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Home My WebLink AboutBuilding Permit # 10/26/2015 OORTH BUILDING PERMIT TOWN OF NORTHANDOVER '0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received 1�)I'Z'u O"ArEP S C Lis Ve Date Issued: kbL 11 IMPORTANT: Applicant must complete all items on this page TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building % One family El Addition El Two or more family El Industrial El Alteration No. of units: D Commercial K Repair, replacement El Assessory Bldg 11 Others: 11 Demolition D Other J/% DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: GL 1ss-G ct OcIt Address: J'elm//i ff 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: $ 231 tQ TEE: $ Check No.: U--'o Receipt No.: V) NOTE: Persons contracling with unregistered contractors do not have access to the guaranty fund u I r I at �Slgn'ature of W- I� ' " ' AM IAORTH own of .. It 11 .7'� ndover O to s WE ® _ __. h ver Mas W. `") COCMICHt WICK �.9 A�R�iTEo AYp'�,`y tS V BOARD OF HEALTH rER I T Food/Kitchen Septic System THIS CERTIFIES THA T .... .....M. ............ M.W".1ro........... ..................... BUILDING INSPECTOR . has permission to erect .......................... buildings on . ....... .............. ... ...!�!`... ............ Foundation� 2M ..... . .M.M.4;. Rough tobe occupied as .... ........................................................................ Chimney provided that the person accep ng 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 PERMIT EXPIRES 16 ONTH ELECTRICAL INSPECTOR ® LESS STR C T S 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. FRANCIS A. HEBB DESIGN/BUILD CONTRACTOR CONSTRUCTION MANAGEMENT AND CONSULTING Residential,Commercial Building&Renovations Construction Supervisory License#033217 Home Improvement License#107916 CONTRACT TO BUILD 70 Lake Shore Road, Boxford, MA 01921-1115 Shop (978)352-6123 Fax(978) 352-5068 Cell (978)423-6637 HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Owner's Signature) Date Signed w C?� (Contractor's Signature) Date Signed t O I � �� The Commonwealth of Massachusetts Department of IndustrialAccidents d 1 Congress Street, Suite 100 �< Boston,MA 02114-2017 www nass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LelZibly Name(Business/Organization/Individual): 1`kcki U%. •� � C1��1' Address: 'ZcD "�_, s," City/State/Zip: KSgk Phone 2,1 Areyou an employer?Check the appropriate box: Type of project(required): 1.[XI I am.a.employer with employees(full and/or part-time).* 7. E]New construction 2.F]I am a sole proprietor or partnership and have no employees working for me in 8. [:]Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition ❑4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition 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. Roof repairs • These sub-contractors have employees and have workers'comp,insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. I Homeowners who submit: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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is pifoviding Ivor kef s'compensation insurance for•my employees.'Beloiv is the policy and job site information. Insurance Company Name: `v^\, htn.Lk",A T, Policy#or Self-ins,Lic. "2cy 611'12;' •-2615-A Expiration Date: W 11(o Job Site Address: LP0 m.PA WC&,J iat City/State/Zip: t\. A-,�u•U cr,&t 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$250.00 a day against the violator.A copy of this statement may be fol yarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofpeijuiy that the information provided above is true and correct. Signature: I Date: W Phone#: Official use only. Do not ivrite in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY 'MIS I Td IS ISSUED AS A MATTER OF INFORMATION ONLY D CONFERS NO RIOWS UPON T14E CERTIFICATE Mathias InsurAnce A"acy, Inc: HOLDER. THIS RT ICA T AMEND, EXTEND OR 200 Sutton Street, Suite 160 L E CO NSE AFFORDED BY THE POLICIES BELOW. W. North , NA 01845 INSURERS AFFORDIN6 COVERAGE r N: oni o' n Co.Inc. WwAERA, 7 0 ukkashore Road qiSvRFR a Insuranc4i CID. , MR 1 TK POLIC WZ OF MSURANCE N,NSTENI KLQW HAVE REEN NESUED TO THE INSURED NAMED ADOW FOR T N,rGY PERIOD INTED NO-fW"146-tANDING ANY RECIARDAENT,TERM OR CONDn*NT CNS OtHER DOCUMENT NTH RESPECT TO WHICH T"NS CERWlCAM My Pt I$SUF-0 N�EN�'k', NNN,.'THE r18 E Ar-F 7 ESN BY THE L NBED HME k M SLNBJECT TO ALNL. 145`FE S.EXCLUSVNS ,NwND ?NDN 4 R R)NS OF UC N t t A TE L s SHOWN � E REDUCED BY� N mm.. LIPSR on, 100.000 14P0020003000688 0688 12/16/14 12/16/1 N N r a � www � �QOAQO r 000 x 00 000.000 Z L AuTomaalutimazy o 100,000 MRS)AK 058017 12/22/14 12/22/15 4 300,000 N X14 Et�+ _ 944 0frUWWWEI VE1wjmU LaN<'N'LmdtNt��N T_ tONAND AN E 'L6L Fr 1�N£xB FaL lc F N,.MWOE,POLICY IWO N�"TwLF CERTIFICATE HOLDER CANCLLLATl0N,,,...,,,.- Townof North Andover N TF� �F.PEO sr�, w��t E �V�N r N�AYs+r 10� Main Street d"NW KIE To l4c-FERTiF� A "MUE N NN ,Kk TO TVNr t EFT.BUT F LUPIE'Cay 00 O 8#0,L 9 SE WOB110AVON 00[IA90TY Of ANY K00 OPO N THE NWRER ffS r VaT-On RU4�*FNWTIVES ��7Z,"lltl aRn2a( ?i9iNN1 F1Pt+f114fId5 lam$ m i Massachusetts.- Dei r fiment of pub sa �r Board ()i Building R.ac+lnticns and Ss;c; „ds t'un,tructiun Suhcr�iour License: CS-033217 `. FRANCIS A HEBB- 7 70 Lake Shore Road Boxford MA 01921 y, Comrissia��r 03/26/2016 //L' V/09l/glto7l(!/BCC((�IL O�U(��CIJJCCC�[CJC� t} Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR h egistration: 107916 Type: j xpiration: 8/10/2016 Private Corporatio;l FRANCIS HEBB CONSTRUCTION Francis Hebb 70 Lake Shore Rd Boxford,MA 01921 Undersecretary k 1 r=;i