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HomeMy WebLinkAboutBuilding Permit # 10/13/2015 ,t%ORTH BUILDING PERMIT 16 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received SsATED5 Date Issued: s on this page IMPORTANT:Applicant must complete all item LOCATION Print PROPERTY OWNER rf" ._ Print 100 Year Structure yes no N\ MAP );-7, PARCEL:0'62--� ZONING DISTRICT: Historic District ye no Machine Shop Village ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building [] One family D Industrial 11 Addition 0 Two or more family Li Commercial 0 Alteration No. of units: tZ,Repair, replacement [I Assessory Bldg 0 Others: 11 Demolition 11 Other 110" mq4p, v.I S F I 0, ""d r �,` � /�li, �; ��/0�,q ,� Jr /i��/,��%/�r lr///�Ojr�����/i / a�.:I,.G,u,uiat�/rlalc, ef „e `/,�9// �� /a,,,,, DESCRIPTION OF )RK TO BE P_Eff7ORMED: I t.f I den 1 1pl on- Please Type or Print Clearly OWNER: Name: it Y'Y\i!). Ai�2 sz Phone: Address: ) y K Contractyr Name: � Qf)Ivkk, hone: Email: 73-co-, CN-.0 Address: Supervisor's Construction License: 0 C Exp. Date: Home Improvement License: Exp. Date: �)-IQJ/ (P ARCH ITECT/ENGI NEE 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: 0<2 —FEE: $ Check No.: (2,�j Receipt NoQIS2­1 NOTE: Persons contracting with unregistered contr tors+not h ve a cess to the guaranty fund 7, 7 7 J VtOR'TH r e town ot ® 0 • O LAME h ver, Mass, COCHICNEWICK 0RATED U BOARD OF HEALTH rER.MIT I L D Food/Kitchen Septic System THIS CERTIFIES THAT ..................Uavt............... �.. '` �: .... BUILDING INSPECTOR has permission to erect .......:.................. buildings on ... ..... .......... Foundation ..b .� .......... Rough to be occupied as ...... F:...................... ...... .. ....... Chimney provided that the pers 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 IT I I MONTHS ELECTRICAL INSPECTOR T T Rough UNLESS TI S 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 Approved by the Building Inspector. Burner Street No. Smoke Det. Back River Development 231 North End Boulevard Salisbury, MA 01952 7 55243733 Contract To: Christa Palmisano Date: September 1.9,2015 Re: Renovations of decks Pembrook Rd.N.Andover,MA Scope of services Replace 8 sections of rails on front and rear decks $2600.00 l_ ,PQ,(I-vn to qu o o Christa Palmisano,Homeowner Willi a` J.Ferris, Back River Development ACORO CERTIFICATE OF LIABILITY INSURANCE ��`N1o/13/)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: M.P. Roberts Insurance AgencyPHONE (978) 683-8073 FAX No: (97E) 6e3-3147 1060 Osgood Street ADDRESS: paula@mprobertsinsurance.com North Andover, MA 01845 INSURERS)AFFORDING COVERAGE NAIL# INSURER A:Merchants Mutual Insurance Co INSURED INSURER B:Associated Employers Insurance 13ACKRIVER DEVELOPMENT LLC INSURER C: 231 NORTH END BLVD. INSURER D: SALISBURY, MA 01952 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 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 - — — —ADDU SUER _ POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POUCY NUMBER M/DD/Y MM/DD/YYYY LIMITS A GENERAL LIABILITY BOPI080037 6/20/15 6/20/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGETORENTED P E SES Ea occurrence $ 500,000 CLAIMS-MADE [K]OCCUR MED EXP(Arty one person) $ 15,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 PRO- g POLICY X ECTFJ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY OPEGdYDAMAGE $ HIRED AUTOS _AUTOS _F UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC-500-5014220-201 1/12/15 1/12/16 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE Y� NIA E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatoryin NH) E.L.DISEASE-EA EMPLOYE $ 5oo,000 If yyes d es cribe under 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CHRISTA PALMISANO ACCORDANCE WITH THE POLICY PROVISIONS. 84 PB BROOKE ROAD NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE hA Michael P. Roberts ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: The Commonwealth of Massachusetts Department of IndlustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name(susiness/Organization/Individual): Address: N � r� i�S 1 v'f-> City/State/Zip: 6, Phone Are you an employer?Check th( e appropriate box: Type of project(required): 1.0 1 am em. a employer with M : employees(full and/or part-time).* 7. ❑New construction 2.l]I am a sole proprietor or partnership and have no employees working for me in 8. [,�A 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 F1 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. 12.0 Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors fiade employees and have workers'comp.insurancet 6.❑We are a corporation and its offigers have exercised their right of exemption per MGL c. 14.Q Other 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. T Homeowners who submit#tris 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-conlracfors have employees,&li 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. Insurance Company Name: . - Policy##or Self-ins,Lia#: W im` (-Q4 — CR 0 Expiration Date: 1 h sa, LP Job Site Address: S I ��f—a [�t:2 City/State/Zip: U, k6&\'pW' rU1 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. .I do Hereby certify under the ains and penalties ofperjuiy that the information provided above is true and correct. Sign 0: h V Date: Phone#: -rl-;, ' 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#: 1 Massachusetts -Department of Public Safety Board of Buildinq Regulations and Standards �ape�;iCUPAwk- License: CS-065005 BRIAN A LYNCH;-` - 31 SEVEN STAR RD GROVELAND M" 01834. J. 3ri4s�` Expiration Commissioner 11/15/2015 License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza=