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HomeMy WebLinkAboutBuilding Permit # 9/16/2015 t%0RTaj BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: � - °r Date ReceivedOOAc- UsER�� Date Issued: 1VIPORTANT: Applicant must complete all items on this page 6' LOCATION Pri PROPEY OWNER IIt1 Print 100 YeanStructure yes MAPu 7 PARCEL: � ZONING DISTRICT: Historic District ye InMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 11Repair, replacement [IAssessory Bldg ❑ Others: ) Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain FJ Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please'Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: ki(AAEL R 1 c c.,Kj Phone: C)'s Email: ✓'V1►64g: eo 14464 W vv\ Address: v4J a VA L r's Construction License: CS - `7 Exp. Date:rovement Licenser Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING P RMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ " �°... .. Check No. e� _Receipt No. 1®TO I E: Persons contrcecting with unregistered contractors do not have access to tl g Jmy and Signature of Agent/Owner Signature of contractor r-11111171 Ara t%®RTH i own ot It '.A'. Andover 0% ® f -A I h tiAK. h ver, Mass, • coc"Ic"twicK AOOATED J"P�`��5 S U BOARD OF HEALTH Food/Kitchen PE R T IF L D Septic System THIS CERTIFIES THAT .......... BUILDING INSPECTOR .. . . .. .. .. ...... .. . has permission to erect ........ buildings on ....... CIO— Os. . Foundation ................. ...... . ..... . .. .... ..... . ... . Rough to be occupied as .......... • .. ... Chimney provided that the person accepting this permit shall In every eSpec 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 MONTHSPERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR UNLESS CONSTRUCT T Rough TL� Service ® .............. ..... ................... ..... BUILDING. N�ECTOR Final " GAS INSPECTOR Occupancy Permit Required t® Occupy 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Afa_ssgchusetis . Department oflndlustrialAccidents 2 _ 1 Congress Street,Suite 100 _Boston,MA 02114.2017 rya. www mass.go vMid sy. workers'compensation Insurance Affidavit:Builders/Conn:actors/EXectricians/J lumbers. TO BE MED WITH THE PERMT: ENTG AUTHORITY. Applicant Information Please Print_Legibly Name(Bixsiness/Oxganization&dividual):��, y�I�II E jUI LS —T—A Y1 Address: --30 t o4NK�F: City/Mate/Zip: Phone 4: !�l�7W— !R 3`2 —7. Are you an employer?Checkthe appropriate box: Type of project(gquired): 1.AIamaemployerwith5;• employees(fulland/orparttime).x 7. ❑Now. construction 2.Q I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 1 Q I am a homeowner doing all work myself[No workers'comp.insurance zequired.]t 10F]BuildIng addition 4.[:]f am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors wither have workers'compensation insurance or are sole t 1.❑Electrical repairs or additions proprietors with no employees. 1i❑Plumbing repairs or additions 5.Q 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.insurauca.T 6.❑We are a corporation and its officers have exereisedtheir right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] I-Any applicant that cheeks box4l must also fill out the section below showingtheir workers'compensation policy information. i Homeowners who submit this affidavit 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. If the sub-contractors have employees,they crust provide their workers'comp.policy number. -1 am an employer that ispr'ovidingworkers'compensation insuranceformy employees.' 3elory is thepolley andjob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: ExpirationDate: Job Site Address:_ CJ�i1 City/State/Zip:LY l�tlJ Attaeb.a copy of the wor It ers'compepsation-policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under MGL o.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 for insurance Coverage verification. X do/iereby cert u er th a' a p aloes ofpeiYwy that the information provided above is true and correct. Si nature: Date: l Phone# U� � —U 4`6N, Official use only. Do notWritein 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#: �p PERFBUI-01 CLEDDUKE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)9/16/2015 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: Kelly Estano,AAI,CISR Rogers&Gray Insurance Agency,Inc. PHONE FAx (877)816-2156 434 Rte 134 AIC No Ext): AIC,No South Dennis,MA 02660 E-MAIL SS:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance Company INSURED INSURER B:Arbella Protection Performance Building Company,Inc. INSURER C:Navigators Insurance Company 50 Tanner Street INSURER D:National Liability&Fire Insurance Company Lowell,MA 01852-4419 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 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �X CBP8051843 07/03/2015 07/03/2016 DAMAGE RE 100 000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ X XCU Included MED EXP(Any one person) $ 5,000 X Contractual Liab PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑ PRO- E LOC PRODUCTS-COM P/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000 000 Ea accident B ANY AUTO 1020004067 07/03/2015 07/03/2016 BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Pera.,denl $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAB CLAIMS-MADE NY15EXC7310221V 07/03/2015 07/03/2016 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN D ANY PROPRIETOR/PARTNERIEXECUTIVE V9WC651428 07/06/2015 07/06/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 A Leased Rented Equip CBP8051843 07/03/2015 07/03/2016 200,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of No.Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow TowOsgood Street ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ��C ((.o)x7Nn1(ronall�o/C�/��rrJJrrc�rlJcllJ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only SOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 161993 Typo: Office of Consumer Affairs and Business Regulation Expiration;,:::'i2122/20.16 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 PERFORMANCE BUILDING CCT_INC. JAMES MCCLUCHY; 50 TANNER ST j LOWELL,MA 01852 14A j. 5C Undersecretary Not valid wiciVout si ature • d r i . } X u R 19assacius s , �r r�n}o Vatic^.s ci Const"c"n sty Or varus License: C'S-077847 AUC'HAEL F BRIT` t 8 FERN ON , STREET cm LMSFORD r6iA O82Q - COI7 m's';ioner r_X10iraf Or I 06/29/2016