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HomeMy WebLinkAboutBuilding Permit # 10/28/2015 4§ %AO oT 6 pMo BUILDING PERMIT TOWN OF NORTH ANDOVER i APPLICATION FOR PLAN EXAMINATION Permit No: Date Received ,. ry o OAT- Date Issued: 4CNlf'S IMPORTANT:Applicant must complete all items on this 2age LOCATION N-0 �" 4"r .' rent PROPERTY OWNER (,- 2 06I. Print MAP NO:j9-�—PARCEL: ZONING DISTRICT Histodc,District ys% no .. Machine Shop 1/illage; yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial V,Sopair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer v� J 12 C Identification Please Type or Print Clearly) OWNER: Name: 5U3&K1 4c4ou.t Ajea(., Phone: 9a Address: CONTRACTOR Name: (PZ.Phone: Address: r Supervisor's Construction License: Exp. Date: a 7 C.SL�laa ,r Home Improvement License: , , Exp. Date: .==/ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ �(� .�' FEE: $ d Check No.: �. VA Receipt No.: NOTE: Persons contracting ith n tered conte tors do not have access t uaranty fund Signature of Agent/Own ignature of contractor , - NORTH Town of 11 .71, ndover ® iL � - C,, h ver, Mass, C coc.ocHewic« y1' A044.r S V BOARD OF HEALTH Food/Kitchen rwERMIT T D Septic System THIS CERTIFIES THAT ....... .............................................. BUILDING INSPECTOR —� Foundation has permission to erect .......................... buildings on �5 &. ��. .....��— ....... .1.. .... .. .......... .]... .0 Rough to be occupied as . .L�....... (�d ...G�?l?lacG .qr.^. .'...... :4-. ..... ........... /%...... Chimney provided that the person accepting this permit shall in every respt conform to the terms of the app ' ation Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alterationand 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 I 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION EgA7Rough Service ......................... .. ................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to 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. � � � Sweepnman, Inc. � � 10OMain Street Building North Reading MAO1884 Phone:<9DN0O4-6O4z � Fax:(978)6641288 � Service Information ����� ���� ��x�nn� ��n ��er Susan Letourneau536 Forest St Billing Information North Andover MA 01845-3216 Susan Letourneau Contact: Susan Laturno 536 Forest St Phone: (978)687-0442 Fax:Alt Contact: Alt Phone (978)807-7323 North Andover MA 01845-3216 � E-Mail: smlet536@gmail.com Marketing Campaign Yankee Job Name Call Ahead Confirmed Sales Rep Terms Type Class Job Type PO# Route Schedl�Start End BrianH 10/24/2015 08:00 AM 02:00 PM Quantity Rate Amount � � � � � � UNER:FIREPLACEUNER - Installation ofappm 6"x25'hybrid stainless 1 $2,290.0000 *2,29000 Liner for customers fireplace insert.This includes all components necessary top and bottom. Permit ' Permit Fee 1 $250.0000 $250.00 MISC.SERVICES - MISC.SERVICE pick up insert,delivery,set up,and installation 1 $250.0000 $250.00 Job Subtotal: $2.780.00 *U.00 Account Balance: $0.00 Total Due: $2.790.00 [-Sysaa info- ---- Home Heating Chimney Inf=o System Chimney Ca�_p Job Notes and instruct ions Customer 1upurchase jotu|wood burning fireplace insert This report iothe result vfvisual inspection done sdthe time ofcleaning. |tiaintended aaa |have read this form and understand the onnvenianoetoourouetomor.nntoeonortifiooUonoffiewmrthineoeoroofety. Since apparent condition ofmyfireplace,appliance, conditions of use and hidden construction defects are beyond our control,no warrantee is chimney,and/n/vent system. Furthermore made for the safety or function of any appliance,and/or system,and not is to be implied. understand the limitations nfthis report osgiven. The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations Congress Street, Suite 100 Y Boston, MA 02114-2017 www.mass.gov/dia /Contractors/ 1e Workers' Compensation Insurance Affidavit: Builders LPlease Print Le ibl Inmat ionnt 't, ne tiollndividual) � (Business/0rganizan GZ�1 Address: Phone 4: City/State/Zip: Type of project(required): Are you an employer? Check the appropri a box: 4. (1 I ata a general contractor and I 6 []New construction 1.[KI am a employer with ___ have hired the sub-contractors employees (full and/or part-time). 7. E] Remodeling listed on the attached sheet. 2.❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑Demolition ship and have no employees employees and have workers' 9_ E]Building addition working forme in any capacity. comp. insurance.} [No workers' comp. insurance 10.❑ Electrical repairs or additions 5. [] We are a corporation and its required.] officers have exercised their I.[]plumbing repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 12.❑ Roof repairs � � myself. [No workers' comp. c. 152, §1(4),and we have no insurance required.] 13. Other employees. [No workers' n � � comp. insurance required.] Ll � Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. doing all work and then hire outside contractors must submit a new affidavit indicating such. Homeowners who submit this affidavit indicating they are ewing the name of the sub-contractors number.and state whether or not those entities have :Contractors that check this box must attached an additional shet sho employees. if the sub-contractors have employees,they must provide their -workers'comp.policy I am an employer that isproviding ivorkers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name: Policy#or Self-ins. Lie. #:� � "31 S '"�"��(�/37��l Expiration Date: 14;z 0 Job Site Address: �J�D ;�lS Y City/State/zip:�U(�f (Y1 G�!� Attach a copy of the workers' compensation policy cieciaration page(snowing the policy nuimbui- And cxpi lion auto. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine 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 finc 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 under tl:enain.dpenalties of perjury tlzat the information provided abovee i true a;<zd correct. Signature: �' Date: Z 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): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ACIJRL/® DATE(MMlDDNYYY) �. CERTIFICATE OF LIABILITY INSURANCEF / / 5 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 c4I CONTANAME: DALE E.JOHNSON 13-JOHNSON INSURANCE AGENCY, INCEx (978 887-8304 FAx : -- — (A/C,No):97$8$7 551? PHONE E-MA DALE JOHNSON- AGENT A DREss:NALE JOHNSON cz FARM-FAMILY.COM 7 GROVE STREET, SUITE 201 INSURER(S)AFFORDING COVERAGE NAIC# TOPSFIELD, MA 01983-1862 INSURER A.MESA UNDERWRITERS SPECIALTY INSURED INSURERB-CERTAIN UNDERWRITERS AT LLOYD'S, SWEEPNMAN INC. INSURERc-LIBERTY MUTUAL 27 LOWELL ROAD INSURER D: NORTH READING, MA 01864 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 I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YY MM/DD/YY '',.. A X COMMERCIAL GENERAL LIABILITY MP0004018000569 11/18/201411/18/2015 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE f XJ OCCUR DAMAGE[ -TO PREMISES(Ea occurrence) 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ,2,000 000 __. X POLICY� PRO- POLICY ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident I L I 1 1 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ Ci WORKERS COMPENSATION INFORMATION TO STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N FOLLOW UNDER E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? N/A - SEPARATE COMER _ _.._$- (Mandatory in NH) E. DISEASE-EA EMPLOYEE $ If yes,describe under DIRECT FROM CARRIER L. — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ R CaONTRACTORS PROFES SIONAL LIABIt.IT`(AND SP00221 11/18/2014 1 1/18/2015 $100,000 EACH CLAIM-PROFESSIONAL LIAMIATY POLL LITION LIABILITY $10,000 EACH CLAIM-POLLUTION LIABILITY DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CHIMNEY CLEANING/INSPECTION, MASONRY,APPLIANCE DISTRIBUTOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SUSAN LETOURNEAU ACCORDANCE WITH THE POLICY PROVISIONS. 536 FOREST STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE dI 2)4& 5 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and loco are registered marks of ACORD P: - --'fl: *1" " -)(-), -111c): At-4 P.39' I-R( -011( ...978887 -,5 '1 A Cl',"CDO I? CERTIFICATE OF LIABILITY INSURANCE UA I I-(MMI00fYYYY) 10123/2015 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 andorsernent(s), NI PRODUCLIZ D-JCO OHNSON INSURANCE AGENCY INC NAWcl 7 GROVE STREET STE#201 PHONE FAX 1-01-SFIELD, MA 01983 -tAK; -----------— JAAXNy):-- -AO I)RI;ss: I R AFFORDING COVERAGE ------- -------------- NAIL it INSURER A LM Insurance Corpora tion 33F X101 INSURED SWEEPNIVIAN INC INSURLIt B 27 LOWELL RD -INSUR-EA C-L.1-111-1-1---------- NORTF-I READING MA 01864 -INSUJILK t) INSURER L Itisumm I:w COVERAGES CERTIFICATE NUMBER: 27027633 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. t,401ANIT'lisTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITI I RESPECT 'TO WI HCH TIIIS CERTIFICATE `VAY BE 18,13,UED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OFSUGH POLICIES.LIMIT881 TOWN MAY HAVE BEEN REDUCED BY PAID CLAIM8. POLICYNslt POLICY XP I'YPE OF INSURANCE I N 8 1)Rwijv D POLICY NUMBER (MM/t)DIYYYYi FuMMMI I S COMMERCIAL GENERAL LIABILITY EACH OCCURRri-ICIF —1 C(AIMS-MADF 0 OCCUR lbl&.KcFYO*k1taTrff -PREMIsE3 Is,,ow,rnvm 1,11;D FXP(Any ono -------------- OFITI-A03ORFGATH LIMITAPPI.IFS PER. G FNFRAL AG CRF(,/,T[:, $ I E R LOC OTHER. PRODUCTS-GOMPM W AGO $ JFCT OTIIFR AU I ONIOBILL LIABILITY CONIBINED SINGLE LIMIT ANY AUTO soolt-y INJURY ALL OV44F I' I 9CI 117DULE-0 AU'ros i AUTOS BODILY INJURY tPorxcitu-no s NOWOWNF�r) PROPERTY OAINZT�--- MRFO,AUTOS ....... AUTOS Por rtdrnu --------------------- ------ UMBRELLA UAB OCCU�R _ rAC,I I CC,CUR RFNCJ: CI AIMS-MADE DFD PrTFNTIONS $ A WOMOMS COMPFNSAI ION -11 S-388119-() 121181201.1 12/181201 R WC!) STATUTF. AND Y/N ANY FROPH It'I OWPAR I Ill-IVEXI.-CUI(VI: 'GOENT 100000 ,)II WINJW-FMHFR I:X('f UNA)? NIA F1- rACI I AC (mmidi(oly in NII) 5 1 if vm, -F L,018(�ASF•F/%EMPI G YkE 100000 DESCRIPTION OF OPERATIONS t;pkm F.1- D19FASI:-PCL!CY 500000 I)LSCIZIPllOt4Or-01'L-itAlIONS/LOCA I-ION$IVLIIICLLS Wot,kor.,;corripemsi-itiot)insurance Coverage applies only to ffio workers Compensation laws of tho stale of MA. This colfficato cancels and supersedes all previously issued cerlifiGatns,only as they relate.to workers Compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE SUSAN LETOURNEAU THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 536 FOREST ST N ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r. J) LQd-A I LM Insur,4nrp.Corporation OP 1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014/01) The ACORD narne and logo are registered marks of ACORD Y-)c•A-Pi,L I L L tb�-r t yviu tea 1.-mu AM (I'DII 1-;,- I of I i R Massachusetts - Department of Public Sa'iey Board of Building regulations and Standards Construction 5upen ko,~:;pecialtN License: CSSL-100886 DAVID A BANCROFT r 27 LOWELLRD.= North Reading MA 01864 r 03109/2016 Commissioner 9 Commonwealth of iMassachuseiis Department of Public Sa+ety Cil Burner i Cchnirian L'cF Ciiica:t License: BU-026558 {' DAVID A BANCROFT r 27 LOWELL RD North Reading NIA 0186Q` - r .. Commissioner �- piration: 03/09/2016 s "usi Regulation License or registration valid for individul use only �.. Office of Consumer Affairs&Busmhss Regulation g Y QME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: T"•'—�' Office of Consumer Affairs and Business Regulation �tegistration: 160389 Type: g 10 Park Plaza-Suite 5170 Expiration: 7/16/2016 Private Corporatior. Boston,MA 02116 SWEEPNMAN,INC. ------ DAVID - DAVID BANCROFT 27 LOWELL RD. NO.READING,MA 01864 Undersecretar 5 Not valid without signature