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HomeMy WebLinkAboutBuilding Permit # 7/20/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page 7777r LOCATION Cif �( s T r PROPERTY OWNER �GC fiU � �� �1'�1 �d� �, P Year Old S trucf 6 yes no tint � ' 100 EMAP NO t�� PARCEL:� ���ZONING DISTRICT Historic Distract yes no e`S Village <<yes ;' no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ire family ❑Addition ❑Two or more family ❑ Industrial Cteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El ,Septic `❑Well Q FloodplainpVlletlands 11, UVatershed District ` ❑�:1lVater%Se�iver. ' :, � . . DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: u �dgq dzA Phone:?P-CP87 -ISO l Address: 673" ��5�-�►i }—. Supervisor's Construction License p Date s Norrie Improyernent License p Date /i; llo c/ Ex 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: $ t OV< FEE: $ Check No.: D OReceipt No.: �- lc�n f y NOTE: Persons contracting with unregistered contractors do not have acce9s1to the gu ran r d w � y Signature of Agent/Owner ature of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - � �o�Tlti own o . � _E . 1, ndover ® 4. I OA No. �' _ s -7 yh ver, Mass, T � LAKE 1, COCHICHEWICK V A�RAT E O P' y `S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System 1 . BUILDING INSPECTOR THISCERTIFIES THAT . ..I.�E.......�.................... �Ne ............................................................ .. �— Foundation has permission to erect .......................... buildings on .....� .........` ... .�.................S=................. (� �� ...... Rough tobe occupied as ....... . /.....�k! i.Cxl ..!.�........ .....1 .!:r...�3'GG�c�`. ................ chimney tin this permit shall in eve respect conform to the ter; the application Final provided that the person accepting p every p 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. y Final PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR UNLESS COSTRUCTIO TA S Rough Service ................. .... .... .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay 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. 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(4a;vfotirids deDrnn nrdcrad cal . equipment.. �g PaYmert torn cry .qac-nbectluoi. nstbasrrtiial rmtt Gantriscomnl t`1LTr mp!tionsch ;{as?c'^i°'�oro r S In .'-dFotoboti7pss tirFction) rote; °°m'secttzrg�{'-3:-t:= � t r enti t�tuir r a z mh' st al atizrxtioad�ait2^ta�Icontram-trmite:durar�3Ymen.. a. ;'arcs torree tL, "1-a-(b the aura Gp d;e cantrzc S°b?- ntv_�'11- � ntv ra°rFlaiensch n!e I» tot .� � Fm omCustoma nsaay ^`Dts_Thecootrz n''OO Rmc2ded r�•, Pzr7/snbcon!victor c° S-estohesoteI* " tenmat:acnr? d mu nJ mz� materials ubb�db-Ma Irespo ° , and lahnrrmder °per- >1�oleFor cr titter °F hnr Contct-E c thisanre"IIenr^ar Ttrecnnk`tnrFutfheramnletion e� contrctshallaotim�-UDnnsigajnc,this o!eI1'rrLdescrib= Le7yofthebe^F�` can rti Srarsinb_s -dr•_ �f.ntne care&t]! Y[ha an3lienor a0�trnentbecactrs �Forslble�r Jtnm�to Dm°r�S drrd Yb.fnreS7• Slriscouc rL otbary �tSster�7 abt°a'nc^nso�undslats. �sv5 Els b Unles,oily COn Tactors."- sen nta o_ il°u't lreI tm lherrsidence .Tenn eaoted il=d,e R'»��d intosignin et: do gibe tI eFDUcrtgrr ubc°r tnDcnnnsctorhas cnah `-t lionsand ken " Women;t)r^ urectorstob , n �aridHo mLme oandfnll e.511 tionbj, 'zsstercdtzitbth De rnt YuDde LnDdit Erskq� �o Lem tsaLmg rD theDirecLDr r orof$men�zctorP,eeistray-an "Ttr `�oosrfsomethin "'tire con�c!orh3r' a-IO4�;p1 i��eatco- b`:zgoire,MD;th gisa clt I��Djrjara 7rCaParf�m'cA�?A$kiveCautr ItD°tuSF7tJ,BaYagt�rcta-<�" �to-7You omtMpr°. rrenicaa d°ctmrcrtE a ���°n..comI 02716orbl r' g517A 3 abouicor!I;�riractoraad Gui.0 o lr Ln� �o`�TpOnsr-ct7itic5•- j,-- 3787 °r e 7Ierta Iar, . -d Ene" °�Da so tl m SSC-?S3 3757. fD 7 vlxl s G�ls�entCamrnr� gyp° tt—Untstionontherevsse�rreps mtYoc confer comm orzSk-to >m- -tGisi conit�elo.ia. `'P �rcvtifi?rusb a�rendgeta tfvrd ='etbJ�h� �Sneca? `� COPY°fib°Con bnstoe3sdIi-V,r"olotssaggie ogee.: elta D2O tneca��to:s mer �:,y A _ ;TO.� sag`�m°°h Ser the a-Ite Intl ga^'ea',03,tele °- , TTaia�,ccot;� C' T `t�`chWnoHe,:of Sersro ,� Fru:dded NanoiripWe �tncetlati°afDrmar ei];nctlafthcnmidol `"tecl= Q• 1 r..=,� o�, . l-a5an of o5tofthe Homcrot:3er gi sa c�t.:e - =LZ,tb;tLc,:�t.t anhar.Ycis Silnahr �<t J Date / Contractor x-rbitrntian The Home Improvement Contractor Lav provides homeowners with the tight to imhan an arbitration action(as as alternative to court action)if they have a dispute with a contradtor 1 he�e has Pright itot a a a Ito a mer.CaUy afforded unless contractor,however- The cuntractorwouldhave to resolve any dispute both parties agree to the optional clause provided below. This clause would g ve the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner herebymutually agree in advance that in the event the contractor has a dispute concerning this contract.,tl?e__:contiaetorilaysubmit the dispate to a private arbitration arm which has been approved by the Secretary of the executive Q�fficefl g-onsumer Affairs and Business Regulation and the consumer shall be required to submit to such ar7irtralzon as pr°Vtr�e In Massachusetis'General Laws,cbaprer 142A. V ; 1,..,.%^ Homeowrmer's Signature Contractor's Signature KOTICEl The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeotivner may initiate alternative dispute resolution even wheyy a this section is not separately signed by the parties. ?oracowner's Rights A homeowner's rights under the Home Improvement Contractor La v QYIGL chapter Ml2 )and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any u'ay,even by agreement. However,ltomeovners may be excluded from certain rights if the contractor they choose is not properly registerad as prescribed by law. Homemmiers who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the liome Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and wor',znanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for worlmmanship or materials. In addition to guarantees or warranties provided by the contractor_all goods sold in Massachusetts rY an implied warranty°i merchantability and fitness for a particular purpose. An enumeration of othermatters an which the homeowner and contractor lavvfhUy Agee may be added to the terof the contract as long as they do not restrict a homeowner's basic consumer rights. if you have ns questions about your consumerlhomeownerrights,contact the Consumer Rifonvalion Hotline(listed below]). �e£ution oa Con¢sact Tire contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached Parties are also advised not to sip the document until all bl- sections have been filled in or marked as void,deleted,or not applicable. On e original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contfactmustbein- -in and agreed to by both parties.Contracted worlcin y not begin until both parties have received a fully executed copy of the contract,and the three dayrescissionperiod has e;.Imired? e'=eceIerateo Payor--e='fSa specified°n thea ent schedule in cases where the z contractor may not demand payments in advance of the domes sp P Yin homeowner deems lihn/herself to be financially insecure. however,in instances].here a contractor deems himllierelf to be financially insecure,the contractor mayrequire that the balance of funds not yet due be placed in a joint escrow account as e,prerequisite to continuing the contracted wo& 4Pithdrawal of funds Rom said account would require the signatures of both parties. Additional Information t Ifuyohave general questions or need additional information about the Home Improvement Contractor Lata or other consumer rights,or if you wish to obtain a fine copy of"A Massachusetts Consumer Guide to home Improvement!' contact: Consumer Information Office of Consumer ufflairs and business Regulation l0 ParkPlaza-Room 5170,Boston,MA 022116 617-973 878-7,$So8 293 3757 or visit the 0CABRwebsite athIna ss. ovloeabr/ If you want to verity time registration of a contractor or ifyou have questions or need additional information specifically about the contractor registration component 1[f the Home improvement Contractor Law,contact: Director of Borne improve-Ment ContractorRegisisation Office of Consumer Affairs-and Business Regulation , l0 Park-Plaza,Roam 5170,Boston,M-A 02116 617-973-8757,988-283-3757 orvisit the HIC website at htW:lliv`arv.mass aoidocahm/ Go online to view the status of a dome huprovement Contractors Registration_- http://db.state.nla.usJhomeimnrovement/licenseelista.w For 2ssistanceth informal mediation of disputes or to register iSirnai complaints against a business,call: Consuner Complaint vection office of the Attorney General 617-727-911100 AND/OR Better Business Bureau .OC-652-4d00,503 75a?S4g or4?'=73j-ilia verionzl-1112?J2010 The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Mashington Street Boston,MA 02111 wipip.mass gov/din Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LetriUl Name(Business/Organirationtindividual): Adenfic , +t iel'iaholl,LLC Address: C t1 V�lile .01970 City/State/Zip: Phone#: 97�JYY- S 3 Are you employer?Check the appropriate box: Type of project(required): 1. am as employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. []Building addition [No workers'comp,insurance 5. ❑We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 R repairs insurance required.]t employees.[No workers' 13. . Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractor that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. I am all employer that is providing workers'compensation insurance for ury employees Below is the policy and jab site information. � r Insurance Company Name: Policy#or Self-ins.Lic.#: 5 6 ;m a I Expiration Date: 0.2 Job Site Address: 61 75— City/State/Zip:66 Admv- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I rlo hereby ceJY under the pa and p Iti ofperjury that the h formation provided above rtsue and correctSignature: Date• Phone#: 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#• Rightfax N2-1 3/10/2015 10: 11 :37 AM PAGE 7/013 rax ,�CIVCL Ac I I I I DATE 03-10.2Q15 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 TAFFORDED BY THE HE ISSUING NSURER(S)CA AUTHORIZED REPRESENTATIES BELOW. THIS IVE TE OF INSURANCE S VE OR PRODUCER,ANDHE CERTIFICATE HOL ERS NOT CONSTITUTE A NTRACT BETWEEN IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGAT!certificate IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: EASTERN INS GROUP LLC PHONE FAx A/C No Ext): AIC No 233 W CENTRAL STREET E-MAIL NATICK,MA 01760 INSURER(Q)AFFORDING COVERAGE NAIC k INSURER A:AMERICAN ZURICH INSURANCE COMPANY INSURED PINSURFR : ATLANTIC WEATHERIZATION LLC 61 REAR JEFFERSON AVE SALEM, MA 01970 : COVERAGES T TE NUMB V N NU ER: 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 POLICY EXP LIMITS TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM1DO/YYYY MMIDDIYYYY LTR EACH OCCURRENCE $ GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY pAMAGES RENTED ce $ CLAIMS-MADE[:] OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY S GENERAL AGGREGATE S GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPrUP AGO S PRO- LOC $ POLICY JECT 11110 ED SINGLE LIMIT $ AUTOMOBILE LIABILITY a accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON ED pPEE Yt AMAGE S '.. HIRED AUTOS AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSUAB J.CLAIMS-MADE AGGREGATE $ '.. S DED RETENTION$ WORKERSCOMPENSATION X WCSTATU- DTH- TORN LIMITS EA AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTN Y/N N 1 A E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? 6ZZUB 03-20.2015 03-20-2016 E.L.DISEASE-EA EMPLOYEE $500,000 (Mandatory in NH) 5B270121 If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below '.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) ET I ROLDER CAL 0 TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 1600 OSGOOD ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF, N.ANDOVER,MA 01845 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.AFI rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERTIFICATEDATE(MM/DD/YYY}') LIABILITY INSURANCE 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 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 CONTACT NAME: Construction Eastern Insurance Group LLC PHONE (800)333-7234 FAx 233 West Central St E-MAIL ac Na: ADDRESS: Natick "' MA AFFORDING COVERAGE NAIC# MA 01760 INSURED INSURER A:Arbella Protection Ins. Co. 1360 Atlantic Weatherization INSURERB:Nautilus Insurance CO 61 Rear Jefferson Avenue INSURERC: INSURER D: .SalemINSURER E: � 01970 INSURER F COVERAGES CERTIFICATE NUMBER MASTER 2015 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 DOCUMENTWITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SUBJECT TO ALL THE TERMS, INSR LTR TYPE OF INSURANCE A D BR POLICY NUMBER POLICY EFFr/20/2016 GENERAL LIABILITY MM IDD/YYYY LIMITS EACH OCCUR"$ 2,000,000 1,000,0001 X COMMERCIAL GENERAL LIABILITY D GE TO A CLAIMS MADE PRE ISES E 50,000 X OCCUR 500042816 /20/2015MED EXP(Any 5,000 PERSONAL& 1,000,000 GENERAL AG2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY X PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JFQT AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT A ANY AUTO Ea accide t 1,000 000 ALL OWNED X SCHEDULED 020015871 BODILY INJURY(Per person) $ X AUTOS AUTOS UT OWNED /20/2015 /20/2016 BODILY I NJURY(Per accident) $ HIRED AUTOS X AUTOS PROPERTY DAMAGE $ Per accident X UMBRELLA LIAR $ OCCUR PIP-Basic $ A EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ 1,^- - RETENTION$ RETENTION$ 4600058654 /20/2015 /20/2016 AGGREGATE $ 1,000,000 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE YINLIMRY LIMITS (MandatoryOFFICERNin H)EXCLUDED? ❑ N/A E.L EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below $ POLLUTION LIABILITY E.L.DISEASE-POLICY LIMIT $ PL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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 John Koegel/PMA ACORD ni (2010105) INS025 r9m ©1988-2010 ACORD CORPORATION. All rights d.reservenns m Tho A(tnDn name and Innn arc reniafarari mnrka of Af:npn 1 Nl a saacIaF.bastn Depa ,€ a"r9' La:d :ase: SCS-087977 a. ERIC W PALM _ i 3 MELTON ST Salem KA 019707' J 5i.21 04/23/2016 . ryf�e�anrnronrverrlf�a�C!��tr.;.;ac✓rtt,clf.1„. Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 142089 Type: 1 xpiration: .3/12/2016 Ltd Liability Corpo:, ATLANTIC WEATHERIZATION L.L.C. ERIC PALM OR JEFFERSON AVE SALEM,MA 01970. Undersecretary