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Home My WebLink AboutBuilding Permit # 8/18/2015 t%ORT#1 BUILDING PERMIT %*TLz D ,6.1. 0, TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#- Date Received S CHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION P * PROPERTY OWNERaAp0yk4.V% MAP PARCEL. Print 100 Year Structure yes no ZONING DISTRICT: Historic District yes n o) o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 2110ne family [I Addition [I Two or more family [I Industrial [I Alteration No. of units: [I Commercial [I Repair, replacement El Assessory Bldg El Others: El Demolition [I Other N C Is HIMI ��,�� i 11>�. ��J��r DESCRIPTIOrF WORK TO BE PERFORMED: :5- V- 1,Y) y-e -- D Id-enificai n- PleaseT e o r Print Clearly OWNER: Name: Phone: 2- CA-I ti 6 Address: bu �"V- �NV Contractor Name: Phone: Email: Address: 2, ncA� 7sl+ Supervisor's Construction License: Exp. Date: Home Improvement License: -Exp. Date: 1() - 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: $ FEE: $ 7 Check No.: Receipt No.: 2,6 z"! NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund b�w j�6L ®RTS Town of IT.", Andover 0 o LAKE h Ve)r, MaSS' COCHICHQWYCK RATED BOARD OF HEALTH Food/Kitchen PtRT LD Septic System THIS CERTIFIES THATlbq��t�n,,,,,,,,,,,,,,,,I'l % ,,,,, ,,rw'o BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on . .......... ....... ..................... Rough to be occupied as ............IS- ..y.......!47:.......p .. ... ....®.......................................... Chimney provided that the person accepting this permit shall in every respect nform 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 MONTHS ELECTRICAL INSPECTOR ® UNLESS I Rough Service ...................... ........ ......JL. ..... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. Baystate Roofers,Inc. P.O. Box 189 Proposal North Reading, MA 01864 Date Estimate# Tel. 978-664-0668 Fax 978-664-4333 7/13/2015 16132 Name/Address HIC # 137193 Deborah Dadak CSSL# 99895 35 Bunker Hill St. N.Andover,Ma.01845 Bay State Roofers inc proposes: Remove approximately 2700 square feet of the existing asphalt shingle roof down to the wood decking. Install new ice and water shield along the 6' roof edge, valleys and around all the roof penetrations. Install new 151b felt paper throughout roof area. Install new white aluminum drip edge along the roof perimeter. A new Lifetime GAF Architectural asphalt shingle will be installed over the prepared substrate. A new ridge vent will be installed to ensure the proper roof ventilation. All roof penetrations and flashing will be installed according to manufacturers recommendation, specification and details. Cut and install new lead flashing on the roof chimney. (1) Install new pipe flanges. Bay State Roofers will properly dispose of all roof debris in our own waste containers. Any wood decking that needs replacement will be an additional $2.50 per lineal foot. Message New Shingle Roof Authorized Signature- Total �— $8,990.00 Waste containers supplied by Bay State Roofers, Inc. are for sole purpose of roof debris. Under no circumstance is the homeowner to use these containers for personal use. 10 Year Workmanship Wairanty on all roofs. (Except Repair Jobs) CONTRACT ACCEPTANCE The specifications,prices,payment schedule are satisfactory and hereby accepted. Date: BAY STATE ROOFERS,INC. is authorized to perform work as specified. Payment will be made as previously outlined. Signature 'jN All bills over 30 days are subject to 1 1/2%finance charge per month(18% annual). Color �9 �WC') The Commonwealth ofAfass�chusetts Department oflndustz^ialAccidents _w tl I Congress Sheet,Suite 100 - M= Boston,MA.02114-2017 zy+4��t www-mass.gov1dia Workers'Compensation insurance Affidavit:Builders/Contractors/.Electricians/Plumbers- TO BE TILED WITH THE PERAUTTING AUTHOWTY. Aplilicant Information Please Print Lep-ribl Name(Business/OrganizationLCndividual): :2;i�� Address: City/State/Zip: a4, Phone#: Areyon an employer?Cheekthe appropriate box: Type of project(required): I.Fq°haunaemployer with ... : employees(full and/or part-time).* 7. E]Now construction 20 I am a sole proprietor or partnership and have no employees working for me in 8. [1 Renio delirig any capacity.[No workers'comp.insurance required] 9. El Demolition 3,E]I am a homeowner doing all work myself[No workers'comp.insurance required.]i 10 FI Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will • XI.Q Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.F1 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs 'These sub-contractors have employees and have workers'comp.insurance.t ' ' 14.El Other 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have na•employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer tfi at is providing workers'compensation insurance for•my employees.'Below is the policy and job site information. Insurance Company Name: ACF- ( Policy#or Self-ins.Lic.#: % C, 0ExpirationDate: 4 � fob Site Address: 3CES VUA City/State/Zip: Attach a copy of the workers'compepsation•pollcy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o.1.52,§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 ofup 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. X do het eby certify Zer tliep ins andpena ties afperjury that the information pi•ovided above is true and correct. r •� Signature: Date: Phone# TMy 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 C2-2 4/15/2015 10:30:49 AM PAGE 3/004 Fax Server Ac o® CERTIFICATE OF LIABILITY INSURANCE 04152015 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 WANED, 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. A 8 K FOWLER INS LLC PHONE FAX 200 PARK STREET AIC IL E.1 A C No NORTH READING,MA 01864 E-MAIL INSURER(S)AFFORDING COVERAGE NA1Cd INSURERA:ACE AMERICAN INSURANCE COMPANY INSURED INSURER B SAY STATE ROOFERS INC INSURER C PO BOX 189 NORTH READING,MA 01864 INSURER D 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, WSR ADDL SUB POLICY EFF POLICY EXP LIMITS LTR TVPEOFINSURANCE INSR WVD POLICYNUMBER M woDIYYYY GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S CLAtMS-MADE I OCCUR RE M ES(Any riap men l MED EXP(Any aria pcnan) $ PERSONAL dADV INJURY $ GENERAL AGGREGATE S OENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMNOP AGG S POLICY PRO• LOG $ JECT AUTOMOBILE LU18e.ITV MBIO SINGLE LIMIT S n AC[NEMl ANY AUTO BODILY INJURY(Pal Person) S ALL OWNEDSCHEDULED -" 4 AUTOS AUTOS BODILY INJURY(per acodent) HIREDAUTOS AUT SWNEO P 9PEPa% AMAGE S $ UMBRELLALLAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAWS-MADE AGGREGATE S OEO I RETENTIONS S WORKERS COMPENSATION x INC STATU- OTH, AND EMPLOYERS'UABILITY Y,N TORY LIMITS ER_ ANY PROPRIETOR/PARTNEWEXECUTNFk NIA 6S62UB 04-12-2015 04.12.2016 E.L EACHACCIOENT y $1.000.000 OFFICER,MEMSER EXCLUDED (Mandatory n NHl 4609P062 E.L.DISEASE-EA EMPLOYEE $1,000,000 It ycs.dcsttAc under DESCRIPTION OF OPERATIONS Cera+ E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES(Anwh ACORD 101,AddMonal Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION BAYSTATE ROOFERS INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B P.O BOX 189 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NORTH READING,MA 01864 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE TL, L., -1 9119118.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Massachusetts De parfinent of Public Safety Board of Building Regulations and Standards Coils truction SupCI' icor Spccialh License: CSSL-099895 ROBERT E OKEEFE` 21 FRANCIS STREET NORTH READING MA 018"" Expiration Commissioner 09/29/2015 /. OfTice of Consumer,Affairs frairs 8 &Business ReuQe� { =HOME IMPROVEME QCTOR gul,tion Registration. , h37193NT CONT Expiration; BAY STgTE RO ;10/15/2016 Type; OF�RJNC. Supplement it ROBERT O'KEEF[_ PO BOX 189 N.READING, MA 01864' i �� — Undersecretary i