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HomeMy WebLinkAboutBuilding Permit # 6/24/2015 I ^i ., oRTy sa o I BUILDING PERMIT � 3?0°"��_a° � TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION Permit NO: ` / Date Received "A 1. ww ��SSa1TOP CHU`' Date Issued: . IMPORTANT: Applicant must com lete all items on this page LOCATION Gam° 4 I : _ Print:- PROPERTY OWNER ; 'Print MAP NO: PARCEL: ZONING DISTRICT Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ❑ One family Addition ❑ Two or more family 216ndustrial Iteration No. of units: H Commercial w-Ke'pair, replacement ❑Assessory Bldg ❑ Others 11 Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District RIVGfier/Sewer s Identification Please Type or Print Clearly) OWNER: Name: Bao- y� t1 Phone: Address: 3SI CI;; 1/0L-V S CONTRACTOR Name: Phone: VA .7 Adtlress: .�'•�- 1i���: §ppervisor's Construction License: Exp. Date: / / _ Horne 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$125.00 PER S.F. Total Project Cost: $ / FEE: $ I/V/, " Check No.: Receipt N 17 NOTE: Persons contracting with unregister d contractors do not have access to the guaranty fund Signature of Agent/Owner nature of contractor i NORTH E ir 0%w. , n of _ ...•.1,., Hdov! er ® �•. to r I T �O LAKE h Ver' Mass., .. •�G� /J COCKICI.l WICK ��• P �®AORATED U BOARD OF HEALTH Food/Kitchen PERM T T LD I Septic System T �+.1.............................� � .. ..... ........................................... BUILDING INSPECTOR THIS CERTIFIES THAT � .. •••• . .. /sof undation fission to erect buildings onFSIhas perm .......................... ... . Rough . .f .�,�. �� �?... ..�.f. 'Pf,�...... .... ¢ �:(.1.:.:�"J Chimney to be occupied as ...........�'�provided that the person accepting this permit shall in every respect conformtothee applicationFinai on file in this office, and to the provisions of the Codes and By-Laws relating to the I 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 PERMITI I 6 MONTHS ELECTRICAL INSPECTOR UNLESS C T CTI S ARTS Rough Service .......... ........ ........... .. . .................................... Final '-1 LDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy BuRough Display in a Conspicuous Place on the Premises — Do Not Remove Final p Y FIRE DEPARTMENT No Lathing or Dry Wall To Be Done ntil Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. IVMAILLOUX BROS. CONST, CO,, INC. 55 Chase St. Methuen,MA 01844 Tel, (978) 686-7147 Fax (978) 6833452 5/27/15 I Bake n Joy 351 Willow St, No, Andover, MA 01845 I RE: Miscellaneous Projects Mailloux Bros, Const, Co„Inc, hereby propose to furnish material and labor for the"Bake n Joy Miscellaneous Projects" in accordance with scope of work, allowance, add/alternates, exclusions, qualifications and special provisions; Wet Department Door and Exhaust Fan Relocation- $9,500.00 • Permits and fees • Mobil and demobilization • Temporary protection • Demo and waste removal • Masonry alterations and materials • Miscellaneous metals • Commercial door, frame and hardware • Paint door, flame and concrete block to match as close as possible • Final cleanup • Tools and equipment • Electrical and fire alarm modifications not included Butter Temperins Room Wall Curb- $6,400.00 • Permits and fees • Mobil and demobilization --- ---- - - - -. Teinpor-ary-protectior----- —-- -- -- -- --- • Fabricate custom forms and concrete(4000psi) • Concrete placement and finishing • Foundation pinning and rebar reinforcement • Final cleanup • Tools and equipment The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 021142017 wwm.mass.gov/dia Workers'Compensation Insurance Affidavit;Builders/Contractors/la leeh'icians/Plumbers, TOB):FILED WITH THS PEI2MITTING AUTHORITY. Applicant Information Flease Print I,et:ibly Name(Business/Organization/Individual); Y'Ui (/otz X Address' _Sxy it pl.� Phone#: City/Stateaip: �11.0•A� P Are you an employer?Checlt the appropriate box; Type of project(required): 1, 1 am a employer with_ employees(full and/or parttime),* 7. New construction 2,L]I am it sole proprietor or partnership and have no employees working for me in 8, Remodeling any capacity,[No workers'comp,insurance required,] g Q Demolition 3.Q I am a homeowner doing all work myself,[No workers'comp,insurance required.]► 10 n Building addition 4,[_]lama homeowner and will be hiring contractors to conduct al[work on my property, 1 will 11,❑Erepairs airs 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.n l am a general contractor and l have hired the sub-contractors listed on the attached sheet. 13, R of repairs These sub-contractors have employees and have workers'comp,insurance# 14 t' Other 6,E]We are a corporation and its officers have exercised their right of'exemption per MGI,o, �t v 152,§1(4),and we have no employees.[No workers'comp,insurance required,] 'Any applicant that checks box#1 must also fill out the scetlon 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, #Contractors that checkthis box must allnched an additional shoot 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 y employees, Below is the policy andaob site I ani all employer that tsproviding workers'compensation insurance for m I llrfPl'/rratl07r. Insurance Company Name; A I � M ����" Policy#or Self-his,Lie,#: -!5- '0 V-.5C! t 2- � �_ Expiration Date; Job Site Address G6L/-// //o p City/State/Zip: �..Lhlli.. Attach a copy of the workers'compensation policy declaration page(showing the policy numbee), Failure to secure coverage as required under MGL c, 152,§25A is a criminal violation punishable b a fine a to$1 500,00 p Y p a 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 cert+ rnldeI,the pairs and penalties of pedaly Iliai the inforinatioll provided above 1�true and correct. t -- �i nti Data --_ - -- —-- - -- c� Phone# E only. Do not write III lists area,to be corupleted by city or tolyl official,n: Permit/License# hority(circle one),Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector rson: - _- Phone#: _ OP ID: MH CERTIFICATE OF LIABILITY INSURANCE DATE 5 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 poiicy(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), coNrncT PRODUCER 978^975.1300 N ME; Russ Mailloux Se neve&Hall Insur,Assoc.lnc 978-975-7596 a°N a Ext: Fn c,No 306 North Main St, s-MAIL Andover MA 01810 ADD Ess; Michael ,Segreve PRODUCER ID#:RUSSE-2 INSURER(S)AFFORDING COVERAGE NAIL# INSURED Mailloux Brothers INSURER A;Arbella Protection Ins.Co, 41360 Construction Co,Inc, INSURERB;A,I.M.Mutual Ins,Co. - - - 55 Chase Street Methuen,MA 01844 INSURER D; INSURER D; INSURER E; 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, INSSR DDL WOR FOLICyyEFF POLID E P LIMITS TR fRAIIAE E OF INSURANCE POLICY NUMBER M DDIYYYY MMIDD GENELITY EACH OCCURRENCE $ 1,000,000 07/13114 07113115 PREM ETORENTED 100,000 A IAL GENERAL LIABILITY 8500060007 PREMISES Ea occurrence $ S MADE ]OCCUR MEDEXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOG - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(per person) $ 100,00 ALL OWNED AUTOS BODILY INJURY(Per accident) $ 300,00 10200020719 05120/15 05120116 - A X SCHEDULED AUTOS PROPERTY DAMAGE $ 100,00( X HIREDAUTOS (Per accident) X NON-OWNED AUTOS OBI $ 250150 Med Pay $ 8,00. UMBRELLA LIAR F—ToccuR EACH OCCURRENCE $ - EXCESSLIAB CLAIMS-MADE AGGREGATE $- DEDUCTIBLE RETENTION $ WC STATU oTH WORKERS COMPENSATION ORY LI ITS ER AND EMPLOYERS'LIABILITY 10/02/14 10/02115 500,000 B ANY PROPRIETORIPARTNER/EXEGUTIVE Y NIA A 5005012557 E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? E L DISEASE-EA EMPLOYEE $ 500,00 (Mandatory In NH) SOQ 00 If yes,describe Under E.L.DISEASE POLICY LIMIT $ + DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES l(Attach ACORD 101,Additional RemarTcs�cfieduTe,it m6r�a aa�isreg��ired) --_-_- - - RUSSELL MAILLOUX & RONALD MAILLOUX ARE EXCLUDED ]FROM WORKERS COMP COVERAGE CERTIFICATE HOLDER CANCELLATION - 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, 1600 Osgood Street -- North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Pul�kc"Saiety Boas- .of BusQ isig pulatiorrNaffd Standards -.(. Con4truc4iotrci-sor ,sem"r License: GAS-04823T. �{Tf• RUSE J MAIL_1J0UX 55 C)€iAS T METHUEN MA 01844 ,` "Ex4oiration Commissioner 02/11/2016 . �, _ _ r=��e�or".>ua�ecoerrlt�o,'C%�lrra�rrc�rr�elt — Office of Consumer Affairs&Business Regulation -T c�IOME IMPROVEME=NT CONTRACTOR egistration ip 077 Type: ;`Ex_piration 7!6/ tr�0 Private Corporation. MAILLOUX BROS.cONST.CU,ifs'`::: Rlasseii Mail loux 55 CHASE STREET g .s 1s:4ETHUEN,MA 01844 iJsstersi cretas:;