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HomeMy WebLinkAboutBuilding Permit # 8/31/2015 BUILDING PERMIT of �aoRrH qpp .1LED 16 'Y TOWN OF NORTH DOVE �� � '` `46 o APPLICATION FOR PLAN EXAMINATION Permit No#: ! Date Received 7RADRATED PPRy�S �SSHC Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION : "Y Print ( a PROPERTY OWNER W JdA-vi i-AL a ( ll Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 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 11Other ❑ ... � ❑Well ❑ Floodplain. ❑Wetlands ❑ W dDsnct tershe DESCRIPTION OF WK TO BE PERFORMED: w -� O C O M A - t i M Identift ation- Please Type or Print Clearly OWNER: Name: (1 �`�, 5 s Yti� Phone. i Address: Contractor Name: Phone:- a 4 ZI Email: Address: 1�A A Supervisor's Construction License: 4. Exp. Date: Home Improvement License: Is i 1- 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: $ ' �/ FEE: $ Check No.: �� Receipt No.: 6 NOTE: Persons contracting with unregistered contractors do not have access t he g i Canty fund AM t4ORT H m'ftd T_E. ®ver ® INoo ® �O LANE y ver, ass, •Q COCNIC MI WICK041 U BOARD OF HEALTH Food/Kitchen PERM� � 11 T LU Septic System THIS CERTIFIES THAT ...,-::5 e--"V"C 5.���"f ••••••.•••.•••..................... BUILDING INSPECTOR .......�Iel ............. ............................................ has permission to erect .......................... buildings on �-� eQ Foundation /V ...................................7....................................... Rough to be occupied as ....A4,fflaa.V....��,... „?............................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMITI IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S TS Rough Service UILDING INSPECTOR. Final GAS INSPECTOR ccupancy Permit Required to Occupy Buildinz 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. COASTAL REMO®EL1N ^ Page No. of Pages Jim Jawoirsm 70 Main Street Remodelinir Proposal Groveland, MA 018 4 . i`; .„ ' CONTRACTOR LICENSE NO. JOB PHONE NO. 1,36, t (978) 372-9862 ` JOB NAME/NO: Submitted To: _. .. _ ---------- ..... ...............___.............. . JOB LOCATION e }} r b .. t .......... .........__ ----- `� .......... `....%.`.. ARCHITECT DATE OF PLA S i.>`�,�'�� o. Y Liar�,n� ��.,'i ,� ��.^,) •�� ""fit ^'.,�1� ,, PHO DATE APPROXIMATE ARTING DATE APPROXI ATE COMPLETION DATE iC' f� t r�.4C• L ' We hereby submit specifications and estimates for r } S'.._._ SIC.'_,_°_�' . ... t__ ..'Tie ./..__.�:tT_ 4i1 > .._. �_lc;,"' _ .C" 11, IV T p_u _0V 4 -C r P j a ...........4z _.�.......... _..�....�_�`�.( f .. 4: "il ?. .. ....1.-1.c.-:4..<_..__�cr_yj .. A.bi' .. €�3 ..,� .___.-------­--­-_.--..- �J1�1T.��`L'� i t ( I,,. ), +.�V�.Y 1 t 1 Gtr 1,.-. xa e...._.___.__.__..__ .. ........ .. _ ........._........ ......._. ___...._..._ --_.._.. �....._._............-__ .__.. _ Y t l4 t } £ .............-. __ __ ._ ._... ....__. _.._. _.........__._.....__._........... —ZZ fir .w` This,�roposal does not include } r }} (�� 5..x,1 _ y � r TIL `d �� U>1'� " , f, oto P91l 1. ti 51� f� �� �t� 1 . .. .._ .._. _ _.. �.� _ . q , �.)T� �J) All material is guaranteed to be as specified.All work to be com- pleted in a workmanlike manner according to standard practices. We Propose hereby to furnish material and labor-complete in accordance with Any alteration or deviation from the above specifications involving above specifications,for the sum of: extra costs will be done only upon a written change order.The costs will become an extra charge over and above the estimate.IhiLis to include butts not limited to hidden damages that are uncovered unng the course of jhe fob anii'addidonai,work requ`ire,ilby cal' build(n Ins ec ors t� All elements of this agreement are contingent upon strikes,accidents d0118CS($ r Paymerit to be made as follows or delays beyond our control.The estimate does not include material price increases,or addRional.labor and materials which may be required should unforeseen problems arise after the work has started. T You,the buyer,may cancel this transaction, at any time prior to midnight of the third '. business day after the date of this trans- action.Cancellation must be done in vomiting. E t,J f !VV may be withdrawn Y A by us it not accepted within �� days. Authorized Signature Acceptance of Proposal: The above prices,specifications and conditiens re satisfactory and are hereby accepted.You are aut orized to do the work as``specified.Pay1I1(Tt ntbe mad as ' e abov . Date Si nature ( ( �/ / Signature�=-.-�;t., -'G-°� ` � � � 7 g ���� Date � l f Page No. of Pages ellre .. end MA 02 �+ _ ,cRemodelfing Propos, v CONTRACTOR LICENSE NO. JOB PHONE NO (978) 372- 2 � �� �� -' JOB NAME!NO. Submitted ..._ , To __ JOB LOCATION ,.w �w81 B - r, ARCHITECT r DATE OF Pt 15 4 y a x �s $, PHONE DA i t � E APPROXIMATE STARTING DATE APPROXIS TEGOMPLETI , ry 99 yy jiY�y ON DATE ai,a 1,�l„Jy 1✓' �'�. ..1k fr9a. t �,�F„yp W t b 1mBapactftgations and estlma��for Vf�ii Y1dt 1! �i 1 4, is E"v LIC. L IL , {lw3yC414a3, Y ! ( ) y �li } f f �} f W kiwi ®�arab aTw ,7 PIyC QAU_'01-1 pia 6 f � t__ This Proposal rice s not include AOV 1- .E M1 1 ��� .J£L C 1'11 r w.m�., ,,�J8e.ik,J,� Yom°v'T•�1� '`✓F}'� s�' �,n k t”h�.7 1 .�E 'C..,F�.�`*'���w1 a � �� All material to guaranteed to be as specified.AD work to be eom- we Pro plated in a workmanlike manner according to standard practices. PM hereby to furnish material and tabor complete in accordance with Any alteration or deviation from the above specifications involving above Specifications,for the sum of: extra costs will be done only upon a written change order.The costs Will ^ ry 11', n�eacoume�raoaom charge overand above and f nal o,rkM estimate.u red b�,,,,, - Ail elements of this agreement are contingent upon strikes,accidents dollarsk .1 t-, ), or delays beyond our control,The esfimste does not include material Payment to be made as follows: P increases.or additional labor and materiels which may be r equlred should unforeseen problems alae after the work has started. A } � } r You,the buyer,may canthi this transaction , at any time prior to midnight of the third r r ' E a_1 ,,E business day lifter the date of this trans- action. ranceaction.Cancellation must bedonein Writing. Notm This proposai may be withdrawn f� =ad Sigttature by us it rwt accepted within day. Alccep►tanft Of PrOP0881: The above prices,specifications and conditions are satry an re hereby accepted.You are �C\\J authorize .#o do the work as specified,Pay fit `ll be mad 1 I edaab e. SignaWre ( 7 �r k / l / !. c. Date ( S4_tu r Date / 1, The Commonwealth of Massa.chusetfs .' Department oflndustrialAccidents W . : .d 1 Congress Street,Suite 100 Poston,MA.02114-2017 www.mass.go-p1dia Wovkers,Compensation insurance Affidavit:Builders/Contractors[Riectricians/Plumbers. TO BE F LED VffTH THE PERMUTING AUTHORITY- Applicant Information Pl se Print Le 'bl Name(Business/Oxganization/Tndividual): ' Ymt .Address: city/state/zip: (� _ 1► ��4 64 Phone#: q7� 3 ) Are yon an employer?Checkt&appropriate box: Type of project()required): 1.0 1 am a employerwith C. : employees(fulland/orpart time)." 7. ❑Now construction 2.tAl ama sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling 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 10F]Building addition 4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole l l.C1 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and 1 have hired the sub-contractors listed oa the attached sheet. 13.0 Roof rep airs Thew sub-contractorshaVe employees andhaveworkers'comp.msurance.� ' � 14.[]Other 6.Q We are a corporation and ifs officers have exercised their right of exemption perMGL c. 152,§1(4),and we have na.employees.[No workers'comp.insurance required.] r: *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 andthen hire outside contractors must submit anew affidavit indicating such. YContractors 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 providetheir workeis'comp.policy number. am an employer that is p/'dviding workrs'compensation insurance for my employees'Below is the policy and job site information. Insurance Company Name: Policy#or Self ins.Lie.#: Expiration Date: Sob Site Address: City/State/Zip: Attach a copy of the workers' compensation•policy declaration page(showing the policy number and expiration(late). 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 WORD 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 to ains a penalties ofpesjury that the information provided/above is true and correct. Si nature: Date: Ao 1 Phone Jk 423 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#: ATE �'� CERTIFICATE OF LIABILITY INSURANCE D/17/IDD/Y5 7/17/2015 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(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 CONTACT NAME: Victoria Lowes CISR MTM Insurance of Greater Haverhill Inc. PHONE (978)3]2_1229 AIC No:(978)372-1334 229 South Main Street E-MAIL Dss:vickiel@mtminsure.com D INSURERS AFFORDING COVERAGE NAIC# Bradford MA 01835 INSURERA:Safety Insurance INSURED INSURER B: James Jaworski, DBA: Costal Remodeling INSURER C: 70 Main Street INSURER D: INSURER E: Groveland MA 01834 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 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 ADD SBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE ❑X OCCUR BMA0021707 /8/2015 /8/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ X POLICYF_J JECT —1 PRO LOC $ AUTOMOBILE LIABILITY EO aBcciden SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ 250000 A ALL OWNED F,__1 SCHEDULED 6212962 /15/2015 /15/2016 BODILY INJURY(Per accident) $ 500000 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident 100000 Underinsured motodst property $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNER/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/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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ron & Joanne Smith ACCORDANCE WITH THE POLICY PROVISIONS. 42 Vest Way North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Mike Traverso/SAMANT ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025/7olon5i m Tho Anopn name and Innn aro roniatororl marlrc of Arnpn Massachusetts-Department of Public Safety Board of Building Regulations and Standards C(�jj%tj-UCtion Supixiisor I &2 Famib- License: CSFA-045856 James Jaworsld 70 Main Street Groveland MA OW41 oA Expiratior 12MV201( Commissioner ......... ........ ce— N, I Office of consumer Affairs&Business Regulation MEIMPROVEMENT CONTRACTOR Type: ' egistration: f94234 Kpiration: 512612016 DBA COASTAL REMODELING r ";04 JAMES jAWORSKI % 70 MAIN ST GROVELAND,MA 01834 Undersecretary