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Home My WebLink AboutBuilding Permit # 6/11/2015 11 0 0O oT �M BUILDING PERMIT 0 TOWN OF NORTH ANDOVER (APPLICATION FOR PLAN EXAMINATION - - M Permit NO: Date Received Date Issued: CHU IMPORTANT:A licant must complete all items on this a e LOCATION 328 Main at Print PROPERTY OWNE=R Eugene Beliveau&-Maryann Beliveau Print MAP N443A) PARCEL: ZONING DISTRICT: R4 Historic District yes no 0C r Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Id One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ® Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic Q Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer Install stainless steel flue. Connect wood stove. Identification Please Type or Print Clearly) OWNER: Name: Eugene& Maryann Beliveau Phone: 978-828-4393 Address: 328 Main St North Andover, Ma CONTRACTOR Name: Restoration Management, LLC Phone: 603-264-1127 Address:.... 100 Carl Dr, Unit 11B M irichester, NH Supervisor's Construction License: Exp, Date: cs-106038 9/26/2015 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Team Engineering Phone: 603-497-3137 Address: 67B North Mast St, Goffstown, NH Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST EASED ON$'125.00 PER S.F. Total Project Cost: $ ZUQQQ FEE: $ so Check No.: Receipt No.: NOTE: Persons contracting wath u registered contractors do not have access to th gra panty rand Signature of Agent/Owner Signature of contractor ` w SORT H own ol-11117 nctovu, r ® 4- 1 -Xit CNO Ve LAME it ver, N.SS' I' C0C.41c"t TICK �A- �7,4 A0�gre® PP��S S tl BOARD OF HEALTH PERM T T LD Food/Kitchen Septic System THIS CERTIFIES THAT I . ... BUILDING INSPECTOR ....................................................................................... has permission to erect buildings on �0.........Y..!.:�.I:..?. ................ Foundation p ..... ...... ,..... Rough to be occupied as ......... �.� .�..U�............. ;�... ...... ...................................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR _UNLESS CONSTRUCTI Rough J� Service ................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay 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. , The Commonwealth of Massachusetts Print Form aE Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 �P Boston,NIA 02114-2017 .Yf www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individuat): Restoration Management,LLC Address: 100 Carl Dr, Unit 11 B. City/State/Zip: Manchester, NH 03104 Phone#:503-413-5883 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 5 4. ® I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction. 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have $• Demolition workingfor me in an capacity. employees and have workers' Y p h'• 9. E] Building addition [No workers' comp.insurance comp.insurance.t required.] 5. F1 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no wood stove conned employees. [No workers' 13.] Other comp.insurance required.] *Any applicant that checks box#1 must also 811 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 for my employees. Below is the policy and job site information. Insurance Company Name:Acadia Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:. , :r City/State/Zip: O 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 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I da hereby cern under the pains and enalties o erju that the in ormation provided above is true and correct, Signature: Date• 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: / � TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement hoPermit Application MGIL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, | conversion, improvement, removal, demolition, or construction of an addition to any pre-existing � � owner occupied building containing at least one but not more than four dwelling units...urbo structures which are adjacent to such residence or building"be done by registered contractors, � with certain exception, along with other requirements. � � Type 0fWork: COSI_2,500.00 � AddressWork 328 Main St,North Andover Ma � [}wne[ N@0Oe: Eugene and Maryann oelivem � | Date of Permit Application: I hereby certify that: Copy vflicense attached. Registration is not [BQUined for the following nea8OD/s\: For office Use Only Work excluded by law Permit NO.________ � DbUOd8[$1'000 Date Building not owner-occupied � Owner pulling OVVM permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM ORGUARANTY FIND LINER MGL o. 142A. Signed under penalties ofperjury: | hereby apply for epermit aethe agent ofthe owner: June 11, 2015 Tom Kaloyanides,Restoration Management,Luo Oaha Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 U Home Improvement Contractor Registration Registration: 180580 FO G� Type: Individual Expiration: 12/4/2016 Tr# 260880 � KALOYANIDES --- ---- .THOMAS -- THOMAS KALOYANIDES 100 CARL DR. UNIT 11 B MANCHESTER, NH 03103 Update Address and return card.Mark reason for change. Address D Renewal [] Employment Lost Card SCA 1 0 20M-05/11 ��e lG'O?ll3)t¢/If[ecfe(ll!O 'IG�IJJ(IC'f7[CJ(�J 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: Zegistration: 180580 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Expiration: 12/472016 Individual Boston,MA 02116 THOMAS KALOYANIDES THOMAS KALOYANIDES ' 100 CARL DR.UNIT 11B MANCHESTER,NH 03103 Undersecretary Not valid withodtsignature l�assachuusefts -Dep artiB?e11Y Of"r'tdbliC Safety Beard of Bu3iding Regulations an,j Standards Construction Supen icor - License: CS-106038 ��, THOMAS S KArLOYANIDES 458 E HIGH Manchester ASH 03 Aiml r s � til Commissioner Expratjon 09/26/2015 A o , WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 B 01 15 Issuing Company: Acadia Insurance Company 4 Bedford Farms Drive Suite 400 Bedford, NH 03110 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY RENEWAL INFORMATION PAGE NCCI Carrier Code No.: 33391 Policy No.: WCA 5081566 - 12 Previous Policy No.: 5081566-11 1. Name Insured and Address Agency Name and Address 03492 Restoration Management LLC (603) 673-7228 dba Legacy Flooring Boyd & Boufford Insurance Agency, LLC 100 Carl Drive 8 Main Street Manchester, NH 03103 Amherst, NH 03031 Other workplaces not shown above: Refer to Name and Location Schedule ^` FEIN: 270880766 Risk ID No.: Bureau File No.: 280085502 Entity of Insured: Limited Liability Company POLICY PERIOD 2. The Policy Period is from 01/17/2015 to 01/17/2016 12:01 AM Standard Time at the insured's mailing address. COVERAGE 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: NH B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part two are: Bodily Injury by Accident$ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states designated in item 3.A. of the information page. D. This policy includes these endorsements and schedules: See "Schedule Of Endorsements" WC 00 00 01 B 01 15 Includes copyrighted material of The National Council on Compensation Page 1 of 4 Insurance, with their permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY SCHEDULE OF OPERATIONS New Hampshire Plan A Policy No.: WCA 5081566 - 12 Name Insured and Address Agency Name and Address 03492 Restoration Management LLC (603)673-7228 dba Legacy Flooring Boyd & Boufford Insurance Agency, LLC 100 Carl Drive 8 Main Street Manchester, NH 03103 Amherst, NH 03031 Premium Basis Total Estimated Rate Per Estimated Code Annual $100 of Annual Loc ST No. Classification Remuneration Remuneration Premium 1 NH 5474 PAINTING OR PAPERHANGING 35,000 14.46 $ 5,061 NOC&SHOP OPERATIONS, DRIVERS 1 NH 5606 CONTRACTOR--PROJECT If any 2.91 $ 0 MANAGER, CONSTRUCTION EXECUTIVE, CONSTRUCTION MANAGER OR CONSTRUCTION SUPERINTENDENT 1 NH 8742 SALESPERSONS OR If any 0.62 $ 0 COLLECTORS-OUTSIDE 1 NH 8810 CLERICAL OFFICE EMPLOYEES 36,000 0.32 $ 115 NOC 1 NH 5645 CARPENTRY-DETACHED ONE 50,000 22.37 $ 11,185 OR TWO FAMILY DWELLINGS Subtotal: Premium Subject to Modification $ 16,361 9812 Increased Employers Liability Limits 1.10% $ 180 9898 Experience Mod, Eff 01/17/2015, Factor.860 $ -2,316 9887 Scheduled Credit.980 $ -285 Total State Standard Premium $ 13,940 —� 9740 Terrorism 121,000 0.016 $ 19 9741 Catastrophe (Other Than Certified Acts 0.016 $ 19 of Terrorism) WC 00 00 01 B 01 15 Includes copyrighted material of The National Council on Compensation Page 3 of 4 Insurance,with their permission.