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HomeMy WebLinkAboutBuilding Permit # 10/26/2015 BUILDING PERMIT Oo oT b�� TOWN OF NORTH A V �� `'`'- ` "`' ° oL APPLICATION FOR PLAN EXAMINATION ® ` Permit No#: Date Received Ygl RATED PPa� �? SsgcwusE Date Issued:abb IMPORTANT: Applicant must complete all items on this page 10) uar �' PF TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑A aeration No. of units: ❑ Commercial ZfZepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other nor r' m i le /i r�r�i ,�,r/r/ rur r � r� ../rf r r.� ,r.r�%.,. / �� �"%,., ,ll;�i,/�f 1, ;.,.fill�,u,L(.d%l 1///r .„ .,/i i/%%IF ao ,eftarla$errs �sl ct, ii; DESCRIPTION OF WORK TO BE PERFORMED: Q24 5�v� ek("4 w Identification- Please Type or Print Clearly OWNER: Name: Phone: , 7 -t' Address: 01 vl e-- r fire r 1 t"6 .. 11,44 0/ 915- 1121/1 1 rl/!�1%/1r!/�/r�/'!// //%%/r%///r%%/;//,l% r2, ,.,,�%� i�% % 1W ARCH r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ CV0 "o, FEE: $ Check No.: Receipt No.: 24 � NOTE: Persons contracting with unregistered contractori do not have ac ces to the uaranty fund / / 1'W r Hlrit SMgnatureof Agent/Qwner ��,. / r,, �ign, tine f�coc /�;�°,�/��%�/„<,, � � , �// OFT rim I own 01 -Anduvuf zolph ver, Mass, /10/__911/ coc.uc..a W.c.. �1• �.AS RATED PX0 r U BOARD OF HEALTH Food/Kitchen ' PE m I i T LD Septic System THIS CERTIFIES THAT ....... ••�::!', � A..... v` Z ��1n............................................................... BUILDING INSPECTOR ....... . ................. has permission to erect buil in son ��� ���«'6 S� Foundation p ...............5. ............................................................................. Rough tobe occupied as ........................................ .... .. ..... 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 IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CTI TARTS 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. Work r Janusz Dziedzic (978)683-5286 10-23-15 213 Haverhill St Methuen Ma Licenses#: CSSL-100965 HIC#:154770 For: Judith A. Pulzetti 209 Greene Street Norh Andover, MA 01945 Work consist of: Removal and disposal of the old roof Install new drip edge Install 3ft ice and water shield and paper for the rest of the roof Install new shingles costumer choice Total includes labor and material: $ 7,000.00 d` t= 'j The Commonwealth of Massachusefts Department of Indust�ialAccideuts 1 Congress Street, Suite 100 -Boston,MA 02114-2017 'l^ ,syti4�t www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAUTMG AUTHORITY. A licant Information Please Print Le ibI Name(Business/Organization/Individual): Q 1 Address: Z 65—"02�i. �� /�( �Lt �L��0_ /�'� - 0/(0/( �,� City/State/Zip: �mU 7e IGJ ���1 Phone#: /7, -'1 Are you an employer?Check the appropriate box: Type of project(required): 1.QJ,ern aemployerwith employees(full and/orpart-time).* 7. 0 New construction .2.[61 am a sole proprietor or partnership and have no employees working for me in 8. [1 Remodelhig 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 10F]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.Q P Bing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurancet 6.Q We are a corporation and its officers have exercised their right of exemption per MGL o. 14.❑Other 152,§1(4),and we have nq 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. i homeowners who sulin it 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-conlracfors have employees,rliey must provide their workers'comp.policy number. -tam an employer tliat is prdvidiiig workers'compensation insurance for•my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lic.#: 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 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 DTA for insurance coverage verification. .T do Iter•eby certify under the pains and penalties ofperjury that the information provided ahove is true and correct. S re: � �'� ( y l G" Date: LP #: 2 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#: NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be .s� sed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: (Locatio f_ acility) Z, � G�GL� 'Signatur it Applicant Date _� e t- hl15 ® DATE(MM/DDIYYYY) A� CERTIFICATE F LIABILITY INSURANCEF 10/26/15 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: Trudy Lawler Armand P. Michaud Insurance AgPHONE (978) 685-2549 AIX No: (978) 794-0822 105 Haverhill Street E-MAIL ADDRESS: Methuen, MA 01844 INSURERS)AFFORDING COVERAGE NAIC# INSURERA:Safety Insurance Co INSURED INSURER 13:*Safety Insurance Co Janusz Dziedzic INSURERC: 213 Haverhill Street INSURERD: Methuen, MA 01844 INSURERE: 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. IL7R TYPE OF INSURANCE ADDL SUBR POLICY EFF POUCY EXP INSR WVD POLICY NUMBER MM/DD/Y MM/DDIYYYY LIMITS A GENERAL LIABILITY BMA0022291 7/30/15 7/30/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIALGENERAL LIABILITY DAMAGE TO RENTED PREMISES E occ a ce $ 100 000 CLAIMS-MADE OCCUR MED EXP(Arry one person) $ 10 000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATELIMIT APPLIES PER PRODUCTS-OOMP/OPAGG $ POLICY PRO-ECT [ LOC $ ',.. B AUTOMOBILE LIABIUTY 6210613 7/14/15 7/14/16 COaBINEDnSWGLELIMIT ANYAUTO BODILY INJURY(Per person) $ 100 ALLOWNED X SCHEDULED BODILY INJURY(Per accident) $ 300 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE '.. HIREDAUTOS _AUTOS eraccident) $ 100 5 UMBREULA LIAB OCCUR EACH OCCURRENCE $ '.. EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N FIR ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCI CENT $ '.. OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,ifmore space is requi 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 Department 1600 Osgood St Bldg 20 Ste2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Konnie Phifer ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 794-0822 E-Mail: konniephifer@michaudinsurance.com V�.G'�477C0'YLCv12dUCdCi%l2!�C`�'7�GCl59CCC�GLi C'��Ji. '\ Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 154770 Type: 1 xpiration: 4/4/2017 Individual JANUSZ DZIEDZIC r` t JANUSZ DZIEDZIC 213 HAVERHILL ST ti�. •,,.� -- x METHUEN,MA 01844 Undersecretary Massachusetts - De Ga;',—ent o' �,-ibj 1 r Board of Building Regu:ations and S;ancard+s Construction Supervisor Specialty License: CSSL-10.0965 -1 i 1" JANUSZ L DZIED, IC 213 Haverhill St. Methuen MA 01944 + , O ¢ r .ommisslooe; 03/26/2016