HomeMy WebLinkAboutBuilding Permit # 10/28/2015 01 t%ORTH
BUILDING PERMIT +
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Permit No#: 0 A
A US
SR
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATIONLt J:hfkJSL: C 10CLE- 99M NOW- MAOkq,5'
1 -1 1.J— Print
PROPERTY OWNER K"A V s-5144 LftL It
",, � IPrint 100 Year Structure yes 0
MAP PARCEL: ZONING DISTRICT: Historic District yes no
0
Machine Shop Village yes Cno
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
[E] New
B
uilding One family
E Addition
[I Two or more family El Industrial
El Alteration No, of units: El Commercial
epair, replacement 11 Assessory Bldg 0 Others:
El Demolition El Other
DESCRIPTION OF WORK TO BE PERFORMED: ,,
L�ta-n�c" �c4' V k-- Y—x iny w ji-c yi--wu) 5:eq UG ti—6z
(y) C2E f,�A2 0 �,-B 8DA 61�Z VL--h T5 11 r byk� V01 V44. rpell&'
Identification- Please Type or Print Clearly q7� -0t
OWNER: Name: kA rN �c U Lac 1i'a Phone:
Address: E C.t6,- Al Q P-f b OVI (11 IA 0 IS
�)LIWA)'S
111 P
Contractor Name: AAJ hone: Idoo 0EWC1,
Email:
Address: k7)q,)g' LW&-T1L--W) /h/L
Wk"
Supervisor's Construction License: —Exp. Date: ,,,,,3 LJS-U� /�
Home Improvement License: )d I bu- Exp. Dater /d-,GU5,
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: .00 FEE: $ Ir-1)?-2,
Check No.: L- Receipt No.: 2e)c:�-1�
NOTE: Persons contracting ivith unregistered contrqctors do not have access tqthe guaranty and
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FORTH
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Town of '� �.. a '' 11 U
le
® ;� _ r '* to
•
0h ver Klass
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IWOC94K., 2V
COCHICNCWICK
A°RAreD )',f 5
S U
BOARD OF HEALTH
Food/Kitchen
rrER L D Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
......... . . ....... .... . .. ....... .m. .......
.. . . . . .. . ... ... . . ... . . ..
has permission to erect .......................... buildings on ......... . ,,,. LAAC .....,,,,... Foundation
to be occupied as ... fp/c
l�Q. ...... .. .sk . .�. .. ... ... chimney
uprovided that the person acthis permit shall Ian every respect cbnf to tf 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
IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCXTSTATS 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
°h
.f
The �"oiti oitweaCtlt o �Iassacltiisetts Print Form
Department of Industrial Accidents
Office o 'Iiivesti ations
1 Congress Street, Suite 100
Boston, 02114-.2017
* k www.inass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1,Q%/�,1 J� i] y�
Address: f
City/Mate/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a emplo er with ., 4. ® I am a general contractor and I
have hired the sub-contractors 6. ❑ New construction
employee fulland/or part-time).
2.❑ lam a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling
ship and have no employees These sub-contractors have 8. ® Demolition
working for me in any capacity. employees and have workers' 9 Buildingaddition
[No workers' comp. insurance comp.insurance.1 ®
required.] 5. ® We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs ,or additions
myself. [No workers' comp. right of exemption per MGL 12.[�Roof repairs 5 1� ( 1, (;01(
insurance required.] t c. 152, §1(4), and we have no ! Afay
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this 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-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. below is the policy and job site
information.
Insurance Company Name: Rnat�-)&) .1,-,A&&, -h a
Policy#or Self-ins.Lic.#: Y Expiration Date: p2C" /
Job Site Address: ams r2 '.(t=' City/State/Zip: 11&1160VLz lull 016V
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify raaatler fleeaiaas aaatl venalties of perjury that the informationprovided above is true and correct
_._..
Signature:e: " _ --- Date: (C h c /
Phone#: !] V-6 1 - 060
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PerrnitA,icense
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#:
OP ID:JG
AOCCARLY DATE(MMIDDNYYY)
liz..� CERTIFICATE OF ii INSURANCE 06106/15
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 poliey(ioo) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terns and conditions of the policy,certain policies may require an endorsement A statement on this Certificate duos not confer iglus to the
certificate holder In Ileu of such endorsemen s.
PRODUCER 978-975-1300
Seg rave S Hall Insur.Asvo0•Inc NAME
305 North Main St. 978-975-7596 PHONE FAX No):
Andover MA 01810
Edward ht mirez ADDR�s:
THOMA-�
INSURER 5 AFFORDING COVERAGE NAICR
INSURED Thomas Quinn INSURER A: Casualty Insurance 42646
dba Quinn's Constructloo INSDRERB,Hartford Ins Co.
1049 Lakeview Avenue,Unit 8
Dracut, MA 01826 INSURER C;Arbella Protection Ins.Co. 41360
INSURER D:COMMeMe $4754
IN$URERE:
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 DRSCRIBED HEREIN I$SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY NUMBER MM1DDD� MMILDro Y EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,00
A X COMMERCtALGENERALLIABIUTY M0350001230 01/15115 01116!16 PREMISES Ea or cu Uwe $ 100,00
CLAIMS-MADE ®OCCUR MED EXP(Any One parson) d 5,00
GGLLYN 11/26/14 11126116 PERSONAL&ADV INJURY S 1,000,00
D X Snow Plow OENERALAGGREGATE 3 2,000,00
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMP/OP A013 5 2,000,00
JECT El POLICY PRC` LOC 3
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 3 1,000,00
ANY AUTO BODILY INJURY(Pet person) S
ALL OWNED AUTOS BODILY INJURY(Per aoddent) S
C X SCHEDULED AUTOS 1020029603 05/07/16 06107/16 PROPERTY DAMAGE
X HIREDAUTOS (Perewdeni) $
X HON-OWNED AUTOS Underinsured s 10013D
Uninsured 3 100!30
UMBRELLA UAe OCCUR EACH OCCURRENCE S
EXCE,"L(Ae HCLAIMS-MADE AGGREGATE S
DEDUCTIBLE 3
RET--N ON $ 3
WORKERS COMPENSATION X VYCSTATU• OTH-
AND EMPLOYERS'LIABILITY
B ANY PROPRIETOR/PARTNER/EXECUTIVEYPN 116P704 01/16/16 01116/16 E.L,EACHACCIDENT S 100.00
O--rFICERIMEM9ER EXCLUOEPT O N I A. —
--
(fdand;toryin NN) E.L.DISEASE-EAEMPL,OYEES 100100
IP es,desrailoe under 5DD,DD
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMITS
DESCRIPTION OFOPERATIONSI LOCATIONS I VEHICLES(Attgdh ACORD 101,Additional Rama"SChedute,If more spRea to mgRfrod)
Sole Proprietor Thomas Quinn is Excluded loader Workers Camp
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
AUYHORIYED REPRESENTATIVE '..
®1988-2009 ACORD CORPORATION. All rights reserved.
ACORD25(2009109) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
10 IPlark Plaza a Suite 5 170
Boston,Massachusetts 02.116
Home 1niprovement Contractor Registration
Registration: 121604
Type: DBA
Expiration: 5/24/2016 TdA 250393
QUINN'S CONSTRUCTION
THOMAS QUINN
868 MAMMOTH RD.
DRACUT, MA 01826
Update Address and return card.Mark reason for change.
SCA 1 0 11 ® Address E] Renewal ® Employment ® Lost Card
Office ofConsamwAflairs&llnsiness winfion License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration d 1'f found return to:
egisiaatianm 121604 Type. Circe of Consumer Affairs and Business Regulation
piration: :512412016 DBA 10 Park Plaza-Suite 5170
Boston,KA 021.16
QUINN's CONSTRUCTIONLo
THOMAS QU.I.NRi
866 MAMMOTH RD_ ;?,�
DRACUT,MP.01826 Undersecretary Not va1Hd withou signature
t 1 Massachusetts -Department of Pv:bft Safety
Boa*rd f BuRdi A Reguh.Aions and Standards
Construction Supervisor UnTeStI df—B+g�I,diQ OfElny UN g'Illi T-Alkh
License: OS-039732 c ; km F 35 QQ :.o (9
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THOMAS J QUH41jL� ° _ , L G _
868 AIAMMOTH-RD
DRACUT MA 01 26
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CERTIFIED
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VINYL.SIDING
INSTALLER
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Quinn,Thomas Expires:4/1/2017
868 Mammoth Rd ID#:17412
Dracut,MA 01826 Certified Since:2014