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HomeMy WebLinkAboutBuilding Permit # 8/14/2015 � y.�ORYy � BUILDING PERMIT O KCLED �, TOWN OF NORTH AOV APPLICATION FOR PLAN EXAMINATION ' Permit No#: Date Received ADRATED PPpy.(5 �SSgCHUS Date Issued:_6 r 1 IMPORTANT: Applicant must complete all items on this page LOCATION z�,� ���.✓'� °' " Print PROPERTY OWNER Print 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District ye cno Machine Shop Village ye cr`►� 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 0,9thers: ❑ Demolition ❑ Other ' s //„ Se .tcc ,Well ,,/,/ � ,/, „r ❑ Flood lain, • ,/.❑Wetla,ds „ ,❑ Water hed Distr►ct /. ,, ..rai� %/r.. �,%�/r�!//..J/�./ ,r�/./•!l./ l / „�I � ////r. � �/�//// ,�r�.irf/r�/i//,t%..r Ji r//. / BE PERFORMED: DESCRIPTION � RIPTION OF WORK TO Identification- Please Ty e or Print Clearly OWNER: Name: W l T ` ~ � Phone: L Address: , .. �,� .ro � �: E Contractor Name: , ��d / Phone: ` " y Email: :� Address: '" � .. (77 f (( ' (-4 2Ln c o . /� " Su ervisor s Construction License: 6,,' Exp Date: � — -- Home Improvement Licenser 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. d Total Project Cost: $ ,�' � " ���°°� '° FEE: $ ' b nuM1 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the,guaranty fund sian �, ®RT mover Town of Anu 0 . ® ® � @ h , ver, ass, 0 COCAK >L1 KS eCK 4�' BOARD OF HEALTH PEK NL D Food/Kitchen Septic System THIS CERTIFIES THAT .................. ..... ................... ....................... ............................ BUILDING INSPECTOR Foundation has permission to erect . ..................... bui Ings on .. . ...... Rough to be occupied as ...... .........p® .. ...................................................................................................... Chimney provided that the person accepng 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 Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MO THS 9S TT ELECTRICAL INSPECTOR SS Rough Service ......... ......... ..... ... ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin Rough Display in a Conspicuous Place on the Premises — ®o Not Remove Final No Lathing or Dry Wall To Be ®one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. MA Lic.#171618Mft Aft Nib Tel:(978)758-7641 Lic.Builder CS#075904 PiculMOSAL 75 Allen Road SE AN T. C 0' LLI NS Billerica,MA 01821 ROOFING & CONSTRUCTION Proposal submitted to Adrian Dawson Phone Date 7/9115 . . :: Street Re(By 123 Bonny Lane city,Stole and Zip code lob Location North Andover, MA, 01845 Architect Date of Plans Job Phone —Cover all walls and grounds with tarps.Strip the entire roof and remove all debris. —Remove gutters,apply coverage,and re-instali gutters. —Replace up to six sheets of plywood if needed,note:(20 ft of trim included),then check insulation. Replace lead flashing at chimney,and then apply"GRACE"ice and water shield to bottom six feet of roof and entire rear shed dormer. Rear shed dormer to recieve continuous vinyl intake venting,apply synthetic underlayment to remaining areas and then apply white 8"drip edge to perimeter. —Apply lifetime shingles:color to match exisiting,and install ridge vent at peak. —Re-flash all obstructions,use new pipe flanges,and magnetize ground for nails. —All work guaranteed ten years,insurance certificate and building permit included. Any materials purchased by homeowner will be deducted frrom total price below. Half labor cost due upon 50%completion. We propose hereby to furnish material&labor-complete in accordance with above specifications for the sum of: Fifteen Thousand, Four Hundred dollars dollars 015,400 Payment to be made as follows: Terms to be discussed. NI work is guaranteed to he as specified.M work to he completed in a erorkmanlike manner according to standard Authorized Signature practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon wriaen orders,and will become an extra charge over and above the estimate. Note:This proposal in withdraw Owner to carry fire,tomudo insurance.Our workers are fully covered by insurance. by us if not accepted in Acceptance of proposal—The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified.Payment will be made as outline above. Date of acceptance: Signature The Commonwealth of Massachusetts Department of. lidustrialAccidents f 1 Congress Street,Suite 100 .' Boston,MA. 02114-2017 www mass,gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): - `c= 3 (. City/Mate/Zip: " Phone . Are you an employer?Checkf6e appropriate box: Type of project(required): 1.❑1 am a employer with employees(full and/or part time).* 7. New construction 2, tw-l'6m a sole proprietor or partnership and have no employees working for me in 8. 0 Remo delirig any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.Q I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1-will ❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 11.• proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[woof repairs These sub-contractors have employees and have workers'comp.msurance.1 19 Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no 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. 7 Homeowners who submit ibis affidavit indicating they are doing all work and then hire outside contractors must s4bmit anew 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-c6n1rac{6rs have employees,they most provide their workers'comp.policy number. I am an employer that isprovidingworkers'compensation insurance for my employees.'.Below is thepolicy andjob site ti o in rmaon. .� Insurance Company Mame: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: z c i City/State/Zip: aexpiration erts Attach a copy of the workers' compensation policy declaration page(showing the policy number and expir ation 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 WORTS 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. e above is true and correct. y 1Y p p• w�. Ido liei'e/i certify det:.tlze ains and enalties o exyuzy Haat the infoz^nzatioDate:vide Y W � S1 nature: :� Phone#: Official use only. Do not 1vrite in this area,to he completed by city or town official._ City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Towyn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ® D IDD/Y CERTIFICATE LIABILITY INSURANCE 7/22/2015 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: Scott Leavitt, CIC, LIA MTMBrainerd Inc PHONE . (978)667-9031 AX. No:(978)667-1018 lA Andover Road E-MAIL ADDRESS:scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC# Billerica MA 01821 INSURERA:Safety Insurance Company 39454 INSURED INSURER B: Sean T Collins INSURERC: 75 Allen Road INSURER D: INSURER E: Billerica MA 01821 INSURER F COVERAGES CERTIFICATE NLIMBERMaster GL 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 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DDnYYY MWEFF DD/YYYY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE OCCUR MA0022049 /14/2015 /14/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ Included GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Included X POLICY PRO- LOC $ AUTOMOBILE LIABILITY '.. COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PeOPERT nt DAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION ORSTIMITATU ER AND EMPLOYERS'LIABILITY Y/N L ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION mdeems@ townofnorthandover. 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 Bldg 20 Suite 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 S Leavitt, CIC, LIA/S ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 igninnm M Tho A(t(1Rrl nam.and Innn aro ronictororl mnrkc of A(t(1Rr) 1 �.. r0ass,achusetts -Deparfinent of Public SafletY oa.rd of Building Regulatic;ns and standard I Cu ','tructio ll superr'i or License. CS-075904 u j Sean T Collin 75 Allen Road = I Billerica MA 0181 �' J f! "Xpi lnda i 09/23/2015 commissioner ;'fic of Consume) Mr-1MPROUEh1FNT C, gistratlpn 171618 t zp�at[on 412/2 1 ividual. 04,tbLUNS ,, � If A LEN RID <l 11..RICA,MA 01821 17itcsecretai ,'%�