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HomeMy WebLinkAboutBuilding Permit # 7/7/2015Permit No#: (2 Date Issued: UILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION L 0 0 Print PROPERTY OWNER L. e> \ (le `1- r A— Print 100 Year Structure yes no MAP PARCEL:6V) I ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building D Addition VAlteration 0 One family 0 Two or more family No. of units: 0 Industrial ecommercial 0 Repair, replacement 0 Demolition 0 Assessory Bldg 0 Others: 0 Other 1 IC ,—, Pfit5—Vvgg t 11 / il ittribt , dif ' FP- 110-11- DESCRIPTION OF WORK TO BE PERFORMED: i 4.47 Gr gc-T-'-S. 4 Identification - Please Type or Print Clearly OWNER: Name: L. geol 4-, --cr-s Phone: q-34z- Sre-2.au Address: loo kb u 4 k A4-5 Lk k Contractor Name: 4-cA,,„\ C. JA._s Phone: q "4-cl - Cr (, Email: i‘ik&-c'sCS Address: 0 s , M 0I 5q. &— Supervisor's Construction License: C-S— C)O 5-1-0— Exp. Date: t 0 — t 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 $125.00 PER S.F. 3$4 0 0 Total Project Cost: $ L, 000 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner ofcontractor '1 r-t- = CU 0 CD z cn �tow O CD O CD® CD CO co 3 CD — CO cn O CD CD O CD 3 O CD naa p o.1 pa.T1n .N0103dSNI 9NIa1If18 rn rn m 0) VIOLATION of the Zoning or Building Regulations Voids this Permit. 0 0 0 0. o ®, co -. 0) CO 1:2- • CD .0 -10 N. 0 0 = 0 0 CD gp_0 CD� 0. 133 a) cn rt CQ O co Cl, CD 0 0 0 CD-0 DA n 0 a) = 0 0. peas o} uolsslu ied seq CERTIFICATE OF LIABILITY INS4J`'': NCE 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 NAME Mathias Insurance Agency, Inc PHONEg7S�688-5531 (NC Nn EXt): 200 Sutton Street,Suite 160 E-MAIL ADDRESS: North Andover, MA 01845 INSURED Charles Construction Company, Inc. 2O Box 847 North Andover, MA 01845 COVERAGES CERTIFICATE NUMBER: INSURER(S) AFFORDING COVERAGE FAX INSURER A Navigators Specialty Insurance Co INSURER B ; $afaty Insurance Co INSURER C :First Mercury Insurance Co INSURER D Travelers Insurance Company INSURER E . LINSURER F : REVISION NUMBER: NAICO 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 SEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDE'S INSR BB INVD POLICY NUMBER LICY SEF t�DOIYYYY) POLICY E (MMIODIYYYY - LIMITS A COMMERCIAL GENERAL LIAUILITY —1 CLAIMS -MADE rill OCCUR _ IS1. iCGI,133i,3.21C 05/16/15 05/16/16 EACH EACH OCCURRENCE I y /� /y /� ry y� $ 1 , 000 , 000 RLN I I:U • PREMISES (Ea occurrence) $ MED EXP (Any ona person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L X AGGREGATE LIMIT APPLIES PER- POLICY [ I JECT I LOC OTHER: PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE " X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS X SCHEDULED AUTOS AUUTOSWNED 62 352 06JO6j15 06JOfi/IS i COMBINED aISINGLE LIMIT $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ OPEIM- (Perr accid OLMAGE 1 , 000 , 000 •$ C UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE N X000o04370102 05/16/15 05/16/16 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 $ DED RETENT ON$ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? (Mandatory (IMandatory in NH) describe under DESCRIPTIQN OF OPERATIONS below YIN N/A 6BUB-9800M24®7-1506/11J1506/11/16 da ® 5d 4, f :.7 STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE;$ 1,000,000 E L. DISEASE - POLICY LIMIT . $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached if more space is requ red) CERTIFICATE HOLDER Town of North Andover Building Department 1600 Osgood Street Bldg, 20, Suite 2035 North Andover, MA 01845 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-20 4 ACORD CORPORATION. All rights reserved, ACORD25(2014/01) The ACORD name and logo are regi fired I -rks of ACORD g NORTH ANDOVER BUILDING DEPARTMENT 1609 Osgood Street North Andover Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS F9R1 FOR TOWN CLE..RIC Nam: 5�,1� ?N\-\An ADDRESS: DD ZONTNG DISTRICT: TYPE OF BUSINESS.: $cwx\ o - BUILDING LAYOUT PROVIDED: YES . AVAILABLE PARKINSPACES: f).0 ZONING BY LAW USAGE: YES NO 'e A 6 Os( Sic) ,3",:t11 / 474) r MILL NG INSPECTOR SIGNATURE NO BUSINESS FORM FOR TOWN CLERK