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HomeMy WebLinkAboutBuilding Permit # 10/6/2015 l OOff3TH BUILDING PERMIT TOWN OF NORTH ANDOVER 0� APPLICATION FOR PLAN EXAMINATION _ o- Permit No#: °' Date Received AC US Date Issued: MPO'R TANT: Applicant must complete all items on this page LOCATION i4 L-T Print PROPERTY OWNER 66p (� Print 1ooYearStructure yes o MAP PARCEL: rye, v ZONING DISTRICT: Historic District yes a" Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family V,;Industrial ❑Alteration No. of units: ❑ Commercial repair, replacement ❑Assessory Bldg ❑ Others: %Demolition Wther ❑ Septic ❑Well Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO DE PERFORMED: e. Identification- Please'Type or Print Clearly OWNER: Name: Phone: P Address: j [ �`� Contractor Name: kel I ne: '109— ?0 Email: a Address; G e i Supervisor's Construction License: . Exp. Pate:' Home Improvement License: r; Exp. Date: ARCHITECT/ENGINEER l Phone - (27,1A 1 1,d, . , �,� eg. No. Address: C`D t,��t.,) �' �. � , i� �`C FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ " o FEE: $ r Check No.: a Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor-/,,,, NORTH Town of It E .4'. ndover so No. C, h ver, Mass, /, % ✓._ cocMicnewIcK 1' �ORATEO S U BOARD OF HEALTH Food/Kitchen PERMIT T/ D Septic System THIS CERTIFIES THAT ...... `�?`� � (:�� �� ::��. :............. ................................ BUILDING INSPECTOR has permission to erect.......................... ... � `ZJ...:: .C?.�1:/ 1.� ....... .,. .. ... .... Foundation buildings on �Y�..r.. ,/. .. .�. Rough to be occupied as ....................... .?�F..... P... ::�`:! �.. ,. .�::: .�: `. �: .... �.:`.�!,: ;G; /I rr. ..c.`.. :t. Chimney provided that the person accepting this permit shall in every respect conform to the term's 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ...............�„l. ...... ......................... 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 Approved by the Building Inspector. Burner Street No. Smoke Det. BELFOR (0) PROPERTY RESTORATION Date: 1, Gerard E. McGonagle Jr. authorize '/ , , my employee at EELFOR Property Restoration, to act on my behalf to obtain any required permits and inspections for the property detailed below: Address: ,.. - '*F` Kw� Property Owner: COV C6 , Please call 866-914-0999 for verification or questions. Thank you for your assistance, Gerard E. McGonagl&*. License#CS59495 MA PLIC# 155902 US EPA 12RP Certificate#R-I-18599-10-00254 BELF®R USA** 138 Bartlett Street, Marlborough MA 01752 866.914.0939 Ph: 508.485-9780 a Fx: 508.544.4324 24/7 emergency hotline: 800.856.3333 a www.belforusa.com 01CO /-I BELFOR WORK AUTHORIZATION License # 155902 PROPERTY The undersigned(insured), Solo Cup Company LLC Of 500 Hogsback Road Mason Michigan 48854 Address city State Zip represents that he/she/they are owners of/or agent for the hereinafter specified property(and/or its contents)and hereby authorize and direct BELFOR USA Group, Inc. ("Contractor") to provide all labor, equipment and materials required to properly repair the specified real property,contents or structure commonly known as: 351 Holt Road North Andover Massachusetts 01845 Address city State Zip It Is understood and agreed that Contractor will perform all repair work in a good and workmanlike manner In accor- dance with our General Conditions,will have a policy of Insurance In full force,will comply with local safety standards and will perform all work according to local building codes.A one-year workmanship warranty will be presented upon full pay- ment for the work performed.The undersigne reby transfers, assigns-and-oon title and as pelley preeeleds a. all drafts for wer-k-perfernied or to be pel—ed-by Gentraoten.Assis"d ngV,undersigned autherizes-and-dhvote4heW4rsure mod bele-,V)Ite make"BELF40 QAl' yee en all insuranee drafts fer all insuranee work-pbe a- ,16n-A L-rl--l-eeter en the ebeve da naged pmper­ The unde-1--e-I else agreesto` frimedWely-enderse-an4tend -produced to the Gentfeeterz. All insurance work performed by t a Cent u lee&4--the te .4-1 .-rme-ekho4asuredpelleye�lksufamea-wh sets the Beeps and larlee of the-work based- upen All uninsured so e upgrade-weric, depreelatien Hour- ones de uatibles-em4ho-res endiellity of t e-undersigned or wrien The undersigned has the right to cancel this Work Authorization prior to the midnight of the 3rd business day of signing this agreement by writing and deliv- ering a written cancellation request to Contractor by such time.The undersigned also agrees to and understands the General Conditions stated below. Date: -35 000 ' (6 M1QUNT-#PL1<N0"" DATE IMURED-OWNER-AUTHORIZED REPRESENTATIVE BELFoR REPRESENTATIVE INSURED-OWNER-AUTHORIZED REPRESENTATIVE INSN PBNGKNWBFR General Conditions owner agrees to allow timely Inspections by munlcipW Inspectors and/or mortgage company agents aaeodraft-so that BELFOR can be timely paid, the-easis or pedarmed ar aataR oo yetrsttteFrrisocielay a provenLtbe payment-oFsaid insaranee he4RsUradAWMe*)-ekhe-Qbsve ntientiened prepony be performed-The Contractor and undersigned aclknowfeWge and agree that the Contractor shall have no liability for;and shall be Indemnified and hold harmless from and against,all claims,damages,liabilities and costs arising out of or relating to the presence,discovery,orfailure to discover, remove,address,remedlate,or chwup environmental or lifological hazards Including,but not limbed to,mold,fungus,hazardous waste,substances or materials,or asbestos unless red by the InsufasPs petiwtoWiswanoe.remedlatlon Is part of the scope of work and such work Is directed by an Industrial Hygienists protocol and clearance test- ing.If for any reason the amount due under this Work Authorization Is not paid when due,the Contractor shall be entitled to its expenses and attorneys fees Incurred In the col- faction of this agreement with Interest on the unpaid balance at the rate of 1.5%per month or the rate prescribed by law.The undersigned permits Contractor to obtain a per- sonal credit report toe praeoedsiaFthts project are nckin jeepardy Any controversy or claim arising out of or relating to this agreement,or breach thereof,may be submitted to a court of competent jurisdiction,Contractor Is In good standing with the Better Business Bureau.Contractor reserves their right to terminate this contract should the client breach any of its terms,conditions or the assurance of payment REV.8110 BELFORUSA 139 Bartlett Street, Marlborough. MA 01752 - 866.914.0937 - ph 508,486.9700 - Ix- 508.485,9783 HEADQUARTERS 105 Oakland Ave., Suite 150, Birmingham, 141 48009-3433 - 888.421.4111 - ph: 248.594.1114 - Ix, 268.594.1133 2417 emergency hotline 800.856.3333 - www.belforusa.com The Commonwealth of Massachusetts a Department of Fire Services Office of the State Fire Marshal P.C.Box 1025 State Road,Stow,MA 01775 �j PERMIT" Date: Permit No Dig Safe Number (City of Town) (If Applicable) In accordance with the provisions of NLG.L. Chapter 10as provided in section 5 2 7 CMR 34 Start Date This Permit is granted to: Ic Full name of person,Firm or Corporation Permission to locate dumpster for construction/renovation/demolition of structure Comments: dumpster be 25 ' from structure or covered with tarp or plywood Restrictions: at end of workday at 2 3 l �14Y T �a Give location by street and no.,or describe m such manner as to provied adequate identification of location) Fee Paid$ 5 71 This Permit will expire 2-?� /5/ (Signature of oila rit} g Permit (Title) TI-11_Q PI=PMIT IT Ml l_fiT RI= n-E11 gP1P_I Inn KI V PO-QT1=11 I IPnM THF PP1=U1C1=Q The Commonweafth ofMassuclimsetts Departmeni of IndusirialAccidews Office of Invesdgations 600 Washington Sireei Bosion, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit. Builders/Contractors/E(lectricians/Plumbers Applicant Information Please Priv Name (Business/organizatiotVlndividLial): Address: 138 Bartlett Street City/State/ZiP:—Narlborough, MA 01752 Phone#: 508-485-9780 Are you an employer? Check the appropriate box: Type of project(required): 1. 1 am a employer with 30 4. El I am a general contractor and 1 6. E]New construction employees(full and/or_p_atl-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance, 9. Building addition [No workers' comp,insurance 5. El We are a corporation and its required.] officers have exercised their 10.E] Electrical repairs or additions 3.[:] I am a homeowner doing all work right of exemption per MGL ILE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.n Roof repairs insurance required.]f employees. [No workers' 13.R1 Other REPAIRS comp, insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ Insurance Co. of the State of PennsvIvania Policy#or Self-ins. Lic. WC067712682 Expiration Date: 7/1/2016 Job Site Address: City/State/Zip: 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 insurapqe coverage ye n I do hereby certify upd'ey, painpand penalties ofpetymy that the information provided above is true and correct. Signature: .......... Date: Phone#: 508-485-9780 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 ® DATE(MMIDD/Y(YY) CERTIFICATE OF LIABILITY]NSU RANCE F 0710212015 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,ANDTHE-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). C PRODUCER CONTACT y Aon Risk services Central, Inc. NAME: c. Southfield MI office (A1C No.Ext): (866) 283-7122 a No., (800) 363-0105 3000 Town center E-MAIL `o Suite 3000 ADDRESS: y Southfield MI 48075 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: National Union Fire Ins CO of Pittsburgh 19445 Belfor USA Group, Inc. INSURER e: The Insurance Co of the State of PA 194Z9 dba Belfor Property Restoration 138 Bartlett Street INSURERC: Underwriters at Lloyds 32727 Marlborough MA 01752 USA INSIJRERo: AIG specialty Insurance Company 26883 INSURERS INSURER F: COVERAGES CERTIFICATE NUMBER:570058585288 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. Limits shown are as requested LTR TYPE OF INSURANCE IVSD WVD POLICY NUMBERMMmD LIMITS • MMIDDIYYYY X COMMERCIAL GENERAL LIABILITY GL EACH OCCURRENCE $2,000,000 CLAIMS-MADE rX1CCCUR SIR applies per policy terns & conditions DAMAGE TO RENTED $2.,000,000 PREMISES Ea occurrence MED EXP(Anyone person) $10,000 PERSONAL&ADV INJURY $1,000.,000 m ,GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $4,000;000 m POLICY �dEC ❑X LOC PRODUCTS-COMPIOPAGG $4,000,000 0 OTHER: C h A AUTOMOBILE LIAB,LITY CA-319-43-30 07/01/2015 07/01/2016 COMBINED SINGLE LIMIT AOS accident) $2,000,000 A X ANYAUTO CA-319-43-31 07/01/2015 07/01/2016 BODILY INJURY(Per person) ALL OWNED SCHEDULED MA BODILY INJURY(Per accident) r0AUTOS AUTOS .. X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE C�.1 AUTOS Peraccidenl X Coil Dad$1,000 X Comp Ded51,000 A X UMSRELLALIAI3 X OCCUR 29157297 07/01/2015 07 01/2016 EACH OCCURRENCE $5,000,000 V .EXCESS LIAB CLAIMS AGGREGATE $5.000,000 DED' RETENTION B WORKERS COMPENSATION AND WC014267780 07 Ol 20I5 07 O1 2016 X PER STATUTE 0TH- EMPLOYERS'LIABILITY YIN AOS _ ER ANY PROPRIETOR/PARTNER I EXECUTIVE E.LEACHACCIDENr $1,000,000 B OFFICERIMEMBEREXCLUDED7 NIA wc014267786 07/01/2015 07/01/2016 - - - (MandatoryinNH) MA, ND,OH, WA, WI, WY E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT JT-10001000- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Evidence of insurance SPA f CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE j POLICY PROVISIONS. - j Belfor USA Group, Inc. AUTHORIZED REPRESENTATIVE �•� dba Belfor Property Restoration 138 Bartlett Street Marlborough, MA 01752 USA I ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i AGENCY CUSTOMER ID: 570000005415 LOC#: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk services central, Inc. Belfor USA Group, Inc. POLICY NUMBER -see--certi-f_i.cate-Number-: 570058585288-- CARRIER NAIC CODE See certificate Number: 570058585288 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE MAIC# INSURER INSURER INSURER INSURER AIDI rn6NAL PomcmS If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY INSR LTR TYPE OP IIVSURANCE ADDL SUBR POLICY NUMBER LIMITS WS] wVD EPI+ECT[VE EXPIRATION DATE DATE (MMIDDIYYYY) (MM/DDNYYY) WORKERS COMPENSATION B N/A wcoi4267782 07/01/2015 07/01/2016 NJ, PA B N/A wcO14267785 07/01/2015 07/01/2016 IL, KY, NC, UT B N/A wco14267784 07/01/2015 07/01/2016 AZ, GA, VA { B N/A wco14267781 07/01/2015 07/01/2016 FL 8 N/A wcOI4267783 07/01/2015 07/01/2016 CA i r i I i i i ACORD 101(2008101) O 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks ofACORD Office of Consa-mer Affairs and Business Regaiation 10 Part(.Plaza- Suite 5170 Boston,Massaqhh,isetts 02116 Home Improvernent Cd4tr, or.Rogistration, Registration: 166902 Type: Private corporation Expiration: 51,17/2017 Trib 2661361 BELFOR USA GROUP, INC. GERARD MCGONAGLE '185 OAKLAND AVC ST E 300 BIRMINGHAM,IVII 48009 Update Address and return card.Mark reason for ChIRge- [] [] Renewal D Employment F Lost Card SCA 1 0 j ZOM-0511i Address mmAX 01�(D'1v1mUr(rk(;w111 Office of Consumer Affair.R,Business Regulation License or registration valid for individul use only ME IMPROVEMENTCONTRACTOR before the expiration date. If found return to, "Istration; 454902 'Type: Office of ConsumarAffah-a and Business ReguisfiGn E',iplwagou-.� Stl7t2Q17 Private Corporation. 10 Park Plaza-Suite 5170 13EI-FOR USA GROO�Ai`4c� Boston,MA 02116 GERARD MCGONAGI F '185 OAKLAND AVE STE 300, BIRMINGHAM,MI 48009 Undersecretary Notvalkwit; ut signature 7 Maasszicshm setts-6]eP mArperit;of Pmbilp!���taty GOEIN of Building RkMI°atlons zine#89 Construction Sgpa'moor License ti 78 Zvi I vmf,,'i . ��., t zit ru l^ i�xpi'nslilcars contain I=dm coanrnisriasi7r�r ��i�f�P.AB�nC 35,000 CA0a •(9911n3)of mlmvda . Fafte W passess a cunededfta dthe Mamdiusett. Ras ink Codeisa au se,for Mum Won of d ft rim nGe, r•�,�raa� -sr�i ss,ea$t. �a ss„�srvJo�s i