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Home My WebLink AboutBuilding Permit # 10/1/2015 %ooRT# s awn n _um 0 ,BLEDOil BUILDING IT TOWN OF NORTH ANDOVER APPLICATION FOR P I ATI � „ Permit 1�O® "_ / bate Received ,s� • " 4 S+ CP4MJ Date Issued: r IMPORTANT: Applicant must complete all items on this a e LOCATION � Print � z PROPERTY DINNER _ Print MAP NO: PARCEL: ONIfVt DISTRICT: Historic District yes o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New wilding ❑ One family [I Addition [I Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement [IAssessory Bldg _ 11 Others: ❑ Demolition El Other El Septic El Well El Floodplain El Wetlands El Watershed District ❑Water/ ewer Identification Please Type or Print Clearly) OWNER: Name: r. V, Phone: l at"..t, I W L Address: Z , I ..rvi N' `l �, .,.� lilt CONTRACTOR Name: _ Phone: Address: Supervisor's Construction License: p. ate: Nome Improvement License: �Exp. Gate: ARCH ITECT/ENGI NEER Phone: Address: Reg. No. FEE scwEDULE:EULDING PEIRMIT:$12.00 PER$1000.00 4F THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total reject Cost: l FEE: Check No.: / 3 2 l Receipt No.: 1 ✓ NOTE: Persons contracting with unregistered contractors Bio not have access to the guaranty fund Signature of Agent/Own r ..t'.,i -� oSignature,of contras oORTH Town of Andover ® O ® r T )ib row O LAKE Ver, ��/ coc"ICNEWICk tea. S U BOARD OF HEALTH Food/Kitchen PEr�x� MIT TU LD Septic System THIS CERTIFIES THAT ................ ........... . ..We IV% ... ...... �1��!. ............................................. BUILDING INSPECTOR p g �� Foundation has permission to erect .......................... buildings on .. . ...... .. .. . . .................... Rough 00 to be occupied as ... )ccepting ... {�. ... ................. :�K.l�� ..... tee......... art..... Chimney provided that the person this permit shall in every respect conform to the terms of!the lication 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 PERMITI I6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION Rough Service ................... ... ..................................I............... Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® Occupy Buildin:; 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. North Andover MIMAP September 30, 2015 ;i � la' 0 0 c+ ) o" r ;I `I is I i vel u N ❑MVPC Bo Interstates Horizontal Datum:MA Slateplane Coordinate System,Datum NAD83, —I Meters Data Sources:The data for this map was produced by Merrimack —SR NpRTN Valley Planning Commission(MVPC)using data provided by the Tovm of Roads QO tt`q C rq'9�O North Andover.Additional data provided by the Executive Office of Cr Easements aq 'q Environmental AffairslMassGIS.The information depicted on This map is ti Parcels 3 L for planning purposes only.It may not be adequate for legal boundary—• to definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING # THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION �sSACMustii V=51 ft " CUSTOM BUILDER P.O. Box 1056 Bedford, MA 01730 781-275-7755 Benjamin and Kristen Dick 28 Wood Ave. North Andover, MA September 24, 2015 Replace 2 Doors and Install Under Deck Shield Permit 280.00 Doors 3,525.00 This includes a new rear door, hardware and storm and a new front, hardware and storm. Certainteed Under Shield 2,580.00 This includes materials for under the deck shield by Certainteed. Labor 5,600.00 Labor to install doors and under deck shield . Demo Removal 225.00 Total 12,210.00 Let me know if you have any questions. Thank you. Regards, William H Waite Jr Accepted } r Date: Deposit: 4,070.00 Doors Installed 4,070.00 Balance on Completion The Comn;onwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A - Applicant Information Please Print Le 'bl Name(Business/Organizadon/Individual): 9kluta Address:E`J City/State/Zi' Phone M '1917 Are yo employer?Check the ropriate box: Type of project(required): 1.UYI am a employer with ,_4' 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g. E]Demolition ' working for me in any capacity. employees and have workers9. E]Building addition [No workers'comp.insurance comp,insurance t required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs . insurance required.].t c. 152,§1(4),and we have no 13.❑Other 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 haveemployees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation-insurance for my employees. Below is the policy and job site information. .� Insurance Company Name: Policy#or Self-ins.Lic.#� � �[� � �� 11� Expiration Date: Job Site Address: (.�/i9 e 0 City/State/Zip:/9vrfLkel oyeyl� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' u er the ains�dpalties of perjury that the information provided above is true and correct Si afore: Date: ® �� Phone# "b /3 — 3 C6 7/,--5 Official use only. Do not write in 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#: 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 pollcy(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). PRODUCER CONTACT NAME: HUB Int'I New England(WILSB) PHONE 978 657-5100 FAX 978-988-0038 A/C,No,Ext): A/C,No: 299 Ballardvale St E-MAIL ADDRESS: Wilmington, MA 01887 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Essex Insurance Company INSURED INSURER B:Safety Insurance Co 39454 William H.Waite Jr.,Inc. ASIC INSURER C P.O. Box 1056 Bedford, MA 01730 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 CONTRACTOR 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 INSR WVD POLICY NUMBER MM/DD/YYY MM/DD/YYYY A GENERAL LIABILITY 3EA5413 6/11/2015 06/11/2016 EACH OCCURRENCE $1,000,000 '... COMMERCIAL GENERAL LIABILITY PREMISES Ea ocMcu ED $100,000 CLAIMS-MADE N OCCUR MED EXP(Any one person) $5,000 JX Bl PD Ded:1,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1,000,000 POLICY X PRO- LOC $ JECT B AUTOMOBILE LIABILITY 3800078 5/01/2015 05/01/2016COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $250,000 ALL OWNED SCHEDULED BODILY INJURY(Per accident) $5003000 AUTOSFXX AUTOS X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $100OOO AUTOS Per accident , $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCC50050149492015A 8122015 08122016 X TpC YTLIM T 9 OT 08122015EMPLOYERS'LIABILITY Y N ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500OOO OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500OOO If yes,describe under 5 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street, Building 20, ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE C�/ze �,z�,za��me�c�f/o�P/luJe�cc/rcceettJ 1' License or registration valid for-individuluse only p Office of consumer Affairs-&Business Regulation g f QME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ration: ,191065 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 xpiration: B/8/2016---_ Private Corporatl.on q Boston,MA 02116 i WILLIAM H.WAITE JR INC William Waite .60 Great Rd Bedford,MA 01730 Undersecretary 0otvalidd without signatP t Massachusetts -Departn"fent of Pubiic Safety Board of Building Regulations and Standards Construction Supervisor License: CS-007381 \.% « , WLt.I.IAM H WAAE 6C DORIS RD 5= BEDFORD MA t�1730 Expirati� 'E 12/1012015 Commissioner