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HomeMy WebLinkAboutBuilding Permit # 7/13/2015 NORTy BUILDING PERMITOF""LFD 16�tio TOWN OF NORTH ANDOVER �� 5w = 6 APPLICATION FOR PLAN EXAMINATION '' p C, Permit No#: Date Received ��I QDRA7ED PPa,cgy SSAcous Date Issued: Z/I -1,-r IMPORTANT:Applicant must complete all items on this page LOCATION 'clVim !; F Print PROPERTY OWNER Print 00 Year Structure yes no MAP ' , PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village y s no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ,QSe fic ❑INeli r, `❑ Floodplain 0 Wetlands Y,'' y,W �; atersed Qstnct µ �� ®fi,VV4`c�„Le�r/S�ewer�fr ...,.`,rr�rr-.,'`���r7...,>n�,.�`�� ,'�,��:,"�.���C'`�.,',',, 1 l�lrarr•'„�r<s fru ,°"r.F`�„�;" F� i v,c r'�„'r�,.-�;%:frr.z n�,,.�;:"�,.^L;�„', �?�7��r„ .� DESCRIPTION OF WORK TO BE PERFORMED: f- e0o S Identification- Please Type or Print Clearly OWNER: Name: Ce tze a Phone: Address: Contractor Name: / Phone: 2& 12-0 Email: to,EE 1v1L/ C� coz-hL45 r , A�,� Address: fe 5'a< t-f-&�- Z-) �, c Supervisor's Construction License: 05-024-f 24"T Exp. Date: ro %r— Zc-1l Home Improvement License: ? -3 7 Exp. Date: CC®%02- c' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT.-$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: 7�'% Receipt No.: z2 NOTE: Persons contracting with unregistered contra toys do not have- ss to the guaranty fund i FORTH - . dover E _uown of ® 0% ® - �AE h ver, Mass, 1 c oc.a1c..e w.c.. 1• ®A0agTE® I PP����j S U BOARD OF HEALTH PER. I L �D Food/Kitchen Septic System THIS CERTIFIES THAT ... fir.... BUILDING INSPECTOR ��,.----�- Foundation has permission to erect .......................... buildings on ......... ...Mn .....�►..1............... ......................................... Rough to be occupied as ........... .... ................ .... / �.�.. Chimney provided that the person accepting t ' permit shall in every respect confor o t e terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating o 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 PERMITEXPIRES IN 6 MONTHS j ELECTRICAL INSPECTOR LESS CO R CTIO S RT Rough Service ................... ... .... ..................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy BuRough 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. WM. I ZANNONI, INC. GENERAL CONTRACTING 806 Salem Road,Dracut,MA 01826 Ph./Fax(978)689-3444 License No.050281 AGREEMENT #070915 To: Anne&Mike Delaney July 7, 2015 92 Andover Street No. Andover, MA 01845 978-681-9133 annedelaney@comcast.net Job: Roof Description: We Shall Provide All Necessary Materials and Labor to Install New roof Shingles on the Home, Same Address as Above, Including: 1. Strip Existing Shingles Down to the Roof and Truck Away All Debris. 2. 8" Aluminum Drip Edge On All Roof Perimeters. 3. Ice&Water Barrier Along the Bottom 6' of the Main Roof, and 15#Black Felt Paper, Or a Better Equivalent Over the Balance of the Roof, and the Two Porch Roofs. 4. Architectural Asphalt Shingles By Certainteed, Grey Blend Color or Similar to Be Selected By Customer. 5. Flashing and Boots As Required Around Chimney and Pipes. Total Job Cost $ 7650.00 Notes: Repairs to the Roof Shall Be Done As Discovered and the Cost Determined in the Field. Customer Shall Be Informed of the Additional Cost and a Change Order Shall Be Executed. Terms: 25%Due With Signed Contract Balance Due Upon Completion NOTE: This Contract May Be Rescinded Within 3 Days of Signing By Customer, and All Deposits Returned. Date: Date: 601n The Commonwealth of Massachusetts Department of IndustrialAccidents a s I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): _yT �✓L/2i// 1J� Address: ,9-6) City/State/Zip: �� LG f.� Phone#: l 2 cI " gzlzl Are y�a..eeployer ployer?Check the appropriate box: �l Type of project(required). 1. with J : mployces(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. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑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. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other oyees.[No workers'comp.insurance required.] 152,§1(4),and we have no empl *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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-coniraclors have employ ees,'ttiey must provide their workers'comp.policy number. -Tam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: f/y`i�Gc- i!?/if Policy#or Self-ins.Lic.#: 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 WORK 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 cer fy un der the pains andpenalties ofperjury that the information provided above is trite and correct. Sinature: IMP- t� Date: 7 ` 3 r Phone#: !0 -6 r3 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 Penson: Phone#: 7/13/2015 10:15 AM FROM: HOWE INSURANCE AGY TO: 978-688-9542 PAGE: 001 OF 001 DATE (MM/DDlYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/13/2015 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 policypes) 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 Phone: (978)475-0400 Fax: (978)475-2171 CONE:TACT Tina Grange NAM THE HOWE INSURANCE AGENCY PH°NEo EM (978)475-0400 nc No: (978)475-2171 INC N 4 PUNCHARD AVE E-MAIL tgrange@howeins.com ANDOVER MA 01810 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURER : National Grange Mutual INSURED INSURER B National Grange Mutual WILLIAM J ZANNONI INC 806 SALEM ROAD INSURER C Liberty Mutual DRACUT MA 01826 INSURER D: NSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 23504 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. WSR ADD'L ER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE SUPOLICY NUMBER(NSR wPMM/DDNYYY MM/DD/YYYY A GENERAL LIABILITY MPB39171 02/26/15 02/26/16 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED $ 500,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence) MED.EXP(Any one person) $ 10,000 CLAIMS-MADE OCCUR PERSONAL&ADV INJURY $ 2,000,000 GENERALAGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 POLICY M PE0. LOC $ COMBINED SINGLE LIMIT B AUTOMOBILE LIABILITY M1 B39171 09/24/14 09/24/15 (Ea accident) $ BODILY INJURY(Per person) $ 250,000 ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ 500,000 AUTOS X AUTOS PROPERTYDAMAGE HIRED AUTOS NON-OWNED (p AUTOS er accident ];DED �RETENTION$ LIAR OCCUR EACH OCCURRENCE $ IAR CLAIMS-MADE AGGREGATE $ WORKERS COMPENSATION WC231S384548-014 01/14/15 01/14/16 WCSTATU- OTH C TORYDMITS ER $ AND EMPLOYERS' LIABILITY Y/N E .EACH ACCIDENT $ 1,00"000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N N/A E.L.DISEASE-F�,EMPLOYEE $ 1,00„000 (Mandatory In NH) Ifyes,descnbe under EL DISEASE-POLICY LIMIT $ 5,00„000 DESCRIPTION OF OPERATIONS beloer DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE J4”' I Attention: FAX#978-688-9542 Christine J. Grange ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �5 a t 4 � - P jd r y C Y 7f, ` a4�i is d Y • � 1 � I $�i'.. R TWO WON j�, 9 S i a. � 'pal aIa�t�rta w 4 m'�� lotJr5 r o