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HomeMy WebLinkAboutBuilding Permit # 10/14/2015 �gilt.OR;T.-•H "C' ,g 4BUIrryqG bf01T 16 TOWN TO N OF NORTH ANDOVER � l� APPLICATION FOR PLAN EXAMINATION Perms t No#° I'"` Date Received �'�s RareD ae��RS s�co�us Date Issued: x PORTANT: Applicant must complete all items on this page LOCATION rin PROPERTY OWNER / Print 100 Ye Structure yesA MAP PARCEL: ZONING DISTRICT: Historic District yes no 40 Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition ❑Two or more family El Industrial 11 Alteration No. of units: [i Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ,,,e,rr,lrr.arr�L,�.. o,o�/��„�rrr.a7,Jd//m,%.,O/fl/r//!fr„,ariniv,r.,1ry,rr.a.-r ✓f//�,/7,..,/rr/r./,,i;,,,%,r.�/,//r/,/r./ri./,/r��r G/r%”//////rir/,/i./r�///�rr/t.:"rrrD�.//e..F:..lo7r:io7.dt.I i.if�/f r „, ./;/J.////,/r0,„,:,/�///rr,..r,.:/fi1,;' s.a..G r GdI �Jr,/,,,,,,cl,,.,k,��/�,,:/,r r/ii.r/e�,I r'�r/'//��i r..,�,„//,�r r/a,✓(�,r�JW.. at�er,r�r�rs.,„h.... ed�(rD,«,ts,t,„rnb.c�„.t,c„,r�yifrra/,,, / ,. ,.ff ,. ,. .ell ..r•r,i<.//,///� „/. ( (,. r,- ,., r ,r, / r rhe i,/,✓� r , r tl. r r;!i r .%/%/�. ,. r r r n ,, ,,r///,, / ,, r / ! r, 1• / rr r ,,1 ,/ fr / r, J 1�,//,ri r r, .h/ �l /.. � .err, r /i � :, ., r �„ ,. , , .r r 1, ,.r✓ (/ //, , ,.,iii r.,�. a ,. .�l ,.,, � � r � r �✓r,,. r �/1 r� n� .�1. r�� .,, / / r, /.//�r/r ,,rid., �� / r �. ll�/, ,,r / /✓. r./ ./.. /l 1 !r/,:rnr ��r:,.„I�,„„r ,�/,_.�C//.,./�/ ZIP 0OF,WORK TO BE PERFORMED: ESCRIPTIO Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: cam-' Contractor Name: /� .�S,'. f Phone: Email: 6 Address: Supervisor's Construction License: ✓p Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING 17ERMIT.$92.00 PER$90o0,o0 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ W FEE: $ r1ni 0,4 Check No.: Receipt No.: contwactin with unre i terecl cont>"actoa do not have access to the,guaranty fun NOTE: Perso ' g rim ®RTF _t own of Anctover ® ON No. _ *h ver, Mass, COCNICKr.WICK 7� DJ SATED S U BOARD OF HEALTH Food/Kitchen P E E[ T L D Septic System THIS CERTIFIES THAT ............... .tau"........ .......o... ... ............... BUILDING......... INSPECTOR . � has permission to erect .......................... buildings on Foundation Rough to be occupied as ......... .. ..�......... .. °....... �.�° ..�.................. Chimney provided that the person accepting this permit s:�?H�n every resp° t 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 c Final PERMIT I Villi�/�®N ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO T S Rough Service ................. .... .. .. ....................................... Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® ®ccupV 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. PYRAMID CONSTRUCTION 508 Lowell Street Methuen, MA 01844 (978) 852-8518 phone (978) 794-1961 fax JOB PROPOSAL Proposal Submitted to: Harrisons Roast Beef/Mike McMains Date: October 7,2015 Job Name: Harrisons Loading Dock Job Description: Rebuild damaged loading dock, 8'x14'as discussed,lnstall metal safety rail on 2 sides, and 5/4 decking to be painted with non slip material. We hereby propose to furnish labor for the sum of: $ 5,000.00 Payment to be made as follows: 100%materials and 50%labor cost due upon approval of proposal.Remainder of labor cost due upon completion All work will be completed in a timely,professional manner consistent with standard practices. Any deviation or alteration of the above proposal involving additional charges will be executed upon written request only. Any such charges will be in addition to this proposal. All agreements are contingent upon the absence of accidents,strikes or other delays beyond our control.The owner is to carry fire and other necessary insurance. All employees of Pyramid Construction are fully covered by Workman's Compensation Insurance. This'pro al may be withdrawn if not accepted within 30 days. Authorized Signature: Acceptance of Proposal The above prices and conditions are.satisfactory.and-are-bireby accepted. Pyramid Construction is authorized to do the work specified above. Payment will be made as outlined above.� Signature: (2z-� Date of Acceptance: /61 A Z", f __ _, ......__.._ ._._ . . ......., ... .._...... ........... ..... t _.. ..... ...w__ ....._ .._ .. _........_ _ ......... .., ..._.. .... ......._ ....._ ..... _ 1 %f f, d f 1 ...._...,... _......,..,........ ._ .............. ..,.,,... ...�.,_..., ......._. ,.......,_._._ ...... .,,.......,-,,....,..- .. W��✓ Ji ✓ _.. .........._._..,..,..._.. ., _.»._.. ,. .�,.. .. .,...._..,...,. .wm.._....., _�............ .. ... ...... w. ......, .... ...,_. ._._...,...... ... .,_,,.,..,. .......,......_.�,.,..,..,»...............,.......u.. ....,........,...,.. .,.,,... .. _......... .,,,... �4 if i ff i 1f s f� i 4 C t _._... ..... ,.__ _. .... ...... .. _..._._ _.a ._ _... _ .._.. ._ ........ ._ _._ �....._. ._.._. .... .... ..... .. __.... . ......... . ..._. .._.... . ......... _..... ......_. .__.......__..... ..._.. 1ead �f t r �r The Commonwealth of Massachusetts zZ Department oflndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dra SJ• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriciansl.Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Nalne(Business/Organization/Individual): V-i5\_V",-l Address: City/State/Zip: to `� �a`— Phone#: a Areyon an employer?Check the appropriate box: Type of project(required): 1.Z]I am.a employer with_�cmployees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodelilig any capacity.[No workers'comp.insurance required.] 3.F1 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. F1 Demolition 10 []Building addition 4.E]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 I have hired the sub-contractors listed on the attached sheet. ❑ 13 F]Roof repairs These sub-contractors Have employees and have workers' $ .comp.insurance. n v 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Otherw tC E� 152,§1(4),and we have na employees.[No workers'comp.insurance required.] *Any applicant that checks b6x#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit 1' is 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-conlracfors have employees,Uiey must provide their workers'comp.policy number. I am an employer that is providiiig workers'compensation insurancefor my employees.'Below is the policy andjob site information. A Insurance Company Name: S V�r 1 l Policy#or Self-ins,Lie.#: c_epe7Q_ 'J6 rvb P.--\ ExpirationDate: 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 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 certify der h6epai s andpenalti of pe 'rrry that the information Provided alcove is t. �true and correct. Signature: Date: Jb 't / `r57 Phone# 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#: AC"R" CERTIFICATEOF LIABILITY INSURANCE DATE(MM/DdYYW) 10/14/15 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: Jansen Hasbany & Regan Insurance AgenPHONE FAX (978) 685-3188 / Na: (978) 685-9460 254 Pleasant Street EMAIL ADDRESS: eric@hasbanV.com Methuen, MA 01844 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A:Capitol SpecialtV Insur INSURED INSURER B:Progressive Peter Budish INSURER C:American Zurich Insurance Pyramid Construction, LLC INSURER D: 508 Lowell St INSURER E: Methuen, MA 01844 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 ADDLSUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INR WVD POLICY NUMBER MM/DD/Y MM/DD/YYYY LIMITS A GENERAL LIABILITY y CS01357938- 8/16/15 8/16/16 EACH OCCURRENCE $ 1,000,000 ED X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENT PREMISES Ea occurrence) $ 100,000 CLAIMS-MADE [A]OCCUR MED EXP(Any ore person) $ 5 000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,0 0 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PCT LOC $ B AUTOMOBILE LIABILITY 07736803-4 12/2/14 12/2/15 EO MB, c .drt)INGLELIMIT $ ANYAUTO BODILY INJURY(Per person) $ 100,000 ALLOWNED SCHEDULED BODILY INJURY(Peraccident) $ AUTOS X AUTOS 300,000 HIREDAUTOS - NON-OWNED AUTOSPe0aceitlYDAMAGE $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC1-31S-379615-015 9/1/15 9/1/16 WCSTATU- X 0TH- AND EMPLOYERS'LIABILITYTOR FR ANY PROPRIETOR/PARTNER/EXECUTNE Y/N N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICERWEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is regui red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Inspector AUTHORIZED REPRESENTATIVE Eric Jansen z 01";�5� ©1988-201 ORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks o CORD Phone: Fax: E-Mail: