The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 10/2/2015 i pd ,,tkOgo " 4BUILDINGIT a TOWN OF NORTHV ° APPLICATION FOR PLAN EXAMINATION Femit NO: � � � Date Received Cate Issued: ' IMPORTANT:.Applicant must complete all items on this a e LOCATION tq rint PROPERTY OWNER_. F'int MAP NO: PARCELMIS11 ZONING DISTRICT: Historic District yesno Machine Shop pillage yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑ One family Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition uD Other ❑Septic ❑Well ❑ Floodplain El Wetlands ❑ Watershed District ❑Water/Sewer q 4 ,4 _mLk, Identification Please Type or Print Clearly) v , GER: Name: ,. JA Phone: � Address: CONTRACTOR.. Name: -—, —Phone.- 66) " :el( r" / " " LL' Address: � � �e" .�� `� Supervisor's Construction License* Exp. Date: X51 90-3 C Horne Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULD/NG PERMIT.MOO 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 contrac ' g)with Lnre � e`` e�ro actors do not have access o' he guar rr Signature of Agent/Owner . Signature of contractorir 6/1m ," t%®RT#i Town of ndover R E j' 0 0 �O LANE very ass, coc Nlc Ml Wtc. _� ® 0 RAT E D J?P �R I L D 11 BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT ............. ...... . . ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR .... .. . ... ... .. ..... has permission to erect buildings on .1.. Foundation .......................... ..... .... ...�!.,..... .................... Rough to be occupied as .......TZ.0.0... . p .....!!!'+.IM44�1L, .w�............................. 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 T ELECTRICAL INSPECTOR LESS CONSTRUCTI T S Rough Service ............... ...... ............ ......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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. Mass Construction Supervisor LIC#094703 �>- Mass HiC License#265732 C'Rstom adypewtr New EwgLawd Making Your Dream Home A Reality Owner Donnie Settlemoir € 90 Lakeshore Dr Georgetown Ma Office (978)769-2114 Celt (603)601-2114 Fax (603) 501-0124 www.customcarpentryofnewengland.com Don—nee@comcast.net ame-2/�v/ z), � — Address 3C Z /�q/-7/ (a/e �'g� "own State i17ZI Zip 01� - j )d 1 Phone "2Y4'x' Email_ �/c� lie✓r, �s � y Referred by 49 _— Description of Service 4L /tO 4� :1—" aA ('' - "L'u 4 c o 5 ; 56 Quotation prepared by Donnie Settlemoir Total Cost Payment 1 schedule goes as followed. Half of the construction cost at the beginning of project $ � � The final payment at the end of project. $ To accept this quotation, sign here and return: I The Commonwealth of Massachusetts Department of IndustrialAccidents d d 1 Congress Street,Suite 100 Boston,MA 02114-2017 Fy;�,wt www mass.govIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ' Addxess: � ° ' t City/State/Zip:f'tfe*� C ek k, tk. Phone#: Y-3 3 "a� Are you an employer?Check the appropriate box: Type of project(required): 1.0-1-am.a.employer with . 0.. : employees(full and/or part-time).* 7. [J Now construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] • 9. El Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 F]Building addition 4.FJI 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. 1Plumbing repairs or additions 5.❑I am a general contractor and T have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp,insurance.t 6.Q We are a corporation and its offa-rcers have exercised their right of exemption per MGT.c, 14.( Other Le 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. Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must sgbmit 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-conlrad&s have employees,'they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees;'Below is the policy and,job site information. WY Insurance Company Name: ..t - *a,._. Policy#or Self-ins,Lic. d Q it Expiration Date: l�C Job Site Address: 3 1t V" °' City/State/Zip: M" I Attach a copy of the workers'compensation policy dec aration 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 WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forurarded to the Office of Investigations of the DIA,for insurance coverage verification. I do hereby cert ,der the pains a penal ies ofpea jujy that the information provided above is trite and correct. Signature: �. � Date: �.. Phone 6 6t 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#: CORbP ACCERTIRCATE F LIABILITY INSURANCEDATE( 0711 THIS CERTIFICATE IS ISSUED AS A MATTER GF RGIRMAMON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TMS CERT IFICATE DOES NOT AFFIRMATIVEL` UIA-fr Y AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCM BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE MMG INSURER(S), AU THOROM REPRESENTATIVE OR PRODUCER,AND THE CERT11FICATE MILDER. ORTANT: ff the certificate holder is an ADDEIMKRL INSURED,the pollcy(ies)must be endorsed. R OGATION IS WAIVED,s fie the terms and conditions of the Policy,certain Policies mW require an endorsement. A statement on this cerflficate does not confer rights to the certificate holder in lieu of such endorsements - Did! M.Pkxgw Insurance Agency,Inc. i 978-352-2533 F 978-352 Main Street A/c No ADDRt�s: S INSURERS AFFOPAMM COVERAGE ca A- Travelers SIMMIER a- Atlantic Casualty Ins Co Donnie Settlemoirdiaa Custom Carpentry of Now England NISURER c: tNSURE3t 90 Lake Shore Drive D Georgetown INSUtR E CO' MA 01833 m-unmF, RAGES CERTIFICATE NUMBER: REVISION NUMBER: TM IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEMM DEWATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER _DOCUMENT WITH RESPECT TO WNICII THM GRUVICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANM AFFORDED BY THE POLICIES DESCRIBED IS SUBJECT TO ALL THE EMIMMONS AND CONDITIONS OF SUCH POLICIES.Umrm sHqmmAymAvE BEEN REDUCED BY PAID CLAMS. TYPE OF KD-13L SUER IMP EFF POLICY EXP LIMITS MMIDD M/DD I COMMERCIAL GENERAL LIABILITY - EAMOCCUR00 RENCE $ 1,000,0 CLAIMS tWADE ®OCCURTORENTEtY— PREMIISM 100,000 occurrence $ ?EXP one person $ 5,000 L143003449 12/17/2014 12/17/2015 pamoNALLADVINJURY 3 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PEP, GENERGGREGATE 2,000,000 POLICY❑EC LOC OTHER: PRODUCT$-C6MP/OPAGG $ 2,000,000 S AUTOMOBILE LIABILnY $ W ff ED da ,l LE LIMIT $ ANY AUTO t ALL OWNED M SCHEDULED YINJURY(Per person) $ AUTOS AUTOS HIRED AUTOS NON-OWNED AUTOS Pfp ROPERTY OAMAtaE $ $ I UMBRELLA LEAD OCCUR IOOCURR@d{E $ EXCESS LIAa E EACH DET) RETENTION ASQRSBAIE$ I S COMPENSATION $ EMPLOYERS'LIABRY H- PROPRIETORPATNEI ?CUTIvE YIN STATUTE ET WREXCLUDED? NIA 7P -1-15 07/15/2015 07/1216 E'E BACCIDENT 100,000 atory In NH) 5 — describeunder FL- E-EA EMPLOYE $ 100,000 PTION OF OPERATIONS het—EL DISEASE-POLICY LIMIT S 500.000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(AGO , Remarks Schedule,may be attached If more space Is t CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIaw POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE QED, <, ACCORDANCE WITH THE POLICY PROvLsIONS, < "r s F ORMM REPRES Alangel) AEORD 88-2094 ACOR ORPORATIOPI. Ali rights 25(2014101) The ACORE3 nwM=td logo are registered marks of AC@RD m F 'Y� r/1,11"(7, � < Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registrefion: 159042 TVpe: DBA Expiration: 3/28/2016 Tr# 249423 CUSTOM CARPENTRY OF NEW ENGLAND DONNIE SETTLEMOIR 90 LAKE SHORE DR. GEORGETOWN, MA 01833 Update Address and return card.Mark reason for change- Address 0 Renewal E] Employment Lost Card „ e...t,e�M" "'fr MAY NABAAMN 4'U'Rdo"�J'I P; l }•�i°� ledVl'dC's'APA:Sa'"Hd __ _._...... Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 155042 Type: Office of Consumer Affairs and Business Regulation w 'Expiration: 3/28/2016 DBA 10 Park Plaza-Suite 5170 Boston,M 16 CUSTOM CARPENTRY OF NEW ENGLAND DONNIE SETTLEMOIR 90 LAKE SHORE DR. GEORGETOWN,MA 01833 Undersecretary Not valid without signature C ion%trua don i , n e: CS-094703 DONNIE SETTLEMOIR 90 LAKE SHORE`DR riff l��f GEORGETO®Vp1 4 �uu°rQp��oeM��. 10/31/2015