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Home My WebLink AboutBuilding Permit # 9/14/2015 FORTH BUILDING PERMIT TOWN OF NORTH ANDOVER ® APPLICATION FOR PLAN EXAMINATION ' p Permit No#: ' m4 l Date Received ACA ( 14 Date Issued; � � ;�'. IMPORTANT: Applicant must complete all items on this page LOCATIONV~)M71LL,0---P ' Pri t PROPERTY OWNER Pri t 100 Year Structure yes CnoMAP 2 PARCEL: 0/9 ZONING DISTRICT: Historic District yesMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resi ial Non- Residential ❑ New Building L/One family ❑Ad ition ❑ Two or more family ❑ Industrial ❑Xteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic Well ❑ Floodplain ❑Wetlands [ Watershed Distract r ❑,WaterlSewer, DESCRIP OF WO TOB RFO Att.mication ase ype or Print Clearly OWNER: Name: Phone: Address: f r C�' Contractor Name: � Phone: Email Address: K��DvYli Supervisor's Construction License: ct/ Exp. Date: - -71&-,A� Home Improvement License: 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.: NOTE: Persons contracting with unregistered contractors do not have access th gu anty fund - - - - 1 tkORTH To' wn oll ndover ® - "i" ' 0 ® e ®® 4 2A _- o h ver, Ma coc NIc MCWIc.t S U BOARD OF HEALTH Food/Kitchen PERMI I I LD Septic System THIS CERTIFIES_THAT ....%AkOt. , BUILDING INSPECTOR .. ............ ..................................... .. Foundation has permission to erect .......................... buildings on ....110..... ... .414+. ........................ ® ................................................... Rough to be 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. �+ Final PERMIT EXPIRES 6 ® S ELECTRICAL INSPECTOR LES T C 1 R Rough Service ........ .......................................................... Final BUILDING INSPECTOR GAS INSPECTOR ccupan&y Permit Required to OccupV 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 Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth OfAfass�chuse is _ . .Department of IndlusttrialAccidents Z Congress Street,Suite 100 4 -Boston,MA.0.21. 4.2017 www.mass.go v/dza 'Workers'Compensation Nsurance Affidavit:Builders/Cont:actors/EXgetricians/pZumToers. TO BE MED STH TBE PERM(TTI G AUTHOPJTY- Applicaut.Information Please Print Ledbly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: C % A,reyott an mployer?Checkthe appropriate box: Type of project()'squired): 1. I aur a employerwith-employees(full and/or part time).* 7. FJ Now construction 2,L]I am a sole proprietor or partnership and have no ernployees Working for me in 8. [1 Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 1❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 F1 Building addition 4_E]I 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 If.Q Electrics p airs or additions proprietors with no employees. 12,❑20pof mg repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. repairs These sub-contractors have employees and have workers'comp.insruauce. 6.Q We are a corporation and its officers have exercised their right of exemption perMGL c. 14.El Other 152,§1(4),and we have no.employees.[No workers'comp.insurance mquired.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. TI Homeowners who subniif this affidavit indicating they are doing all work andthea 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 fiavo employees,they rimst provide their workeis'comp.policy number. $am an employer that ispi'oviding workers'compensation insurance for my employees-'Below is thepolicy andJoh site information. Insurance Company Name; Policy#or Self ins,Lie.ff: ExpirationDate: Job Site Address: City/State/Zip: v Attach a copy of the workers' coznpensatlon'polxcy declaration p ge(showing the policynumoe a dercJ Jration date . Failure to secure coverage as required under MGL c.152,§25A is a eximinal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the foam 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 for insurance coverage verification. Y do herehy cert under i n dn [ties ofperjury that the informationprovided above is true and correct. Signature: Date: Phone#: OffzciaZ use only. ➢o not write in this area,lobe completed by city or•town official City or Town: Permit/License 9 Issuing Authority(circle one): 1.Board of Health 2.BuildingDepartment 3.City/Town Clerk. 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MCERTIFICATE OF LIABILITY INSURANCE 612512 1,:D"YY) 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), AUTOORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. i IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be en orsed. 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 righ' to the certificate holder in lieu of such endorsement(si. PRODUCER T Eaton& Berube Insurance Agency, Inc. NAME:PHONE Cathyj�eauregard FAX 11 Concord St (A/C,No, -886-4 30 L Nashua NH 03064 ADDREss:cbeaureaard0eatonbFrube.c!)m INSURER(S)AFFORDING COVERAGE MAIC 9 ...INSURER A' h Insurance INSURED AJCPR INSURER e:River ort Insurance Qn=any P AJC Properties LLC INSURER C:MM—G Insurange Co dba AJC Roofing c/o Mark&Shirley Freeman INSURER 0: 11 Daylily Drive INSURER E: Nashua NH 03062 I INSURER F: COVERAGES CERTIFICATE NUMBER:1428287359 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 4VHj6H THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TH51ERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR -11—DOL INS ' LTR TYPE OF INSURANCE R POLICY NUMBER POLICY EFF POLICY EXP (MMMDIYYYY LIMITS IMMIDDIYYYY) A GENERAL LIABILITY AGLOO1113600 14/13/2015 4/13/2016 EACH OCCURRENCE $1,000,000 E X COMMERCIAL GENERAL LIABILITY -0-AwGE TO RFN NE PREMISES lEa occurrence) $100,000 X 500 CLAIMS-MADE FTIOCCUR MED EXP(Any one person) $10.0001 - PERSONAL&ADV INJURY $1.000,600 GENERAL AGGREGATE $2,000000;; L MIT rGENr'L AGGREGATE LIMIT APPLIES PER: 000.0L 0 X POLICY P O_ PRODUCTS-COMP/Op AGG $2. R _12 000.00 i LOG X POLICY El M I C AU OMOBILE LIABILITY KA0113773 6124/2015 6/24/2016 COMBINED-S[NGLE (Ea accident) $1000 000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per acciclant) $ J NONOWNED X HIRED AUTOS AUTOS IsPer accident 7-1 s UMBRELLA LIARI OCCUR EACH OCCURRENCE S EXCESS LIAO -- H CLAIMS MADE AGGREGATE $ DED RETENTIONS $ B WORKERS COMPENSATION WC288300204707 6/2712015 6/27/2016 OTH- AND EMPLOYERS'LIABILITY X 8 ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N TOP I)MIT- OFFICER/MEMBER EXCLUDED? O N/A E.L.EACH ACCIDENT $100,000 (Mandatory In NH) U es,deicrft under E.L.DISEASE-EA EMPLOYEE $100,000' DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101.Additional Remarks Schedule,It more space Is required) ti CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS, C/o AJC Properties LLC 11 Daylily Drive AUTHORIZED REPRESENTATIVE Nashua NH 03062 1988-2010 ACORD—CF0—RPOR.ATION. All rights:iraa6rved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD i Office of Consumer Affairs&Business Regulat on,l r 3 NOME IMPROVEMENT CONTRACTOR Registration: 153131 _-— Type: -Expiration: 10/30/2016 Ltd Liability Corpe AJC PROPERTIES DR. MARK FREEMAN 11 DAYLILY DR. NASHUA,NH 03062 L�ndersecretan t: CS-0961,94 f }1ARK 1'RERi4MAr; 11 DAYC.ILY DgLVE Nashua 03062 07/1412016 r '4