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HomeMy WebLinkAboutBuilding Permit # 9/8/2015 BUILDING PERMIT 0.1 t%ORTH q TOWN OF NORTH ANDOVER .;6 APPLICATION FOR PLAN EXAMINATION o x Permit No#: %'' Date Received q 01PAo 7' RATED PP 'jy cHus�`� Date Issued: IWORTANT: Applicant must complete all items on this page LOCATION t `!fi 9 61919� Print PROPERTY OWNER Print 100 Year Structure yes MAP PARC ING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11,Addition id-Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial yi-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed Distract DESCRIPTION OF WORK TO BE PERFORMED: I � -42,McASIA S 114 Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: 9 u)06 d ws� kt J,� Contractor Name: gni► Phone: l Email: Address: ® o Supervisor's Construction License: f7 Exp. Date: Home Improvement License: I ` 917 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: $ a� FEE: $ Check No.: 16, Receipt No.: T � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fun ' Ago FORTH - Al% daw -re," i own at mi V I • 0796 P r r, O LA1lE ver, Mass, COCHIC ME WICK a' A0*',�'M1TED V BOARD OF HEALTH PERIV = T T LD Food/Kitchen Septic System THIS CERTIFIES THAT ............................ . ...... .............................................................. ......... BUILDING INSPECTOR ... Foundation has permission to erect . ...................... buildings on ...... ........ bew&.....4(.!;*!.... ! hok &A Rough tobe occupied as ....... .. . . . . . ..... ......... ......... ............................................................. Chimney 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 Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final ERMIT EXPIRESl T ELECTRICAL INSPECTOR UNLESS CONSTRUCT S S Rough y Service ........... ...1 ...... ..................................................... 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 r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. _ Tran Fully Insured MA License #143543 617-794-0797 CS: 096170 Fully licenses &Insured 64 Robertson St. _ Call for estimates & - *>� �t Quincy MA.02169 �.: -��- -' Ideas Cori: t-na tio.u- LLC Date: Owner names: Contact information: Address: kJ I Work site address: Lam - IN v Scope of Work: -' VV 1c, CA V26A A IF GiA6 r1 11 da-_ Y 1 C�. NOTE: All workmanship is under warranty for 1 year. We propose herebyto r ish maul and labor-complete in accordance with above specifications,for the saran of $: Payment Schedule: I. Deposit for ordering material $ II. Start work $ 20 III. After completion of 1 week $ IV. After completion of work $ 4 i. TOTAL $ All material is guaranteed to be as specified.All workle Ompleted in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written order,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Authorized Signature: or ___ _ _ Note:This proposal may be withdrawn by us if not accepted within_7 days. Acceptance of Contract.The above prices,specifications and conditions are satisfactory and hereby accepted. You are authorized to doF,7;� irkspecified.Payment will be made as outlined above. Date of Contract: .�— Signature , A Signature the Cor monwearth of.Mass�chuseis .Depart tent ofindus, d Aeddlents _ 1 Congress Sheet,Suite 100 M. `d ' Boston,MA.0.2114.2017 www.masssgo-p1dia Workers'Compensation Insurance Affidavit:Sunders/ContzactorslElectricians/Plix hers. TO BE MED WITS THE PEI2MLTT NG AUTROR[TY. Aplplicantlnformation Please Print Lebly Name(Stisiness/Oxganization/lndividual): qm .A.ddxess: W-P U `r 14 City/State/Zip: G� Phone 17 ^7 9 c/- 07 9 7. Are you an employer?Cheek the appxopriatebox. Type o£project()required): L. Ul am a employerwitfi employees(fullandlorpart time)x 7. NeW construction 2.01 am a sole proprietor or partnership and have no employees working forme in &. Remodelhig any capacity.(No workers'comp.insurance required.] 9. El Demolition 3..[]!am.ahomeowner doing all workmyself [No workers'comp,insurance required.]t 10 Q 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 11.[]Electrical repairs or additions proprietors with no employees. 12_❑Plumbing repairs or additions 5.❑I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13.C]Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 14. Other 6.❑We area corporation and its officers have exercised their right of exemption perMGL c. [] 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showingtheirworkers'compensation policy information. 7 Homeowners who submit#his afftdavit indicating they are doing all work andthen 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. Tf the sub-contractors have employees,they must provide their workers'comp.policy number.' $am an employer t7iatispi'oviding-workers'compensation insurance for my employees'Beloiv is thepolicy and job site information. /� Insurance Company Name: l VW Policy#or Self-ins,Lic.#: _F, Expiration Date: Job Site Address: X' -'-r_V 6U U--111�L ko City/State/Zip: Attach a copy of the WOY]Kers'coznpensation-policy declaration page(showing the policy number and expiration elate). 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 WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA fox insurance coverage verification. f do hereby cert der pains an pen hies ofpeijuiy that the information provided above is true and correct. signature, Date: VT/ Phone Official use only. Do not sprite in this area,to be completed by city or town official.. City or Town.: Pernilt/License# Issuing Authority(circle one): 1.Board of Health 2.$uildingDepartm.ent 3. City/Town Clerk 4.Electrical Xnspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: TAMTR-2 OP ID:JG CERTIFICATE OF LIABILITY INSURANCE F DATE(0/222/12/1MYYY) 14 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). CONTACT PRODUCER 978-975-1300 NAME: Segreve&Hall Insur.Assoc.lnc 978975-7596 PHONE - FAX 305 North Main St. A/c No Ext: A/c No): Andover,MA 01810 E-MAIL Patrick D.Hall ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Co. 34754 INSURED Tam Tran INSURER B:AEIC 11104 64 Robertson Street Quincy, MA 02169-1217 INSURER C 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. INSR I kDDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A COMMERCIAL GENERAL LIABILITY BGKDXT 09/11/14 09/11/15 PREMISES Ea occurrence $ 100,000 CLAIMS-MADE 1-1 OCCUR 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 $ 2,000,000 POLICY PRO- LOC $ JECTAUTOMOBILE LIABILITY (CEO, SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PeOaaciR'Ztj AGE $ HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE r---Y/N TBI 09/11/14 09/11/15 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? IY N/A -- (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 1 7 . ___-L DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE .DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD cJlze on�nzoozulea�l a P/��:taac zccoeGt-` -- _Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ({DOME IMPROVEMENT CONTRACTOR before the,expiration date. If found return to: — tegistration 878976 Ty!e: Office of Consumer Affairs and Business Regulation -� ,expiration: 616/201:6 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 TRAN CORNER STONE GENERAL CONTRACTOR TAM TRAN 64 ROBERTSON ST QUINCY, MA 02169 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards. Construction Super isor License: CS-096170 r.t +� Tan V Tran 64 Roberton Street Quincy MA 02169 Expiration Commissioner 05/05/2016