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HomeMy WebLinkAboutBuilding Permit # 6/11/2015 %sAOucRaTFI rb BUILDING PERMIT TOWN OF NORTH ANDOVER " APPLICATION FOR PLAN EXAMINATION a Permit NO--Z [late Received Date Issued: RTANT:Applicant must complete all items on this page LOCATION A &, J Print PROPERTY OWNERtc °I "G ,�' Print MAP NO ARCEL: . ZQNINO,DMSTRICT: Historic'District y ,o Machine Shop Village ye n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential I I New Building ,r-Tine family U Addition U Two or more family F] Industrial U Alteration No. of units: F] Commercial repair, replacement U Assessory Bldg U Others: U Demolition U Other nSeptic In Well U Floodplain U Wetlands n Watershed District n Water/Sewer z4, r Identification Please Type or Print Clearly) OWNER: Name: r°� Phone' 508- Address: 0 'Address: 1 - CONTRACTOR.' latn Phone: Address: ".n * " Supervisor's Construction Licence: Exp. Date: , Home Improvement License: Exp,. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. I — Total Project Cost: $ FEE: E: $ ' Check No.: P No.: r NOTE: Persons contra in ith un gister d contractors do not have access to the guaranty fund Signature of Agent/Owner' Signature of contractor F t4ORTH Town It E ®ver o No. /0 3 � z - h- y� L] O ver,a� LLSS� c oc"1 4t wfc K RATED PkV S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........I>% ., .. ,fir„kV... .� ,, BUILDING INSPECTOR . . has permission to erect .......................... buildings on .M..'........ .� ,.,.�,,.�. . Foundation Rough to be occupied as .......`�. .... ..... ........(20A.M.. ... . � ..011� ......dommom...........OOW...................................... chimney provided that the person accepti this permit shall In every respe nform 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 EPIRES IN 6 ONTHS ELECTRICAL INSPECTOR UNLESS CO STRCT tT S Rough kti Service .... ..................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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 Approved by the Building Inspector. Burner Street No. Smoke Det. C.0roor Npe, LEMENS&SONS INFORMATIONOWNER INFORMATION CONTRACTOR Owner- Daniel7ehnerCompany: CLEMENS&SONS CONSTRUCTION CTIO a ROOFING Address: 191 Bruin Hill Rd Website: clernensroofang corn North Andover oma Address 67 9th Ave Phone: 508-287-4827 Haverhill, MA 01830 Email- Dzehrier4@verizon.net Phone.,, (781)547 9292 ErruaiL Sharme.c�er�nerisr-ocmfit,ig Rrnai�.e:oni PROPOSAL Clemens & Sons Construction will perform rm the following: inn: Roof Replacement Strip entire roof to boards Replace up to 150 lineal feet of boards if needed Apply ice & water shield to first 3' of roof Apply ice & water shield to all flashings and protrusions Apply 151b felt paper to entire roof Install " drip edge to perimeters Install GAF lifetime architectural roof shingles Cut open & install ridge vent Remove uatter guards Clean gutters Re-install existing gutter guards Clean & remove all debris Pull all necessary permits with the town Shed Roof include Clemens & Sons Construction & Roofing fin Inc. is a licensed and insured General Hama Improvement Contractor imp the Commonwealth of Massachusetts. All workmanship is guaranteed for 5 years (state min. I Year), ALL WORK TO B E COM PLETED FOR THE SUM OF C C�C�. Q TheCommonwealth of M. assachusetts Department of Industrial Accidents Qf ea of Investigations 600 Washington Street .Boston,MA 021.71 ivww.massgov/dia Workers'CoMpensgtion, i rirsnce,Afflidavit:Buildbrk/Con k-i at6IWEtettridhLIkdP' t }s Applicant Information Please PrinttLe' biv Narne(BusinesdorganicationllndWidual):: Address: Cit+/State/Zip• ( c� , Phonp#: G Y Are ou an employer.?Cheell 1te<appropriate.box: 'lope of project(reyutrtd); i XI am a.em to er with C Q Lam a.general contractor:and j & P Y . QNewoonsttuation employees-(full audloi `.. .studte):* have hired the sub-contractors 2.[] I am a sole.proptiei4r orpartne_r- listed-on the attached sheet.t t 7. []Remodeling. ship and have:uo employees: These-sub-contractors have 8-Demolition working.for mein an a workers'.cgrrtp.insurance. y,apaFity: 9. [}Building addition [No workers'comp,insurance S. ❑ We are a corporatiott.and its 10•0Electrical repairs or additions required.] off ceis have exercised their 3.Q I am a homeowner doing all'work righi of exemption per_NIGL: l l,❑7'lutnbiit9 repairs ijt`z ditlOfis :myself.[No workers'comp. e.152,§1(4),and we have no repairs insurance required.]t employees..[No.Wgo kers' .11.'0 O6tZr co insurance.. 'Myapplicant that checks.box Nf tnti"90 Hll 000hC"aeeti6a bdow showing theaworkc:s'compensadwo Policy inforMadon. t Hoineownem wfio submit this a0davioinAii*dr4ohey aro doing sll work and then hiteoudOde contractora.tutut submit a new affidavit uulicaGul WI tCootractors that cheek this hox maxi a an addidonal sluet.ahocvi;t th o t--Ite sub comrectots aynd thea wDritas•comis.Boliey in(o a . I:tttnan employer that is pt�ovJdurg;►tigrlret's�.'�C,drtipetrsatlotr firsut'aace for my emptoyees Bolofn is theptlicy nrifij s7ie inforrnarion. Lrisurance Company Narne: _ Policy#or Self-ins.Lir.#:: U Y��_�11 . IT_ Ex1Sh tion Ltate: � J Job Site Address: ��Wlly t��.l City/State/Zip: �J�! /l %7/1. A -Appy<ofhthi Workelrs'dlbf MW policy'declaratioln pago;(1wivingtheptol q number.atid-es0iratioii;date). Failure to secure coverage as•,regttir l ut>der:Scctton.23A oiivlGL c 152 cur lead to the it�positioa of ittr3 t[�1�leS;of a foie up to$1,500:00 and/or one-year itnpzisomnent;as.well as.civil penalties in-the formof aSTUP WO&K lO$Dl t tf4 a hole of up to$250.00 a day aggittsfthe vloJator, Be.;advised that a copy of this statement-may::be forwarded to the Office of Investigations of the DTA.for,in4utat►ce=cavetage verification. I do hereby certify r mss 'd.ietfabya ofpertury thati e-information providedob6ve-is trite-iihdtorre%t tur a e•. Com. Phone#: G. ficial use only. Do not write in this area,to.be completed`byeity.or town oj*&L City or Town: Permit/Lteense# Issuing Authority(circle one):. 1.Board of Health 2.Building Mpartment 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector A.Other Contact Person: Phone#: Rightfax C3-2 6/10/2015 5 : 16: 32 AM PAGE 2/002 Fax Server DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE '1 R11FICATE 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: FARQUHAR&BLACK INS AGE PHONE FAX 85 EXCHANGE STREET (A/C,No,Ext): (A/C,No): E-MAIL LYNN,MA 01901 ADDRESS: 22PTJ INSURER(S)AFFORDING COVERAGE NAIC q INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY CLEMENS&SONS CONSTRUCTION&ROOFING INC INSURER B: INSURER C: INSURER D: 67-69 9TH AVENUE INSURER E: HAVERHILL MA 01830 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 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DMYYYY) (MMDD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE [—]OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY [�]PROJECT F]LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINEDSINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWN ED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION AND xZ WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-4790159-14 09/23/2014 09/23/2015 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under F.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS TIES REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION m�-mm ��.........� TOWN OF NOTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B.E DELIVf4ED p 120 MAIN ST IN ACCORDANCE WITH THE POLICY PROVI AUTHORIZED REPRESENTATIVE j NORTH ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP RA�� �igtl s reserved. From:Marian Cruz Fax:(781)780-2453 To: 19786889542@rcfax.cc Fax: +19786889542 Page 2 of 2 06/09/2015 1:08 PM '4C"R"® CERTIFICATE OF LIABILITY INSURANCE 6/9/2015 YY) 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 CONTACT NAME: Christopher Kennedy Farquhar & Black Insurance Agency, Inc. PHONE (781)599-2200A/C No: (781)581-3940 65 Exchange Street - Suite 101 ADDRESS:Chris@FandBInsurancc.com INSURER(S)AFFORDING COVERAGE NAIC# Lynn MA 01901-1475 INSURERA:Essex Insurance INSURED INSURERS Charter Oak Fire Insurance Co. 25615 Clemens & Sons Construction & Roofing Inc INSURERC: 67-69 9th Avenue INSURERD: INSURER E: Haverhill MA 01830 INSURER F: COVERAGES CERTIFICATE NUMBER•City of North Andover 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 ALWL SUBK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 50 000 PREMISES a occurrence $ i A CLAIMS-MADE I—XI OCCUR 3DU5700 6/17/2014 6/17/2015 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1,- 000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 X POLICY PCT LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident S 300,000 B ANY AUTO BODILY INJURY(Per person) S ALL OWNED X SCHEDULED -6307RS74-14-AUF /22/2019 /22/2015 BODILY INJURY(Per acciden0 S AUTOS AUTOS HIRED AUTOS NON OWNED PROPERTY DAMAGE S AUTOS er accident Uninsured motorist BI split limit S 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATIONSTATLL OTH- AND EMPLOYERS'LIABILITY Y/N TORY UMITSI ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Workers Compensation Insurance Coverage is written with ACE Group Insurance Coverage effective 9/23/2014-9/23/2015. ACE Group Insurance Company will issue the Workers Compensation Insurance Certificate directly to you shortly. CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Marian Cruz ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS17195 oninn'N m 'rho Arnpn -I I--- ......I--te-of A rr)Dn i Massachusetts -Departrrie of Pubiic_Safety I 1 Re uiations and Standards Board of Building 9 construction Super icor Speciaits' License: CSSL-101231 IRAN-ML F CUNDONS - 67 9th Avenue. = -111511 ��l 01$30 ; � ' Hi Lverhill NIA %R Expiration 11/06/2015 Commissioner Off cc of Consumer Affairs&Business ion ME.IMPRO`✓EM ENT'CONTRACTOR egistration: 169611 Type:' xpirationi 7/8/2015 Individual DANIEL CLEMENS DANIEL CLEMENS. b7 9TH AVE. .HAVERHILL,MA 01830• Undersecretary