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HomeMy WebLinkAboutBuilding Permit # 8/27/2015 ........... .......................... .......... ......................................................... BUILDING PERMIT t40RT#1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 0 Permit No#: Date Received Date Issued: j(l C US IMPORTANT:Applicant must complete all items on this page / ri / 1 / r r,,rr- , / r 111, / / / r r cif/� i / / �,/ roc D r r TYPE OF IMPROVEMENT PROPOSED USE esi tial Non- Residential L1 New Building One family 11 Addition 11 Two or more family Ll Industrial L1 Alteration No. of units: L1 Commercial L1 Repair, replacement 0 Assessory Bldg L1 Others: 0 Demolition 0 Other -------------------------------------------------------------------------------------------------- DESCRIPTION OF WORK TO BE PERFORMED: Ce L�e OWNER: Name: Identification- Please Type or Print Clearly ::I:h '6qah Rale h Phone: 978-835--,4/q Address: ru � e, r , � / G/ r � r , ,�, / f r yr �,, „r J , �//fir% x , ale�/� / /, / / Home Irn r,i �/ /,��fig �, / / /�/ , ,: Ir,/m(firirla/iClo/� rrr� / ,/ �'{J/ I ,a r,� r//� / it//��//r ,/ / ..f,/ � r ,. 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: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;Signature of Agent/bw-' ner- ign ature of contract%�4� w7vxttt. r-M-9 9111"a tkO }{' i ,own ot RT Andover R T"?, 0 No. 2wb �t - `o L^K6 ha ver, SSS, 51 'Q CoCKICN/'WICK y1. �®A04ATED /kP��.$�j S U BOARD OF HEALTH Food/Kitchen PERM T �T LD Septic System `Q BUILDING INSPECTOR THIS CERTIFIES THAT .............. ..... .......... ...................�•........... ................................................. , 3 ��#4..�C+ Foundation has permission to erect .Ah ........... buildings n`.. . ........�..`......... ............... ............... �A •I`'''�l �41 ft. 5�� Rough to be occupied as ......... ........i ....................'Y............... .... .................. ........ ..... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the applica n 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 I 6 ON ELECTRICAL INSPECTOR LESS C TRC ST 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 Approvedthe Building Inspector® Burner Street No. Smoke Det. 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Guide to the iieate -2d Fra 87 o. c^ L 3'oR can c L_ rG, ro6 +'tcoRanctorla;_- garmntru ano"theiz" Gnfintcovaam;ors;to s n 1>c'nt~ deflf tiisfo. I .fs ccntrct l,.II Ii - I7tifith sh s az 2hdaataQoPyoftl7eConcumer tbtIsine s d s�t2 is%Re m of£)ce yre ou 'o E:2° c2GIC­Iy ordleMi IP �(F: P tbca-. az Y2eIC-g� tar,,- -led u:fid dp 'notify no5c "a, n.I,r o °qY no:Im ;k the --lca mai c U�t t1:t, GF R FOen_bree-7laRnttoR s fJt p^ � .Qdttni=,pto e 'aFit�.b-t�.i-gs:aC;:):s... ��' J1�•-�'Z!F+'.{u?t?�.('7Ri cmeQi:ae;s i.� 'i��' ` �> dtuL-ptb:•tom �retac CQnitaClQl'fiSILMShia' ^�_ Date o'/ The Commonwealth of Mast'Chusetti9 Department of InclustrialAceidents ti X Congress Street,Suite 100 Boston,MA.02114-2017 www mass.gov/diar ' Warkexs'compensationp � insurance Affidavit:E�e �AUTI�ORITYetriciansl.PlumToexs. Please Print Legibly Applicant Information Name(Business/0rganizati0n/Individual):___/��. �G• /yam, W^"""` n �`� Address: City/State/Zip: Phone#: ce Areyou an employer?Checkthe appropriate box: Type of project(xequixed): employer-with em to full and/orp art time)* J. E]New construction 1, am a P Y ees( 20I am a sole proprietor or partnership and have no employees working forme in $• Remodeling 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.]t JOE]Building addition 4•❑I am a homeowner andwill be hiring contractors to conduct all work on my property. Iwill ILEI Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12 Plumbing repairs or additions proprietors withno employees. 5.❑I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. 14.�--1 �Cs F 1 D lJ 6.[]We are a corporation and its officers workescom insurance ir right required]MGL c. 152,§1(4),andwehave no emplay [N P *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit tris affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. ?Contractors that chock this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ees,rliey must provide their workers'comp.policy number. employees. If the sub conlracors Have employ lam an employer tliat ispi'dviding workers'compensation insurance fox my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lie. h Expiration Date:=.�0 q 6 3 S �-2 WL S4- City/State/Zip: /1� do)-4 V4A-_� r' Job Site.Address: Attach a cope ofthe vvoxl�exs' coxnpensation•pohcy declaxatron page(shoyvingthepolicynumbex and 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 penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a and/or one-year imprisonment,as well as civil be forwarded to the office of Investigations of the DIA for insurance day against the violator.A copy of this statement may coverage verification. under thepains andpenalties ofperjury that the informationprovided above is true and correct I do hereby cert . ate: Signature: Phone#: Official use only. Do not write in this area,to he completed by city or town Of Mal 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##: R.ightfaX N2-1 3/10/2015 10: 11 :37 AM PAGE '!/V10 ' "" "••8 -- DATE 03-10.2D15 AC RV® CERTIFICATE ONLY EXTEND OR ALTER THE COPON THE VERAGE THIS CERTIFICATE IS ISSUED AS MOT AFF AFFIRMATIVELY ORNNEGATIVELY CAMEND, �NS7 HUTEUA CONTRACT BETWEEN HOLDER. THIS CERTIFICATE DOES N NOT AFFORDED BY THE POLICIES BELOW- THIS CERTIFICATE R R DUC R,ADOESNHE CERTIFICATE HOLDER. THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER, otic certain policies may require an endorsement A statement on this certificate does 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, not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: FAX PHONE AJC No EASTERN INS GROUP LLC A1C No EXI: 233 W CENTRAL STREET EMAIL NAICH NATICK,MA 01760 INSURERIS)AFFORDING COVERAGE INSURER A:AtdERICAN ZURICH INSURANCE COMPANY INSURER B*- INSURED INSURED INSURER C: - ATLANTIC WEATHERIZATION LLC 61 REAR JEFFERSON AVE INSURER D; SALEM,MA 01970 INSURER E: INSURER F: R 1S1 N = COVE GE CET T U BETO THE INSURED NAMED THIS IS TO CERTIFY THYT ERIODOINDICAO D'N NOTW THSTAND NGELOW ANY REQUIREMENT,MAY EHAVE BEENS SSUED OR MAYITIOPERT OF ANY HIS CERTIFICATE AIN,THE 1 ABOVE FOR THE POLIC CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICM T INSURANCE AFFORDED 8Y ES.LIMIOTS SIHOWN MAY HADVE BEENIN IS SUBJECT To ALL E TERMS, EXCLUSIONS AND REDUCED BY PAID CLAIMS. CONDITIONS OF SUCH POLIC POLICY EFF POLICY EXP UMRS AODL SUB POLICY NUMBER (MM/DOIYYYY MMR)0.rYYYY INSR TYPE OF INSURANCE INSR WVD EACH OCCURRENCE S LTR GENERAL LIABILITY PAPIAGE TO RENTED « $ COMMERCIAL GENERAL LIABILITY MED EXP(Any One Pelson) S CLAIMS.MADE r OCCUR PERSONAL&ADV INJURY S GENERAL AGGREGATE 5 PRODUCTS-COMPIOP AGG 8 GE NL AGGREGAT PLRIOMR APPLIES PER: POLICY PRO LOC OMBI(NED SINGLE LIMIT $ JEr a acadent — AUTOMOBILE UABILnY BODILY INJURY(Per Person) 5 ANY AUTO - BODILY INJURY(Per accident) S ALL OWNED SCHEDULED AUTOS PE Y AMAGE S AUTOS NON-0v'JNED S HIREDAUTOS AUTOS EACH OCCURRENCE S UMBRELLA LIAR OCCUR AGGREGATE S EXCESS UAB CLAIMS-MADE S DED RETENTION$ X WCSTATU- OTH- TORY LIMITS ER WORKERS COMPENSATION CIDENT $500.000 YM AND EMPLOYERS'LIABILITY E.L.EACH AC ANY PROPRIETORIPARTNERlEXECUTIV� OFFICERMlEMBER EXCLUDED? t_.I N 1 A 6ZZU8 03-20-2015 03.20-2016 E.L.DISEASE-EA EMPLOYEE $500,000 (Mandatary in NM 58270121 E.L.DISEASE-POLICY LIMIT $500,000 II yes,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach ACORD 101,Addillonal Remarks Schadule,I more space to required) c Nc Amo CERTIFICA HOLO R SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE TOWN OF NORTH ANDOVER CANCELLED', BEFORE THE EXPIRATION DATE THEREOF, 1600 OSGOOD ST NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE N.ANDOVER,MA 01845 POLICY PROVISIONS. AUTHORIZED REPRESQ'ISATIVE 11'—� D 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ACCORD CERTIFICATE IF3/3/2015 DATE(MMIDDNYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(fes) must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Construction Eastern Insurance Group LLC PHONE (600)333-7234a o: 233 West Central St E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURER Arbella Protection Ins. Co. 41360 INSURED INSURERB.NaUtilu$ Insurance Co Atlantic Weatherization INSURER C: 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 INSURER F. COVERAGES CERTIFICATE NUMBERMSTER 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. ILTR TYPE OF INSURANCE D UBR POLICY NUMBER MM1DDDY/YY MNWD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO E TED PREMISES Ea occurrence $ 50,000 A CLAIMS-MADEOCCUR 9500042816 /20/2015 /20/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 [GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY Ea COMBINED eISINGLE LIMIT(Ea 1,000,000 AHANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 020015871 /20/2015 /20/2016 AUTOS AUTOS BODILY INJURY(Peraccident) $ HIRED AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE AUTOS Per accident S PIP-Basic $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAR CLAIMS IJIADE AGGREGATE $ 1,000,000 DED RETENTIONS 14600058654 /20/2015 /20/2016 S WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N I ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? NIA [E.L.EACH ACCIDENT $ (Mandatory in NH)IF yes,describe under .L.DISEASE-EA EMPLOYE $ 8 RIPTION OF OPERATIONS below .L.DISEASE-POLICY LIMIT 1$ B POLLUTION LIABILITY PL200378613 0/1/20140/1/2015 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION 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 NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE John Koegel/PMA ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. IN.Rn2519n1nnsi m Tha Af`Amn name nnei Innn=pa raniafararl marlee of acnfan Cun"I'LT C'Olt 2 "M. Llcansa: CS-087977 JL'RIC WPAIM 3 H[LTON ST Salem MA 01970- 0412312016 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991M3)of- enclosed 991M3)of- enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Fiorl)PSUcensinginformatlonvisit www.Mass.Gov/DP5 A AP� lir/feanunanraerrllG/nIrtut(rc fnee of Consumer Affairs&Business Regulation Q ME IMPROVEMENT CONTRACTOR istration: 142089 Type* piration: . 3112/2016 Ltd Liability Corpo*',, ATLANTIC WEATHERIZATION L.L.C. ERIC PALM -61R JEFFERSON AVE SALEM,MA 01970 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: OWIce of Consumer Affairs and Business Regulation 10 park Plaza-Suite 5170 Boston,MA 02116 Z Not valid without signature