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HomeMy WebLinkAboutBuilding Permit # 9/28/2015 t%OR BUILDING PERMIT "Fo '� TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received °RnrE°@Pea`�5 �ss�ecHuS�� Date Issued: llql ls�- IMPORTANT: Applicant must complete all items on this page 1 rI� O( ,6 ,/,,,�,„J,f�//`lr.�lf.j1�/.�r,%irl�l..,v.,rIr,l.%,,„ri%i l-/!l�yr,//�.�i.!�/,�1.,�✓,1./(��I�r�';�fr�”��(f�' r�i/1!r��r,,�� ; i � f r y � v r w � w I p r°trrearwy f (gq ffifIl 1 �l 1�1 ,� � .��II� IN lllli/� /Dl"S,T, � ...,, a I / / / ��1L.,�..., lJ 7,I�1✓r ,.� .. I!.: �,.1. / TYPE OF IMPROVEMENT PROPOSED USE Resicintial Non- Residential ❑ New Building ® ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition 6-0ther ' /,.,,✓i.. ..r, ,.....///�. ,,, ,.,, / „//// . J, / ,, ,r / s , /,// / /❑„Waters ed D str�c // lai, /❑Wetland.. ,,, , // / / /: „, ❑�Floo n , /, / r / / / /Wel. /S / / r � _ DESCRIPTIO OF WORK TO BE PERFORMED: ce'— Vr Iden 'ti atio P ease T pe or Print Clearly OWNER: Name: Ca 0 � Phone: Address: ClrONGI7tir �/llr ri�i�,Gt/ !/rl� �l,�,�r, , I Jrr r1// r, 11111001)), ,6/� �1 r `r, /059w%% �i : , / /,�1�„////, D/��lf�/1 I Js/I/Ili /��� ,� �l ,��1/eft � �/1���/��'���� 1111x11;h11�vrl�WwN�rNnar�fn�rll��.�ki.�rar��rrv�7nulJ�aYrrua+�w,.Uri/rimiiio/i//rrr,(moiiii i.. �rrrNi/Rrnvv,ltyd /%,,. 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: $ �� f (-: f FEE: $ Check No.: N ReceiptNo.: NOTE: Persons contracting with unregistered contractors do not have access th guaranty fund Signature of Agent/Owner Signature of;contractor I Town of' 'A' nclover ® T Y' ® LAKE ♦ er' ^SS' COC MI C NE w.CK BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT S4b BUILDING INSPECTOR has permission to erect .......................... buildings on Foundation Rough p? to be occupied as .... .���. . ..... .......... ... ........... ..................................................... , ............. Chimney provided that the person accepti g 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 tTS Final PERMIT EXPIRES I ELECTRICAL INSPECTOR I,,, CONSTRU I _ Rough Service ......... ... ......... . i.... .i............................ Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® Occupy Building Rough Displayin a Conspicuous Place On the Premises — Do Not Remove Final No LathingOr Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Baystate Roofers, Inc. Promsal P.O. Box 189 North Reading,MA 01864 Date Estimate# Tel. 978-664-0668 Fax 978-664-4333 8/3/2015 16166 Name/Address HIC# 137193 Scott Robertson CSSL# 99895 191 Haymeadow Rd. N.Andover,Ma.01845 Ray State Roofers Inc proposes: Remove approximately 3300 feet of the existing asphalt shingle roof down to the wood decking. Install new ice and water shield along the 6'roof edge,valleys and around all the roof penetrations. Install new 151b felt paper throughout roof area. Install new white aluminum drip edge along the roof perimeter. A new Lifetime GAF Architectural asphalt shingle will be installed over the prepared substrate. A new ridge vent will be installed to ensure the proper roof ventilation. All roof penetrations and flashing will be installed according to manufacturers recommendation, specification and details. Install new pipe flanges. Bay State Roofers will properly dispose of all roof debris in our own waste containers. Any wood decking that needs replacement will be an additional $2.50 per lineal foot. Message New Shingle Roof Authorized Signature- T®tal $14,135.00 Waste containers supplied by Bay State Roofers, Inc. are for sole purpose of roof debris. Under no circumstance is the homeowner to use these containers for personal use. 10 Year Workmanship Warranty on all roofs. (Except Repair Jobs) CONTRACT ACCEPTANCE The specifications,prices,payment schedule are satisfactory and hereby accepted. Date: ` S BAY STATE ROOFERS,INC.is authorized to perform work as specified. Payment will be made as previously outlined. Signature All bills over 30 days are subject to 1 1/2%finance charge per month(18% annual). Color The Commonwealth of Massa chusetts f Department of IndustrialAccidents b 1 Congress Street, Suite 100 Boston,MA 02114-2017 sy*u�t www mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FMED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lelzibl Name(Business/Organization/Individual): Address: tv l I if City/State/Zip: � Phone #: " �G Are you a employer?Check the appropriate box: Type of project(required): 1. am a employer with 1 employees(full and/or part-time).* 7. []New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t �4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition 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. tt d li t t b h d hi d I h 1 am a general contractor and rethe sub-contractors listed on the attached sheet. ❑ 13. Roof repairs These sub-contractors have employees and have workers'comp.insuranceJ ❑ 6.F1 we are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q 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. lam an employee•ttiat is providing ivor•liers'compensation insurance for my employees.'Below is the policy and job site information. C Insurance CompanyName: r // �1 l rC�"��✓"r • Policy#or Self-ins,Lie.#: _)Ll L -2- Expiration Date: Job Site Address: CA City/State/Zip: Attach a copy of the workers' compens tion policy declaration page(showing the policy number and expiration 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 WORD 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. I do hereby c rtif der the at ed en l -es ofpeejuey that the information provided above is true and correct. Si nature: Date: I y Phone Official use only. Do not write in this area,to he 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#: ASC"R" CERTIFICATE OF LIABILITY INSURANCE —DATE /20111) M/ 05/20/2015 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: A & K FOWLER INS LLC PHONE FAX 200 PARK STREET (A/C,No,Ext): (AIC,No): E-MAIL ADDRESS: NORTH READING MA 01864 INSURER(S)AFFORDING COVERAGE NAIC# 29JGW INsuRERA:ACE AMERICAN INSURANCE COMPANY INSURED INSURER& BAY STATE ROOFERS INC INSURER C: PO BOX 189 NORTH READING MA 01864 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE D OCCUR MED EXP An one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG POLICY PROJECT F I LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO SCYEDSULED BODILY INJURY Per erson $Ao '.. ALL OWNED NON-OWNED BODILY INJURY Per accident $ '.. AUTOS AUTOS PROPERTY DAMAGE '.. HIRED AUTOS Per accident $ $ I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDI IRETENTION $ $ WORKERS COMPENSATIONWC STATU- 0TH- A AND EMPLOYERS'LIABILITY (6S62UB-4609POG-2—15) 04-12-115 04-12—`16 X TORY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? Y/N E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) N NIA E.L.DISEASE—EA EMPLOYEE$ 1,000,000 '.. If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT $ 1 ,000,000 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES(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 THEREFO,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. BAYSTATE ROOFERS INC. AUTHORIZEDR IV PO BOX 189 NORTH READING MA 01864 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD . " TZ. Office �orrv»zaauueal o�� ac�ivae6 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: 137193 TYpei1 1 Expiration: 10/15/20-16 Supplement t BAY STATE ROOFER"INC. �I I ROBERT O'KEEFE` PO BOX 189 N. READING, MA 01864 Undersecretary Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supell isur Spccialh License: CSSL-099895 f� ROBERT E OKEEFE � 21 FRANCIS STREET " NORTH READING MA 01864 } J +w �I J'A ` Expiration 09/29!2015 Commissioner