGHU`-'�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION I CJ i Print �Y OWNER PROPERT. II' Print 100 Year Structure yes no MAP PARCEL: 1- ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED SED 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 .enact• , l Pf :-rit '-sfr "7rs°"fi I 1, trdrvrr:r ;+� r r'„ '7' .r,rF `;u;.:'^` �.a,t _. Jr 1, ❑.FCood latn C�Wet[andsro Watershed,,[)�strict f , . e ttc . ❑1Nello p.,, *,r>n". ,fir;," ,rrf r# � "ricer `T ''f k ` �� DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: �r �n $�S to Phone: Address: Contractor Name: Pool S con&1-4 6. 1 -„J Phone: �7 �" ��. `' z-1 Je , Email Address: ; �dkr•1zt,fey�- Jr Cu Ul 0/YC Supervisor's Construction License: 6s -o9'77 �r 3 Exp. Date: l /0 Home Improvement License: `7 Exp. Dater 7 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: $ J Check No.: �hL Ci Receipt No.: -�ZJ�' 3 5" NOTE: Persons contracting with unregistered contractors do not have a ess to ie uaranty fund ur r F t%®RTH Town ofE ItAndover ® 16 `A;�f h ver, Mass, Ar COC NI Cna wIC lc �1' �•4 A°RATED S tl BOARD OF HEALTH Food/Kitchen P �ERMIT T LD Septic System THIS CERTIFIES THAT 5 ��1'.� ....:.:�! „CtS C s^rly. BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ...... .............. .. .a.�'.�. ......................................... Rough to be occupied as .............. <.,�1. r.. .. ' .. / 5................................................. 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMITI IN OTHS ELECTRICAL INSPECTOR UNLESSCTIO STARTS Rough ............ Service ........' �4c ................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Building 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts F DepaYtment oflndustrialAceidents n 1 Congress Street,Suite 100 Boston,MA 02114-2017 o`y www.mass.gov/dia 0M S��y ' Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAIITTING AUTHORITY. Please Print Le 'bl Applicant Information `� Name(Business/Organization/Individual): S Address: City/State/Zip: -e V 1 �J y�3Phone Are you an employer?Check the appropriate box: Type of project(required); 1.0 I am a employer with :f^ employees(full and/or part-time).* 7. E]New construction 2,F1 I am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.F1 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance$ 14.Q Other (;.FJ 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. i 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. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. Yam an employer that is providing worlters'compensation insurance for•my employees. Below is the policy and job site information. Insurance Company Name: sExpiration Date: Policy#or Self-in .Lic.#: Job Site Address: City/State/Zip: 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. Ido hereby ce 'y under,the ains andpenalties of perjury that the information provided above is trove and correct. Date: 2? Si ature: n Phone#: �g Official use only. Do not rvrite in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): [6. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Otherontact Person: Phone#: Rightfax N1-1 5/28/2015 6 : 07 : 42 AM PAGE 2/002 Fax Server :a; DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE T .. R1lFICATE 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: GEORGE GATH INS AGCY INC PHONE FAX 703 CHELMSFORD STREET (A/C,No,Ext): (A/C,No): E-MAIL LOWELL,MA 01851 ADDRESS: 73LFC INSURER(S)AFFORDING COVERAGE NAIC If INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA PAULS CONSTRUCTION LLC INSURER B: INSURER C: INSURER D: 35 PARICWOOD DR INSURER E: PEPPERELL,MA 01463 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MMADD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE F__1 OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY [�]PROJECT[—]LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND x WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-2E76537A-15 03/09/2015 03109/2016 LIMITS 0 ANY PROPERITOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below '. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION $ TOWN OF N ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT/}.TIVE ' 0 .: . . . N ANDOVER,MA 01 845 +` � :�. �`�`i; ,.�.:: _ +=�,:• ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1488-2010 ACORD CORPORATION. All rights reserved. fie 7�o��za�rcuP.a�i a�✓l�scze>luaeG76 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR U Registration:,''-'168378 Type: Expiration: 2/912017, Corporation PAUL CORVINO PAUL CORVINO 35 PARKWOOD DR. PEPPERELL,MA 01463 Undersecretary Mass achusettss—Department of-Pub licSafety Board of Building Regulations and Standards j _ CGiiStI'iICtiOii aUjit.i-1iSOi License: CS-097783 Paul A Corvino `r 35 Parkwood Dries Pepperell MA 01463 i ;• r �L Expiration Commissioner 12/08/2016