HomeMy WebLinkAboutMiscellaneous - 19-25 SECOND STREET 8/3/2015 BUILDING PERMIT 01 %AORTH
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION 0
PermitNoM Date Received
Date Issued: .-I CHU51
IMPORTANT: Applicant must complete all items on this page
LOCATION — ) A,Jo ver
"J" 11 Print
PROPERTY OWNER 0 r,!04-16A.)
Print 100 Year Structure yes no
MAPDI�b PARCELU ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 11 One family
11 Addition Li Two or more family 11 Industrial
Ll Alteration No. of units: El Commercial
El Repair, replacement El Assessory Bldg 11 Others:
Li Demolition El Other
NO
DESCRIPTION OF WORK TO BE PERFORMED:
_2
rot)il
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
-
Contract;prName: &L )-V/H&vk�kl P : 9-2,?_
Email: kioyL
Address: ',e� - e-o //,-- I-J'" AAJ,� b3o';7
Supervisor's Construction License: Exp. Date:
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" "F.
Total Project Cost: $ FEE: $
Check No.: � )(-)5— Receipt No'.:'
NOTE: Persons contracting with unregistered contractors do not have access to e g arant
y
7Z
V%ORTH
Town ofEAndover
0 . to
IL h
o LAK� h ver, Mass,
COC NIC Mt WICK
,® RATED
S U
BOARD OF HEALTH-
F �ERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT ........ BUILDING INSPECTOR
.. .. ..... ......... ..... ............................................. .......
. . ..... . .....
e Foundation
has permission to erect .......................... buildings on .... . '., t�r... �C r^4 :......... ...f ......
® Rough
° ® t
to be occupied as .. .. . .., ........�r.� l... . ..... .... ... .... ?Y.i.� �,r.� .................. Chimney
provided that the person accepting this permit shall in every.4ect conform 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
PERMITI E IN 6 MONTHS ELECTRICAL INSPECTOR
.UNLESS CONSTRUCTION STARTS 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.
Page# --- -- of -
-----pag(
HOYT MASONRY
RO OOR 1136
NYMOOO NH 03077
970390*3456
PROPOSAL SUBMITTED T0: 4 JOB NAME
ADDRESS JOB LOCATION
V
"..
DATE DATE OF PLANS
r
PHONE d ry FAX A s ARCHITECT,-
_31
RCHITECTr j
e hereby submit specifications and estimates for:
y m-
� t
Lc 4
r
r ,
n,
i 2 i st -
�� :YF,_ -
j
t
)j
1
( J
1.7,Y--_ ,✓`f ��1 L.1` _ �"-- �..__,T _ r �. _ .j.._
xa
r
ero ; hereby to furnish material and labor complete in accordance with the above specifications for the sum of:
t4lP P�e Y
tl
w a
with payments to be made as follows: _
� r
Any alteration or deviation from above specifications involving extra costs eP y
Res ectfuPl
will be executed only upon written order,and will become an extra chargeSubm
t itted
over and above the estimate. All agreements contingent upon strikes,
accidents,or delays beyond our control. , % a f Note—this proposal may be withdrawn Ify us if not accepted within_ _ _days.
r t't
The above prices,specifications and conditions are satisfactory and are i^ t
hereby accepted. You are authorized to do the work as specified
Signature- t t
Payments will be made as outlined above. Sig -
Date of Acceptance
A-NC3819/T-3850 09-11 — — —'_--
The Commonwealth ofMassuchusetts
Department of Industrial.Accidents
I Congress Street,Suite 100
Roston,M4 02114-2017
www mass.gov/dna
,y. Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers-
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legib
Name (Business/Organization/Individual):
.Address: c
City/State/Zip:
Phone#: 7 ?P2�. 6
Are you an employer?Check We appropriate box: Type of project(1'equired):
l.C]I am.a.employer with employees(full and/or part-time).* 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working:for me in 8. Remodeling
any capacyty.[No workers'comp.insurance required.]
� 9. ❑Demolition
3. I am a,�bomeowner 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
eteure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
r .•. '
p:ra
e13,[�$�otors with no employees. 12,Q Plumblug repairs or additions
5.k]I general contractor and I have hired the sub-contractors listed on the attached sheet. r°of repairs
These sub-contractors have employees and have workers'comp.insurance.
6.F1 We are a corporation and its of �cers have exercised their right of exemption per MGL c.
14.®Other '~
152,§1(4),and we have nQ employees.[No workers'comp.insurance required.]
*.Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
fi 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 must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-conlraclors have employ ees,1hey must provide their workeis'comp.policy number.
I am an employer that ispidviding workers'compensation insurance for my employees.'.Below is thepolicy andjoh site
information. I ' !0 a {
Insurance Company Name: 7`� '� t �°
Policy#or Self-ins.Lia#: O 1 Expiration Date: °JJV
Job Site Address: i C'C" f i (� `~ City/State/Zip: r / Jove,r 1,11'f, 01(?,/S--
Attach
1(?,/ -Attach a copy of the workers'compensatiou 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 cert under th=ain
perjuiy that the information provided above is true and correct.
Signature: Date: "
Phone# „_.� L ' '1: l
Official use only. Do not write in this area,to he 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#:
■
0810312015 08:45 Stewart Ltd/Insurance Managment (FAX) P.0011001
DATE
® CERTIFICATE OF LIABILITY INSURANCE 6/3/2015 Y)
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: 0 tho certificate holder Is an ADDITIONAL INSURED,tho polloy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terint and conditions of the policy,certain policies may require an endorsement. A Btetement on this certificate does not confer rights to the
certlffcato holder In lieu of ouch'endorsement(a).
PRODUCER
STEWART LTD/INSURANCMGMT PHONE E (603)895-2200 (603)895-6761
10 Freetoarri Rd ADDREss:b.rent@wJstowartinsurance.com
Raymond, NH 03077 INBURER(B) AFFORDING OOVORAOR NAIca
INSURERA:Pe®r1QMS Insurance
INSURED Hoyt Masonry LLC INSURER 0;Cincinnati Insuranne
Sean Royt INSURER C;
BO BOX 1136 INSURER D:
Raymond NH 03077 INSURER E:
INSURER F;
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 16 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.
MOR TYPE OF INSURANCE use vivo POLICY NUMBER M D M LIMOS
X COMMBRc1AL OItN1IRAL LIABILITY EACH OCCURRENCE $-1.,000 000
CLAIMS-MADE D OCCUR PREMISES Eo occurrance S 300,000
MEO EXP(AnX onepawn) $ 15"000
A BKS55460465 04/21/15 04/21/16 PERSONAL&ADV INJURY $ 1,00 000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAI. AGGREGATE $ 2,000,000
POLICY Q JEC LOC PRODUCT8-COMPIOP ADO $ 2 OO O OO O
OTHER: $
AUTOMOBILE LIABILITY COMBINED
a 6 1 O00 000
ALL OWNED SCHEDULED BKS55460465 04/21/15 04/21/16 ANYAUTO
ALL
INJURY(Per person) $ '..
A AUTOS AUTOS BODILY INJURY(Per eoeldenl) $
X HIRED AUTOS X
NON-OWNED PROPERTY DAMAGES
AUTOS Per aceldent
6
X UMBRELLA LIAR' $ OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIJW CLAIMS-MADE AGGREGATE 07/07/15 07/07/16 AGGREGATE $ 1,000,000
DED RETENTION$1 O 0 0 0 $ '..
WORKERS COMPENSATION ER
Y� 07/07/1'5 07/07/7 6 STATUTE ER -
ANDEMPLOYERS'LIABILITY
B
ANY PROPRIPTORMARTNEWEXECUTIVE UBOG14039 E,L
OFFICERNErdeER EXC ,EACH ACCIDENT ¢ 100,000
LUDED? y NIA
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,006
I(yyea daccdbcivndgf
OHS4tRIPT10NOFOPERATIONS below E.L.DISEASE-POLICY LIMIT 6 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
CERTIFICATE HOLDER CANCELLATION
Evidence Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
North Andover MA, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS-
AUTHORIZED REPRESENTATIVE
I
01988.2013 ACORD CORPORATION. All rights reserved.
ACORD25(2013104) The ACORD name and logo are registered marks ofACORD
4h - / 9q --7r7y
-2--