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HomeMy WebLinkAboutBuilding Permit # 10/8/2015 %AORT#i BUILDING P IToF�4L�a ,e 9+ TOWN F THANDOVER °� o APPLICATION FOR PLAN EXAMINATION T _. mh^ Permit iso#: Date Received Q°p Ar Eo PPa` •(�J Date Issued: "� IMPORTANT: Applicant must complete all items on this page ���r / / I�I�,�������II�III����lll���ll.III%�//�I)�I�1���1����/�I�ll/l�lf l��������f������1�//�////l�� i,r/��� �/�///;.,%/1J/I/ Ml !./f�i ,��J/J%r/J Ili, rif/����1�✓9/ilii,f,/�/ / 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 ❑ Other /,// r// / /i f/ ❑,, ood lain,,r etla ds ,/, /i/,/ /,,❑ W,a e r e � str c rr � / / � r DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly ` I OWNER: Name: TH 0 /'1,,i I M & Phone: I Address: /i f /r /r r,ri / l i iii /i/ f ,// �/ ✓ ,- r i 11� PII V / . r ti „ / / � i � f ,;.. �r. /OBmrrak nl7dd,�tl0�w'xv�viv�dra�yar���iDfinr-Nb�rult>�rnm io�,�oarunii��w�r�, �� ...., ;,��v rr�n�lu"I�i�rglWrmi6in vnrrf��h� ���1,i1�� ,,,,. ��1 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: $ i FEE: $ Check No.: Receipt No.: NOTE: Persons contracting wl0h ung istere contractors do not have access to the guaranty,fund Si nafiure ofr,'contractor; . Signature ofi Agent%Owne `_, g I NORTH Town t E . 1,ofAndover 0 to 2,al fp * � h ver, Mass D .. U 7 A. COCHICH[WICK y V BOARD OF HEALTH Food/Kitchen rF. RMIT T. LD Septic System fivxTHIS CERTIFIES THAT ��........ .. .(. BUILDING INSPECTOR has permission to erect buildings on ..f ..... ......... Foundation .......................... ....{,.,..Ll.��. .......f Rough to be occupied as ............. . .�1 ..�. .......... .6Q `. ....�� !� !!!...... .a.�.............. 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 3-D PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TA 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 Approved by the Building Inspector. Burner Street No. Smoke Det. SORT H O'hwn ot nur4over 0 Aft ® T C, LAKE h verq S$sA'' I q COCKICMEWKK T LD S u BOARD OF HEALTH Food/Kitchen PF= RMIT T. Septic System THIS CERTIFIES THAT .......... BUILDING INSPECTOR ............................... ....�.. . .. . . .......................................................... Foundation has permission to erect .......................... buildings on .. ... ....... .!® ... ........ . I,.................. Rough tobe occupied as ............. ....... ..�.. .............. .......Q.... ...... . . .:�!`� ....... ... ... .. ..... .............. 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 Rough VIOLATION of the Zoning or Building Regulations voids this Permit. Final PERMIT3-D EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CTI T,4 Rough Service ..................... . . ...... ........................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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. i mmy ;�rr,:�w,r, „wmuWnuwr��n ,v srvx,.r, ��.mrn .r;�mrvnsrvnrt� W�>eWr� ,e.rra,u /!?nw�,.. _, ,.. veli v.ei ,. �aerX.v tri.N�.e'uv 11.W,.n,YP%rvd;.WdpiWWWrtIMWVWau"✓ie:.'tai�.^,aWF✓ WWmN9WUNUWWW'Gµm amxxrvnii.'.ndNm�Wu.'Y'.�WIWUI W'r'�INNWWWiV D� rYffi✓^iM1TA��J Ap iuraremrarcm�nfror�mr�, 'A C'I G0� r �,.... N (NII Nq L 1 ��� ;b r„ CI1"'tc sT ( fs'l�lI �a •, TB A T TH& O mr'x&, I'A, , � ft L(07'7' �,...�~. AN CJS WA v l w ���"d'8YIV A.CV.J) `C' 4l 07 I tdr, r q`�" �i IUTY '1Wpa TowN op NORTH AhrDC VAf ' �""CJ���� � � Irf,F. � j C°`ROMs"T1'r IV I" P S f(101V P, !�I��,Cr Cp�l"Cf.> �YC�R,1��pfr"r �<<� WHO�U ��"�'��������"-A P . �� d� O'N PA'Afl' ¢ fiP J r I . , (JWf.0 1 g; DRAWN . "fix .... JCI.Jl., a,,, N P�OR 1l," HCl+'h7 fe 4 crye,�r�' 1tir DA IF yc7t J J Y b v tr Fl .{._ CAiYe"ST'. 'rt �PF"°OR Xi A'41A"f�w..., r YYs �,�.niL ,� d4 d Jar l� ad. i t ✓�C�CEI �i".F t� �� t� P�Gd 1�d IV.L4 .N� X_Je,6Vtt�61W 1'.�J'�ad"I�l��' "r l', t'��//u�A�e i W pp +�W / X y} � ( ✓ y} Itbf rr r�k � AC d'�ln���O )), r i( .e�y� g }�y,/ lJ4'� R�PR,(MIC µ,f� 1T The Commonwealth of Massa chusetts z Department of I"ndustrialAccidents r: d 1 Congress Street,Suite 100 Boston,ALL 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information f' ' Please Print Le ibl NaMe (Business/Organization/fndividual): 1 r Q�7nS ,1/ �' L Address: 10 0 PC �i/Z�f L. A til; City/State/Zip: DRIP-) N) I VE R `114 049 Phone#: Are yon an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part:-time).' 7. ❑New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]i 9. El Demolition 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 hidhb I have rethe sub-contractors lid thttah ors steon e aced sheet, ❑ 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14. �g 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. I Other �i )w� (41.1yi 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 1 pj t tndl etc� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submif•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 have employees,they must provide their workers'comp.policy number. I am an employer that is pfovidfirg workers'compensation insurance for•my employees.'Below is the policy and joh site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: 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 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. £do Hereby certify i der the pa' andtattles ofperjuiy that the information provided above is�true and correct. Sign e: �' l� � Date: 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#: l ® DATE(MM/DD/YYYY) ACC>RV CERTIFICATE OF LIABILITY INSURANCE 10/7/2015 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). CONT CT Christopher Kennedy PRODUCER NAMEA Farquhar & Black Insurance Agency PHONE (781)599-2200 aC No: (781)581-3990 85 Exchange Street - Suite 101 E-MAI ADLDRESS:Chris@ FandBInsurance.com INSURERS AFFORDING COVERAGE NAIC# Lynn MA 01901-1475 INSURER A:Penn-America Insurance Co. INSURED INSURERB:Safety Indemnity 33618 Hyde Brothers Contractors INSURER C: 76 West Park Drive INSURER D: INSURER E: Wakefield MA 01880 1 INSURER F: COVERAGES CERTIFICATE NUMBER:Thomas Ringler 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. IN RI TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DDY EFF MM/DDYEXP/YYYY LIMITS LTRINIR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE I—XI OCCUR PAV0062800 5/14/2015 /14/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ O NED AUTOMOBILE LIABILITY Ea accidentSiNGLE LIMIT 500,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED }( SCHEDULED 021390 9/18/2015 9/18/2016 BODILY INJURY(Per accident) $ AUTOS NONOOWNED ATS PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident ' Medical Payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ TATU $ WORKERS COMPENSATION WC SLIMIT OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (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 THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Thomas Ringler 204 Coventry Lane AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Marian Cruz ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. I1MR17195 f9n1nnF1 M TI-Arnon n-nnr1 Innn nrn rnniafarnri mnrrlrc of Ar(npn DATE(MMIDDIYYYY) ACC)"R® CERTIFICATE OF LIABILITY INSURANCE 10/07/2015 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 poilcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject t° 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). CONTACT PRODUCER NAME_:_ Marian Cruz _ _ A i,--,.._ T fIC FARQUHAR&BLACK INSURANCE AGENCY INC. IM E Q§11599- 1200 E-MAIL _ADDRESS: _manan OC7fandblflSUranCe.COm 85 EXCHANGE STREET-STE.101 INSURER(S)AFFORDING COVERAGE NAICN_ LYNN MA 01901 INSURERA: ACADIAINSCO _T 31325 INSURED INSURER B: HYDE PHILLIP _lN SURER C: -—...— DBA HYDE BROTHERS GENERAL CONTRACTORS INSURER D: ! ----- 76 WEST PARK DRIVE INSURER E: _- WAKEFIELD MA 01880 INSURER F: COVERAGES CERTIFICATE NUMBER: 4256 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 --- --ADOL SUER —_ POLICY EFF POLICY EXP L TYPEOFINSURANCE POUCYNUMBER MM M1DD LIMITS COMMERCIAL GENERAL LIABILITY ' FACHOCCURRENCE _ 5 __,_ CLAIMS-MAGE OCCUR T�f2ENTES PREMISES(�a oaurrenceT_.._ i MED EXP(My one person) S N/APERSONAL&ADV INRY $ GE_N'L AGGREGATE LIMIT APPLIES PER: OEE9 - REGATJUE 5 PRO- (- t------- POLICY PRO- LOC PRODUCTCOMPlOP AGG S JECT OTHER: —..—. AUTOMOB)LELIABILITY fI OEaaawdaDli_ LE LIMIT S _ ANY AUTO ___ ( BODILY INJURY(Per person) S ALL OWNED (- SCHEDULED j N/A i' BODILY INJURY(Per accident) S AUTOS AUTOS NON OWNED II PROPERTYDAMAGE S HIRED AUTOS f AUTOS UMBRELLAUAB OCCUR I j EACH OCCURRENCE $ _ '.. i EXCESS LIAR CLAIMS_MADE1 N/A AGGREGATE $__ OED RETENTIONS �---- _•-- - S WORKERS COMPENSATION ,X STATUTE iERH '.. AND EMPLOYERS'LIABILiTY YIN S $40,000 ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT_ O? NIA A OFFICERIMEMBEREXCLVOENIA,NIA WC202000521901 03/12/2015 03/12/2016 E.L. A ISEASE- EMPLOYEE 5_550,000 (Mandatory In NH) I -- --- If yes,describe under E.L.DISEASE-POLICY LIMIT i$ 500,055 DESCRIPTION OF OPERATIONS below i N/A DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(ACORD tat,Additional Remarks Schedule,may be attached if more space is required( Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 8,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www-mass.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. 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 POLICY PROVISIONS. Thomas Ringler 204 Coventry Lane AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.Cro jeey,CPCU,Vice President—Residual Market—WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD