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HomeMy WebLinkAboutBuilding Permit # 6/26/2015 NORTH A BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 0 ry APPLICATION FOR PLAN EXAMINATION Permit No#: Date ReceivedI,9 q�RTA7E0 4"1 kc CHUS Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER G &cA�,Wf� V�\ Print 100 Year Structure yes no MAP I PARCEL: ' ZONING DISTRICT: Historic District ye no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 11 One family [I Addition L1 Two or more family 11 Industrial [I Alteration No. of units: D Commercial 11 Repair, replacement [I Assessory Bldg 0 Others: [I Demolition [I Other INWev DcOCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: �NCvvy4�.t". Phone: (o Email: ck,,T P, � io!�� Address: 10 f4Att!1 A O&Z-) Supervisor's Construction License: Exp. Date: -H Home Improvement License:-41_ � [ Exp. Date: --7"SSN- 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: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acces to the guaran, nd 'F 7, N®RTH Town of ndover No. 1,11114 -15 o h ver, Mass,,,j Lki�e- coCMiCNlw�C« I- ��QDRATED S V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT 9(n&e - '`""�S�`� BUILDING INSPECTOR ............................. ........... ....... ... .......... has permission to erect .......................... buildings on Foundation J..........' ...... � "............................. Rough tobe occupied as ...........15 .......�...'r.��0�.........................:. ........................................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI N STARTS Rough 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. ANGELANGELO J. ROMAN® ROOFING CO. Residential ®Commercial• Industrial 19 BLOOMINGDALE STREET CHELSEA,MASSACHUSETTS 02150 (617)884-4753 Date:June 26, 2015 To: George Russo Subject: 25 Mill Rd North Andover Ma,01845 1) Strip entire roof down to boards. 2) Inspect decking and replace up to 100 Ln ft. of boarding where needed. 3) Install ice and water shield to entire roof. 4) Paper in existing roof area with#15 lbs. felt. (N/A) 5) Install aluminum drip edge to perimeter edges. 6) Shingle over underlayment's with CertainTeed Landmark Series shingles. 7) Install ridge vent across peak of roof. 8) Contractor to pull all permits needed. 9) Contractor to clean all debris from site. 10) All workmanship warranted for five(5)years. 11) Roof warranted by CertainTeed Inc.for life time. Furnish all materials and labor for the lump sum of$14,800.00 Payments as follows:$7,400 deposit$3,700 when half done $3,700 upon completion. Signature: �� Date: Signature: - Dater(I The Commonwealth ofMassgchusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,M4 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. _ TO BE FILED WITH TEE PERAUTTING AUTHORITY. Applicant Information Please Print Legibly t Name (Business/Organization/Individual): "g tE : or Address: �S' p' � � l I' a Ci /StatelZi Phone#: ' Are you an employer?Check the appropriate box: Type of project(I'equired): Lp I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.F]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions 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 t ached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q Other 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. If the sub-contractors have employees,'ttiey must provide their workers'comp.policy number. I air an employer that is providing workers'compensation insurancefor my employees.'Below is the policy and job site information. Insurance Company Name: 1r ` r � Policy#or Self ins.Lie.#: � C+ `° Expiration Date: 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. I do Hereby c tify der'the ain a dpenald perjury that the information provided above is true and correct. Si nature: Date: G /A 6 f Is Phone#: , 1JQ 3_ 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#: �CJQRL2' CERTIFICATE OF LIABILITY INSURANCE DATE(MAZ12QLYYY) TIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: BIKOFSKY INS AGCY INC PHONE FAX 793 WASHINGTON ST (A/C,No,Ext): (A/C,No): E-MAIL NEWTONVILLE,MA 02460 ADDRESS: 72L6P INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY ROMANO,ANGELO J DBA ANGELO J ROMANO ROOFING INSURER B: COMPANY INSURER C: INSURER D: 19 BLOOMINGDALE STREET INSURER E: CHELSEA,MA 02150 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 (MMIDDIYYYY) (MMIDMYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED $ PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY E]PROJECT[71 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 $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB ]CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION AND XWC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-2E296062-14 06/28/2014 06/28/2015 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ! ' (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSURED'S MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSURED'S MA EMPLOYEES IN STATES OTHER THAN MA. NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN STATES OTHER THAN MA IF THE INSURED HIRES,OR HAS HIRED EMPLOYEES OUTSIDE OF MA. THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR ROMANO,ANGELO J. CERTIFICATE HOLDER CANCELLATION BOSS FACILITY SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1 ROEBLING COURT BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIO f„4 AUTHORIZED REPRESENTATIVE RONKONKOMA,NY 11779 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP A 6W..r 1TT1§lits reserved. Mass achtrsetts _ Board©f Bui/di Ogt�artrr�etit of ublic Saf Conttrrtc tig I egulatior',,anP ety Licens tion Sul�ert iso, d Stan�'ards e: CS-0g 69g6 ANG&0 J ��%�l r ,% 1pE11� RO��o Peabody -ET j �� '-_ i 019&0 F' r mmissioner -- 6xPiratior, -- - 04/0 412016 ��e�pa-��a��LaaatoeulC�o��CYf�uJdac�uJej Office of Consumer Affairs&Business Regulation I 0ME IMPROVEMENT CONTRACTOR gistration: 151814 Type: i xpiration: 7/5/2016 DBA ANGELO J.ROMANO`ROOFING CO'' ; I ANGELO ROMANO 19 BLOOMINGDALE STREET CHELSEA,MA 02150 Undersecretary