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HomeMy WebLinkAboutPermits Permit # 10/23/2015 �0RT#1 9 BUILDING IT 0� TOWN OF NORTH ANDOVER / a ! APPLICATION FOR PLAN EXAMINATIO - Permit NO: Date Received b" ,w I SgcwusE��� Date Issued: IMPORTANT Applicant must complete all items on this page r ,/i ✓> �/r%�1 � r, �it , r�� / ,lir / / r/ / /r ,/ r,��/,// / // / r,,. ✓ r rr r, / /r� 1 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 El Assessory Bldg 11 Others: ❑ Demolition ❑ Other ❑;, � �fppKK r I / r / %r ice�, ! / ,/. r rrr, � r ,;, /;., /D r,/, ( / / O/,:,�{ rr/a, r/ a/rii .;./ iii, ,;>..✓ ,,rr .,,, 1 � � r ✓//r ,,/i ////i r, 6 ;, /i/ / / rr// / j S / 1 Identification Please Type or Print Clearly) OWNER: Name: ............. C vnovPhone: �f Address: , ItI r / / r r ,,,,r ,r/ /r ,/i;,, r rte, v, ,r / //,✓� r,r r ,r, r ,� ,� ... �/ / i, „ / � / / / /r ,/ it ✓ ,, r� / r/ r , � / rr rr r lig "".✓, . U / r r: rra, ,./ /.. r. rr r / r / , r / / ✓ /rr � / / / l r l� r r / � // , rr, rrl,r /i rrr„ / / rr, r / / / ✓ / ,, r ARCH ITECT/ENGINEER1 � i` . _ p . Phone: Address: B lr_r + ��, i � " 1 � Lz r eg. No. o Oay FEE SCHEDULE:BULDING P RMIT:$1T 00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. r� Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund g SNgnfuitie ofnrctor r' rra ure °f, + nt/p�rner r , r rim OCR TAndover ' i own of ® 0 ® C, `. h VeY', Mass, jjn L A IE 2�1 COCHICHe WICK �ok� AERATED S ll BOARD OF HEALTH Food/Kitchen PtR T L D Septic System THIS CERTIFIES THAT .......THIS INSPECTOR VOODOO has permission t e .......................... buildings on *AA1 .... Foundation .... ... ..... .. ............ Rough to be occupied ... ... ..... . ..... �..�...... �. ... ........................ Chimney provided that the r n accepting this p mit 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 MONTHS ELECTRICAL INSPECTOR 51P+Fk® S RTS Rough Service ............ ... . ........ ................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy.Buildin 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. Sport Court of MA � fl/IIa�� 4lfV��l� P.O. fox 5178 Andover, MSA 01810 Tel: (978)474-4029 P 0 R T Fax: (978)474-0135 C 0 6J R 11 bane McGillivray 77 Bear Fill Road North Andover, MA 01845 .. ®py Mpry W �.. 1,600 sq. ft.) COURT Sport Court of Massachusetts hereby submits specifications and estimates for the above project: Includes the following options: Pro ,Adjustable Slam Basketball System(s) with 42" x 72" backboard. peach will be - 6" or X48". Padding: Pole, Anchor, Backboard Multi Sport Net Adjustment System Multi Sport Net bouble Metal Halide; Lights Sport Gear Fun Pack Painting of Basketball A Game Liras i Sport Court - Power Game Flooring 0 Colors and layout as designed w Installation W 15 Year Mfg. Limited Warranty - Tile e 10 Year Mfg. Limited 'Warranty - hoop and steel components 0 Freight - Salt Lake City, Utah a Sales Tax Please note; only components listed above~ are included in this contract. Any changes need to be submitted in writing and signed by the original contract signer and Sport Court representative. These changes may incur additional charges and/or cause delays in the original timehedule. Initial li t v iualual Sport Cour`of FSA l/ice . P.O. Box 5178 Andover, IIIA 01810 Tel: (978)474-4029 P 0 R T Foix: (978)474-0135 r- 0 U R T bave McGillivray 77 Bear Hill Road North Andover, MA 01845 a AbbITIONAL SITE WORK OPTIONS. r f I i f The Commonwealth of Masscichusetts Department of bidlustrialAccidents . : 1 Congress Street, Suite 100 M Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY- Applicant UTHORITY.A licant Information L A' Please Print Le0b Name(Business/Organization/Individual): Address: V lQ( 1 City/State/Zip: /Vint Q bd�ldC/I.t/�4�-- 0 41_ Phone#: Areyo n employer?Check the appropriate box: Type of project(required): I. I am a employer with 7.(full and/or part-time).* 7. VNew construction 2.E]I am a sole proprietor or partnership and have no employees working for me in $, E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition I rl I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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.[J Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.[_1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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 submif this affidavit indicating they are doing all work and then hire outside contractors must s4bmit 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-contractors have employees,tfiey must provide their workeis'comp.policy number. X am an employer that is pi•dvidiizg workers'compensation insurance for my employees.'Below is the policy andjob site information. r Insurance Company Name: �a � Policy#or Self-ins,Lic.#: C � lY Q� Expiration Date: / J Job Site Address: 7� � �'` I('� City/State/Zip: r'&,I;� Q"� ` V ' 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 o. 152,§25.A.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 cer ify Under'thepNns and penalties of perjury that the information provided/a)hoy is tr e and correct. Signature: � - L �'"� Date v � 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: OP ID:CORA I II INSURANCE DATE(MM/DD/YYYY) CERTIFICATE OF 07/24/2015 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). PRODUCER Phone: 978-688-6921 NANracr Macdonald&Pangione Insurance PHONE Hannah Courtemanche AAI CISR AX P.O. Box 428 Fax: 978-688-5350 ac No Ell:978-688-6921:978-688-6921 (ac,NeZ 978-688-5350 104 Main Street E-MAIL m hannah ins.net North Andover,MA 01845 ADDRESS:hannah@mpins.net DGCON-1 Donald Schemack CUSTOMER ID#: _ __ __ INSURER(S)AFFORDING COVERAGE NAIC INSURED D G Contracting,Inc ID 646648 INSURER A:Travelers Prop&Casualty CL 25674 428 Pleasant St North Andover,MA 01845 INSURER B:Safety Insurance Company 39454 INSURERC:National Liability&Fire Ins INSURER D: 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. -- TYPEOFINSURA NCE - - -POLICY EFF i PLICY /NSR� ADOLSUBR,' LTR i i VD POLICY NUMBER �MMIDDlYY MMO/DDIYYYY LIMITS GENERAL LIABILITY 1 EACH OCCURRENCE S 1,000,000 A X_ COMMERCIAL GENERAL LIABILITY X j 1680-1553R18 05/17/2015 105117!2016 AGE pREMJSES�a occurrRENTEDence_ S 300,000 — —– – -- – CLAIMS-MADE X OCCUR 1 I MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY _ S 1,000,0_0_0 GENERAL AGGREGATE _ S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMPIOP AGG S 2,000,000 !. POLICY-X PRO- PRODUCTS T I LOC I $ AUTOMOBILE LIABILITY I (COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO (Ea accident) - BODILY INJURY(Per person) S ALL OWNED AUTOS 1 — � BODILY INJURY(Per accident)I S B X SCHEDULEDAUTOS ( 3116538 07/12/2015 07/12/2016 PROPERTY DAMAGE XHIRED AUTOS i (Per accident) ---- - S — - I X ! NON-OWNED AUTOS S 1 X UMBRELLA LIAR XOCCUR EACH OCCURRENCE S 1,000,000 - - EXCESS LIAR I j CLAIMS-MADE] AGGREGATE S 1,000,000 A /CUP-0090153321 05117/2015 05/1712016 DEDUCTIBLE S l I RETENTION S I I S WORKERS COMPENSATION j X TORY LA ITS OER AND EMPLOYERS'LIABILITY y I N C 1 ANY PROPRIETORIPARTNER/EXECUTIVE F- NIA IV9WC640862 03/31/2015 03/31/2016 E.L.EACH ACCIDENT 1$ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) i E.L.DISEASE-EA EMPLOYEI S 1,000,000 If yes,describe under -"---- --------------__-- ----"-"—- - DESCRIPTION OF OPERATIONS below ( E.L.DISEASE-POLICY LIMIT S 1,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) '.. Re: 70 Possum Road, Weston MA. Additional Insured: Alan Rottenberg, Martin Glazer as Trustees of 70 Possum Road Realty Trust c/o Goulston and Storrs, PC, Andrew and Melissa Janfaza, LLC and the Legasse Group, LLC CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sport Court Of MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. P O Box 5178 Andover, MA 01810 AUTHORIZED REPRESENTATIVE I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD WssachusMs De"nmm" M puww SMmy or'd of BuiMng RguNatjounci incensei C 00182 ,m,,,,9rmflon 11411',/^pv7°oc 9�/, �I]""'. 31 DAVID P GULL IAN 428 PLEASANT$T NORTH ANDOVER Mk/,//'� <pu norf COMMON" WHIM WWROVfNEWT CONTRACTOR C Tww 1,20199 J DAM 01 IMS DAND UNEVAN 429 PLEASAI T61" NCR'll i ANDOVER,,MA(lifW$