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HomeMy WebLinkAboutBuilding Permit # 7/29/2015 f 0ORT11 BUILDING PERMIT TOWN OF NORTH ANDOVER 3a - 4s APPLICATION FOR PLAN EXAMINATION ® ' w __ Permit NO: Date Received 2 A 1• •.q AERATED CHUS Date Issued: . IMPORTANT:Applicant must complete all items on this page rL'C7CATION rr p 1- �r�t OPERTY/OWNER- ,R, r / r �/ r / �ri� ✓ / / // / N1AP'�10 ,K rr �F'ARCEf. �� ZrO�Ma�IGDISTRICT HisfoT�c District yes r 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 Septic ; Well Floodplain Vo 6d, Wtitershed D�stnct W' ter/Sewer DESCRIPTION OF WORK TO BE PREFORMED: dentificatiop Please Type or Print Clearly) OWNER: Name: ,fie Phone: Address: � � ra-_ ��. � f r' - cof-51 / r r cr r CONTRP►CTOR Name �iri ; Phone: 7 1/ / / / r l// j✓/, ///i// /r;,/ r/i ri;!r%/ %/i r /i,, / r r r,. it / rii %Address µ raw : ,,,,., L rcer�se , riEx °bete Supery�s�?r'�srCa�nstr/�c�or�, 20 r Home lmprouement �Lieer�se: E � xp: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1 0.00 OF THE TOTAL ESTIMATED CO BASE ON$125.00 PER S.F. 17> Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to h ara n Signature of AgentlOwner—, ''Signature of contractor ti r ttORTH I L 10"h W nuu V O CO �A.c. h ver, ass, COC MI CHEW'CK �.4.44 04 S V BOARD OF HEALTH PERMIT I D Food/Kitchen Septic System /� • .Y.v'G BUILDING INSPECTOR THIS CERTIFIES THAT has permission to erect buildings on 1..�.r�r4, Foundation ...........®............. .. ..... ...... ........... ........ Rough to be occupied as ............ t .......................... Chimney provided that the person acceptin this permit shall in every respe onform 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 M NT ELECTRICAL INSPECTOR LESS CTI 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. Date: 7 d �1 1' RALPH J. BURKE A Family Business Since 1941 Roofing - Gutters Rubber Roofing DANIEL M. BURKE 781-249-7110 C 617-640-1110 C RALPH J.BURKE,JR. TELEPHONE 781-245-1110 office FULLY INSURED - LICENSED 27 BYRON STREET,WAKEFIELD,MA 01880 Estimated price for labor and material to: Remove all roof shingles Replace rotted/broken roof boards up to 100 square feet Re-nail loose boards Install aluminum drip edge It 6 feet of ice and water barrier '... " CERTAINTEED Synthetic roof underlayment " CERTAINTEED LANDMARK ARCHITECTURAL shingles, hand nailed =A1J0 rn14 P20 Reflash all vent pipes and chimney n2 d Remove all roofing debris from the yard Total cost 47 .3o�.J` All workmanship guaranteed twenty years. Please remove or cover all items in attic, as dust and roof particles may settle on attic floor. Thank you 5 j The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations " 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information j � Please Print Lepibiv Name.(Business/Orgasm ion&&,ideal): ��-y4t Pf4 E ryi_r`� Address: / ��.�,,P? J City/State/Zip: . ��� 1 �=/�G°� Phone.#: � !�eO Are you an employer?Check the appropriate bog: Type of project(required) 1.RI am a employer with 4. E] I am a general contractor and I employees(foil and/or part-time).* have hired the sub-contractors 6• ❑New-construction 2.13 I am a•sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling shipand have no employees These sub-contractors have . 8. E]Demolition working for me in any capacity. employees and have workers' uilding addition [No workers' comp.insurance comp.insurance.t' 9. El required.] 5. ❑ We are a corporation and its 10.0•Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions .myself.[No workers'comp. right of exemption per MGL 12. Roof insurance required.]t c. 152,§1(4),and we have no repairs employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks bbx#1 must also fill out the section below showing their workers'compensation policy information. t 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. N the sub-contractors have employees,they must provide their workers'comp.pody number. Yam an employer that isproviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date:--7/ Job Site Address: G 01 -2- 22y City/State/Zip:AV' IW b 0 dG 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 tip 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverag=e verification. Ido hereby certjfy e p ' s d nalties ofperjury that the information provided ab ve is to and correct Si ature: / - - Date: _ Phone#: Official use only. Do not write in this area,to be completed by city or town official j z i City or Town: Permit/License# Issuing Authority(circle one): .1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: X •1 From:Linda J Caruso FaXID:SALEM03 Date:7f29/2015 7:46:10 AM Paae:2 of 2 _.�_04N RALPJBU-01 LCARUSO ACORO" [DATE CERTIFICATE OF LIABILITY INSURANCE (MMIDDIVYYY)7/2912015 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: Salem Five Insurance Services,LLC PHONE (781)933-3100 AX No;(781)933-9048 445 Main Street A/c No Ext: Woburn,MA 01801 E-MAIL SS:insurance.services@salemfive.com INSURER(S)AFFORDING COVERAGE NAIL k '.. INSURER A:Penn America Insurance INSURED INSURER B:Amguard Insurance CO '.... Ralph J Burke Roofing INSURER C: 27 Byron Street INSURER o Wakefield,MA 01880 INSURER E: 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. INSRADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MMIDDIYYYY '.. A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 - A—MAGE I CLAIMS-MADE Lkl OCCUR PAC7052055 0511712015 05/17/2016 PREM SES Ea occur ante S 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY 5 500,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X POLICY 1:1 PROJECT F-]LOC. PRODUCTS-COMP/OP AGG S 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) S ,, ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS NON�OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB HCLAIMS-MADE AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION X PER OTH AND EMPLOYERS'LIABILITYSTATUTE ER B ANY PROPRIETOR/PARTNERIEXECUTIVE Y� NIA R2WC627096 06/20/2015 06/20/2016 E.L.EACH ACCIDENT s 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Building Dept North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building-Regulations and Standards Cl v1.11/1 J�/Cl1a1LV License: CSSL -099814 Ralph JBurk, 54 Paddock Lane Dracut MA 0182& r JJotla�� Commissioner Expiration 07/03/2017 0 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 107146 Type: DBA Expiration: 7/29/2016 Tr# 253422 RALPH J. BURKE ROOFING - Ralph Burke - - - 27 Byron St - Wakefield, MA 01880 Update Address and return card.Mark reason for change. scat :: 201-A-05111 �1 Address ,__I Renewal f—I Employment Lost Card Office of Consumer Affairs&Business Regulation License or registration valid for individul use only SOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ' Office of Consumer Affairs and Business Regulation ! �-��,tRegistration: 107146 Type: g 10 Park Plaza-Suite 5170 Expiration: 7/29/2016 DBA Boston,MA 02116 RALPH J.BURKE ROOFING Ralph Burke 27 Byron St Wakefield,MA 01880 Undersecretary Not valid without signature NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 5q , is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c I 1, S 150 A. Also,, note Pen-nits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: 611(2 (Location of Facility) Lure of Pen-nit Applicant Date