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Home My WebLink AboutBuilding Permit # 7/15/2015Permit No#: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER. APPLICATION FOR PLAN EXAMINATION - Date Received IMPORTANT: Applicant must complete all items on this page •uiriii• „( 1111,140 ooroolOO Afq ilt1112 11/1111111111,11#110100114111: Dird 1YO I a AmoORPhirleft oof TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 Addition i A Iteration 0 One family 0 Two or more family No. of units: 0 Industrial 0 Commercial 0 Repair, replacement D Demolition, ” 'f/t, 0 Assessory Bldg 0 Others: 11,(9434i4iii 4, , riforrrort, ''r r rttliar° r000,0/el , 7`7(Wgetliiied%riskrof,r/ / r DESCRIPTION OF WORK TO BE PERFORMED: OWNER: Name: Identification - Please Type or Print Clearly -C) NiA,Qeils\- 614 Address: I /41‘.1,1 / 7ffil f/r, 4 1p#01771,(Frifff7/r, //ii,2/7/pfyfwr (iJ,i1,1 /7 16/f fio ',Aro lamri 7/ 1 it IN - Phone: 10 - LS- 0 el( pede." ARCHITECT/ENGINEER _c /4 PI i1e.,o4.•T‘nrtzPhone: ci —7 --- 7 Address:, 35 -S7 J • Reg./No. A 0 0 0 FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125 00 PER S.F. D t , Total Project Cost: $ ( 6(( g (I —Li— -- FEE: $ 3 ? )) b-t) Check No.: Receipt No.: ' ..,,e_ ' 1 NOTE: Persons contracting with unregistered contractors do not have access t the guaranty fund ignature of Agent/Owner Signature of contractor 0 C- 0 0 n 0 0. 0 0 1 U) 0 CD B v)' o' 0 Co C) 1VHl S31l112130 SIHJ CD CO (Q cn 0 0 03 CD 0 CD 5' O N C)� a) CD 0 CD 3 CD y Z 0 CD 3 0 CD z c• naap of palmn NO103dSNI ONla1lfl8 Cl) cD cn cn cn SHINOW 9 NI SMIdX3 111AIN3c1 VIOLATION of the Zoning or Building Regulations Voids this Permit. w r Cl) f�D U) co 0 CD .a CD C 0 CD O O 0 CD CD CD y CD C) C) O 0 3 0 m CD B y 0 CD O O The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA. 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TH H: PERMITTING AUTHORITY. Applicant Information `� Please Print Legibly Name• (Business/Organization/Individual): �� ` W N cL \ G' �i—' �— Address: 3 t c_.M t1 N t�, 3 s t/ K d urns, i\f&N 01. 1 Zj t City/State/Zip: tA% t5 YA()trc 1 0 L (a r Phone #: - U 6 2- " (.9 Are you an employer? Check the appropriate box: 1. I am a employer with L.— employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 proprietors with no employees. 5.0 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. n We are a corporation and its officers have exercised their right of exemption per MGL G. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] I I Type of project (required): 7. ❑ New construction 8. 0 Remodelirig 9. ❑ Demolition 10 0 Building addition 11.0 Electrical repairs or additions 12.0 Plumbing repairs or additions 13.0 Roof repairs 14.0 Other *Any applicant that checks box Ill 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. tContractors that check this box mustattached 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: t Q -'x-'� Y li 'TV 1 2 N.s Policy # or Self -ins. Lic. #: W C Z -3(4 0 Z d ®0 I Expiration Date: Job Site Address: t-t-- M l G-R-f v N ?<I ri D l'1ti6`. City/State/Zip: ti Attach a copy of the workers' campensation 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 certify under the pains and penalties of perjury that the information provided above is tr e and correct. Signature: c� Date: 7 S g l / / Phone #: 6 1 r - 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 #: ACGRD® CERTIFICATE OF LIABILITY INSURANCE ‘a.,,./.' DATE(lAWDD/Y""") 3/2/15 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. AND CONFERS NO RIGHTS UPON THE CERTIFICATE EXTEND OR ALTER THE COVERAGE AFFORDED HOLDER THS BY THE POLICIES AUTHORIZED A CONTRACT BETWEEN THE ISSUING INSURER(S), IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 Dupont Insurance Agency, Inc. 18 Copeland Street Quincy, MA 02169 NTMT NAME: Maria PHONE FAx C (617) 479-9121 (A/CN&FM1. (617) 376-0795 WNoi: s: me@dupontinsuranceagency.com INSURERS) AFFORDING COVERAGE NAICIII INSURERA:Main Street America INSURED JK Contracting, LLC 31 Richmond Street Weymouth, MA 02188 INSURER B : INSURERC: INSURER D : INSURERS: INSURE F : COVERAGES CERTIFICATE N UMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATE). 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 POUCIES. LiVIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADM INSR SUER NMDMB POUCY?AER POUCY EFT RAM/In/YYYY► POLICY EXP (MNIDDIYYYY) LETS A GENERAL LT)' COMMERCIAL GENERAL LLABIUTY MPT7794M 2/10/15 2/10/15 EACH OCCURRENCE $ 1,000,000 X E TO RENTED PREMISES (Ea occurrence) $ 500,000 CLAIMS -MADE X OCCUR MED DP (Airy one person) $ 10,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPUES PER POLICY ERCa n LOC PRODUCT'S - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALTOS I ED SCHEDULED NON -OWNED HIRED AUTOS _ AUTOS COMBINED SINGLE LIMIT(Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraeddent) $ _ $ UNBREUJ►UAB EXCESS UAB OCCUR EACH OCCURRENCE $ CLAIMS -MACE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE MEMBER EXCLUDED? fAandabry In NH) If yes describe under DESCRIPTION OF OPERATIONS Y / N N! A WC STATU- OTH- TnRY I IMITR FR E.L. EACH ACOOE NT $ E.L. DISEASE - EA EMPLOYEE $ below E.L. DISEASE -POUCY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Mach ACORD lot, Additional RIMrics Schedule ifmore space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. .11.1111111111.11111111111E •111111.01111111111111.11 AUTHORIZED REPRESENTATIVE 1 Bridget McGowan ACORD 25 (2010/05) Phone: Fax: 01988.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD E-Mail: apedranti@erowninshield. coin `�3/3/2015 7:22:03 AM PST (GMT-8) FROM: 100005—TO: 16174799121 Page: 2 of 2 o CERTIFICATE OF LIABILITY INSURANCE DATE (IBEDD/YYYir) 3/3/2015 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 poiicy(iss) 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). PRooucER DUPONT INSURANCE AGENCY INC 18 COPELAND ST QUINCY, MA 02169 JK CONTRACTING LLC 31 RICHMOND STREET WEYMOUTH MA 02188 • CONTACT NAME: PHONE No. Ems): FAX IAA.. Na INSURER(S) AFPORDINO COVEiiAGE V SURERA: Liberty Mutual Fire Insurance NSURER 0 : INSURER C : NAIL 23035 INSURER D: INSURER E: !)BURR P ; MBER: v.AJVCRA1.11GM vc.n. .u.v/.. ...IMY.wv....v LW, , YAL 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 POUCIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS VEER LTR TYPE OF INSURANCE MSG) POLICY NUMBERAUSR CY EFP (lie POUCY E7si L ORTS COMMERCIAL GENERAL UABLITY EACH OCCURRENCE S I E TO RENTED DAMAGE PRseB fEe oenrrrenral $ CLAIMS MADE OCCUR MED E P (Any one peraan) S PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ 0P41. AGGREGATE LIMrr APPLIES PER: POLICY ❑SOT LOC PRODUCTS - COMP/OP AGO $ $ AUTOMOBILE `— IJABa.IIY ANY AUTO ALL OWNED HIRED AUTOS _ SCHEDULEDAUTOS AUTOS AuTos-0m®N CCO 8r4G1E LIMIT Me $ BODILY INJURY (Per person) $ BODILY INJURY (Per eeddert) $ f ea E $ $ UMBRELLA UAB EXCESS LIAR OCCUR CLAIMB•MADE EACH OCCURRENCE $ AGGREGATE $ $ DEO I I RETENTION i A WORKERS communal' MD EMPLOYERS' LIABILITY ANY PROPRETORIPARTNER EXECVTNE Y / N N/A WC2-315-601698-015 2/17/2015 2/17/2016 , r 9s'rATUTE pi - E.L. EACH ACCIDENT E 100000 EL. DISEASE • EA EMPLOYEES 100000 OPER:ER/Ir1EMEEEXCLUDED? (Mandatory In q0 If DESLIRS�TION earbe OF OPERATIONS below Y EL. DISEASE - POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS / LOCATIONS I % MO ES (ACORD 1Q1, Addleor.l Remark. Schedule, may be iaached if more sperm Is required) Workers compensation Insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously Issued certificates, only as they relate to workers compensation coverage. CERTIFICATE HOLDER • ACORD 25 (2014/01) 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. AUTHORIZED REPR NTATNE r Liberty Mutual Flre Insurance 01888-2014 ACORD CORPORATION. Ali rights reserved. The ACORD name and logo are registered marks of ACORD CERT NO.: 23677622 CLIENT CODE: 1644469 Lucy Maxfield 3/3/2015 10:19:07 AN (EST) Pegs 1 of 1 40, Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-066334 rrr, o` ''I,. KIERAN T WHEItN - 31 RICHMOND ST WEYMOUTH MA v Commissioner Expiration 09/26/2015 J