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HomeMy WebLinkAboutBuilding Permit # 8/7/2015 1 � �,►OR � BUILDINGPERMIT ® %AORY}r 't'® TOWN OF NORTHANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received pDR1TE„D PPa' c5 �'Ss CHUSE G Date Issued: IMPORTANT: Applicant must complete all items on this page � //i/oi /ri r / / i //! ri r r /%/// // //i i/ / � i// / rill ///// / /i/,✓i/r r r iii rr / /i 2 DISTRICT Historic D�stnct Yes no. Machine Sloop 1/illage ye"s' no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial IR Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg X Others: ❑ Demolition ❑ Other d Septic ❑1Ne11 ElFloodplain ElWetlands ❑ 1Natershed District DESCRIPTION OF WORK TO BE PERFORMED: t � � (, ii e eta 4t 'Yds Ckn& Yyl� W& 000OS 4`ee,(, 1 h g 't-tf ex I'x" `1-t`e l.,U"'LK..to� (n cl t 4q-®6) ,C,)E 'a"\ddE Identification - Please Type or Print Clearly OWNER: Name: d 64 ok Phone: CtT Address: ~ r V Contractor Name ,,Phone !/ Address r r / / / r Su erulsor�s,Construction,License �; ", ���"' ..� „ :`:Exp Date % r�� ���i�-fir , ' rl////�,�jf//�//�%/fir/��� rr/ fir l// %ii / %/ /i .i✓,,, ,„fLi �,,,//i;, / // r//i/ Home;lmprove'ment„License//%// r Exp 'Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ O FEE: $ . Check No.: A Receipt No.: ” MOTE: Persons contract' g w u is contractors do not have access to the guaranty fund Signature of Agent/Owne ignature of contractor — %A® TH Town of Andover No. T- _ _ LA.e h ver, ass, 7' COC HIc Newlc O( y1' A°R'A E C) LlBOARD OF HEALTH L mD Food/Kitchen rER.MIT TSeptic System d �e^i i i'L1�9 Cc �� ' .4�........................................ .............. I BUILDING INSPECTOR THIS CERTIFIES THAT .................. ............................. Foundation has permission to erect .......................... buildings on .. G:S.... ^!•• ••1....................../%•••�•� e. Rough /�lr�CJ /`?f�. .a................. ......Ir �..r. cs .. ............................... Chimney to be occupied as ......... .......`........ .... provided that the person accepting this permit shall in every respect 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT E I E IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION START Rough Service ....................... ......... .... . .. Final B ILDI�i� TOR GAS INSPECTOR Occupancy Permit Required t® 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 ntil Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. � uraION "OFFICE +- interiors 726AN00ARS. 9 9T�A WRA,NSM0.MA 01801 ,EEPNONE 715 78,.316.6400 FACSMRE 181�74754D I 4T f PED 334 ROP05ED o V6X6 , ` q AUSTIN FLl RECONFIG. T45 - -5 - 941 6x6 ° a T44 sxs •« � MERRIMACK m o It C$LLEGE —� REGISTRAR STORAGE a� T49 ��n4 609 ii I I 31-2 MECRAWNGS CCN7ANSD NEREWSMN ARE041RUMENA - OF PROFESS0 Nµ RIX£ $A N01 BE W *RWPARE.FORAHYT4O PROJECT OMER INANf"f f0P W"C" 84�AMEY WERE CREAM.NOR �j '� WI#0Uj WDttPPYEZWRrt�i9iARrc. CO EMOFQNKMOFFLEAND I I G WRNDB[OFFICE COMPENS W TO RNUllOFNCEAS MPERFA.NEOet BNONOffiCE. II copte T35 ' OAfE 07.0:.,5 1tEV A:07.07.i5 i SCALENES REP 8:07.03.15 963 AA '+ DRAWN By.SiF RE,FC�07.1a.15 I_ CNK6£OBri 4EV O: [i Department of Industrial Accidents Office of Investigations �d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers (Business/organization/Individual):Applicant Information Siena Construction Corporation Address:25 Birch Street Cambridge,MA 02138 Phone#:617-547-4546 City/State/Zip: Are you an employer? Check the appropriate box: Type of project(required): 4. [] I am a general contractor and I 6 New construction 1.M I am a employer with 3D have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet. 7. Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have 8. []Demolition ship and have no employees employees and have workers' 9. 0 Building addition working for me in any capacity. comp. insurance.t [No workers' comp. insurance 5 E] We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work per ht of exemption right p p tion MGL myself. [No workers' comp. 12.E]Roof repairs c. 152, §1(4),and we have no 13.[]Other insurance required.] t 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. ffidavit t Homeowners who submit this aan additional sheet showing h indicating they are doing all wrk andname of the sub contractors and state whether or not those entitiesnhave then hire outside contractors must submit a new a tContractors that check this box must attached 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:Selective Insurance Company of Southeast WC900B328 Expiration Date: 01/01/2016 Policy#or Self-ins. Lic. M City/State/Zip: Job Site Address: don Attach a copy of the workers' compensation policy deet MGL a 52 caage n lead t wing tithe imposition of criminal penaltiesmber and expiration aof a Failure to secure coverage as required under Section s w o fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties lii.s stat ent ay be forwardedof a STOP O�th the �d a fm� of up to$250.00 a day against the violator. Be advised that a copy Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Date: Signature: Phone M. 6175474546 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 on 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• �► CERTIFICATE OF LIABILITY INSURANCEL123MzL.. TE(MMIDDIYYYY) 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(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 NAME:C Ted Matthews The Driscoll Agency, Inc. PHONE R4,781-681-6656 ac No• -681-6686 93 Longwater Circle MALI, P.O. Box 9120 AD12HESS:JbdB-dr'scQllagency.com Norwell MA 02061 INSURERS AFFORDING COVERAGE NAIC# INSURER A: iVe Insurance.Ca of Southeast 39926 INSURED 17558 INSURER B: Siena Construction Corporation INSURER C: 25 Birch Street INSURER 0: Cambridge MA 02139-4514 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:259111424 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. ILT R TYPE OF INSURANCE INSR WVQ POLICY NUMBER ADDLSUBR MOI ICY EFF POPOLICY/EXP LIMITS A GENERAL LIABILITY S2139638 /1/2015 /1/2016 EACH OCCURRENCE $1000,000 X DA A E COMMERCIAL GENERAL LIABILITY PREMISES Me occurrence $100,000 CLAIMS-MADE F OCCUR MED EXP(Any oneperson) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $3,000,000 nPOLICY X PRO- LOC $ A AUTOMOBILE LIABILITY A9099881 111/2015 /1/2016 Ea accident $1,000,000 ANY AUTO BODILY INJURY(Per parson) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) _$ X X AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS $ A X UMBRELLA LIAB X OCCUR S2139638 1/1/2015 /1/2016 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$NOne $ A WORKERS COMPENSATION NC9008328 1/1/2015 /1/2016 X I TWO TLIM TS AU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE aNIA E.L.EACH ACCIDENT $1,00,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-FA EMPLOYEd$1000,000 it yea describe under E.L,DISEASE POLICY LIMIT $1,000 000 DESG� RIP TION OF OPERATIONS below A Leased/Rented B2139638 1/1/2015 /112016 Per Single Unit $100000 Equipment Aggregate $100000 DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more apace is required) CERTIFICATE HOLDER CANCELLATION Siena Construction Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 25 Birch Street ACCORDANCE WITH THE POLICY PROVISIONS. Cambridge, MA 02138 AUTHORIZED REPRESENTATIVE r ' ©1988.2010 ACORD CORPORATION. All rights reserver ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Department artment of Public Safety Massachusetts - P ulations and Standards Board of Building Reg Construction Supervisor License: GS-083597 AN S DIC 43 FAIRF S X144 Somerville MA a-'�, Expiration 01112/2016 commissioner Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991M )of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license, I For DPS Licensing information visit: www.Mass.Gov/DPS