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HomeMy WebLinkAboutBuilding Permit # 9/21/2015 ................................... BUILDING PERMIT0JILED t%ORTH6' TOWN OF NORTH ANDOVER §01. 6 APPLICATION FOR PLAN EXAMINATION Permit No#- Date Received A �pssgc�ous`�4�� Date is Issued: 4 n ORTANT: Applicant must complete all items on this page LOCATION &4?44' & 70. :. Print PROPERTY OWNER— eel I'l 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 I�-One family [I Addition D Two or more family 11 Industrial ?Alteration No. of units: 11 Commercial 11 Repair, replacement ri Assessory Bldg El Others: Li Demolition El Other 11 Septic FJ Well [I Floodplain 1:1 Wetlands [I Watershed District El Water/Sewer DESCRIPTION OF WO r TO BE PERFORMSrl: 1z 15) 14 lee" U �Identlficv I 6 z. OWNER: Name: Location 02 No. Date Address: Contractor Name: TOWN OF NORTH ANDOVER Email: Address: C'r�A Certificate of Occupancy $ Supervisor's ConstructionBuilding/Frame Permit Fe Licen e Foundation Permit Fee Home Improvement License: Other Permit Fee TOTAL ARCHITECT/ENGINEER Address: Check# FEE SCHEDULE:BULDING PERMIT.•$12j Building Inspector Total Project Cost: $ Check No.: Receipt No.: 07"-!J —.1z NOTE: Persons contacting with unregistered contractors do not have access . guaranty fund to Signature of Agent/OwnerZj�l �ignature of contractor :X 111k— cz FORTH Town of nclover No. - 0O LANE h Ver, 6.®.ss9 r2...6115 COC KI CMEWICK S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ......... ...... . 4 ........ .1. .. BUILDING INSPECTOR 4'... .............................. ... ......... y� 1 Foundation has permission to erect ... ..................... buildings on ......t.5 . B '..... .:�. ......!...1 !. ...... .........>..... 1 - Rough to be occupied as ......... ..... ........ .. .[..,. ....... ........... ......1 .......� ....................... Chimney provided that the person accepti g this permit sha n every respect conform to the terms 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 ITEXPIRES IS ELECTRICAL INSPECTOR LESS CONSTRUC S Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy BuiidinRough Display in a Conspicuous Place on1AT the Premises — Do Not Remove Final No Lathing orDry Wall 1 o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Pagel of, pees —propoal PROPOSAL SUBMITTED TO; JOB NAME JOB ik ADDRESS JOB LOCATION DATE DATE OF PLANS PHONE# FAX# JARCHITECT e hereby submit speDifinatfiDns and estimates for; 14, Y� e propose hereby to furnish material and labor--complete in accordance with the above specifications for the sum of, __Dollars with payments to be made as follows: Any alteration or deviation from above speclflcatfons involving extra costs Respectfully "'ll Will be executed only upon written carver,and will become an extra charge submitted,, ����f � � � over and above the estimate. All agreements contmnent,a pon stokes, accidents,or delays beypnd our control Note this proposal may be withdrawn by os if not accepted within j Zirreptance The above prices,specifications and conditions are satisfactory and are thereby accepted. You are authorized to do the work as specified. � Yg Payments will be made as outlined above. ignatuc Date of Acceptance Signature A-W3419/T4ee0 09.17 A 91 i The Commonwealth of Massachusetts Department oflndustrialAccidents " a d 1 Congress Street,Suite 100 Boston,MA 02114-2017 sv.y`�t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl i Name(Business/Organization/Individual): 5 r 1✓-57 �G vel Address: ( C(gin C 'f 4 6 vim' lmEtrCity/State/Zip: Phone#: 9 ?P ��6 ` ._� el-5- Are e you an employer?Check the appropriate box: Type of project(required): 1.❑1 am a employer with employees(fall and/or part-time).* 7. ❑New construction 2.04 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑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 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL G. 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit'this affidavit indicating they are doing all work and then 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 must provide their workers'comp.policy number. I am an employer that is providing workers'compensatioiz insurance for my employees.'Below is the policy and joh site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 11 t, �d'1 City/State/Zip: 1411dmf Attach a copy of the workers'compensation policy declaration page(showing the policy number and expi a ion 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 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. Ido herehy certify under the,pains and penalties of pezjuzy that the information provided ahove is true and correct. n Signature: Date: l Phone#: Official use only. Do not write in this area,to he completed by city of 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 9/22/2015 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 Ste hanie Morrissette NAME: p MTM Insurance Associates aHc°NNo Ext); (978)681-5700 (FAC X,No: (978)681-5777 1320 Osgood Street AIL ADDRESS:stephaniem@mtminsure.com INSURERS AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURERA:Travelers Casualty Ins Co of 19046 INSURED INSURER B: John Morrissey INSURER C: 57 Concord St INSURER D: INSURER E: North Andover MA 01845 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 ADDLITYPE OF INSURANCE INSD WVQ SUER POLICY NUMBER POLICY EFF MMIDDnYYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED300,000 PREMISES Ea occurrence $ 6802D8957331542 6/18/2015 6/18/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 M'OTHER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑ PRO JECT ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 PRO- A101 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED pROPERTYt DAMAGE $ HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ '.. DED I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STERATUTE EERH ANY PROPRIETOR/PARTNER/EXECUTIVE NIA (Mandatory 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 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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 Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE P MacDonald CPCU, CIC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 1901401 Massachusetts Department of Public Safety Board of Building Regulations and Standards Construction SuperN icor License: CS-105236 "~ JOHN MORRISSFt'I' 4 2 57 CONCORD S'I= NORTH ANDOVER MA',i 01845 Expiration Commissioner 11/26/2015 --71, I.,pt lit r�rrrr�.rr�/� r� Regulation Office of Consumer Affairs&Business RACTOR Type: (HOME IMPROVEMENT CONT Registration: 169543 DBA P1 Expiration: 71512017 JOHN MORRISSEY REMODELING'. JOHN MORRISSEY 57 CONCORD ST MA o1s45 Undersecretary NORTH ANDOVER, b Sachusett3 -1Je Searcy or s ilciinr Repartnient of`'itL�t;y S- e$ . Const' gcrI,a ions .t lacrion S t Si4andargs License: aPcn.i.srir CS-105236 JORNMoRRIss57 coN NORC SfANDO TH " ARCom r777SsiO n e r _ Ni attpn 11/262015 Office of Consu a�a�azd'a`Qa//X 041E iryip mer Affairs&Bus'incss o Registration,OVEMENT CONT regulation 169543 RACTOR Expiration 7/5/201:7- TYpe: JOHN MORRISSEY ELIN_GDBA DSA REM_ JOHN MORRiSSEY= 57 CONCORD S7- NORTH TNORTH ANDOVER, MA 01845 Undersecretary