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Home My WebLink AboutBuilding Permit # 11/16/2015 RTH AF��ED ' BUILDING PERMIT 466 TOWN,OIF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION - 8 ' Date ReceivedADRAED TPea Cy Permit No#: ��SSAc�aus�c Date Issued: I I IMPORT AI0IT: Applicant must complete all items on this page r r , Pnrltr ,'< `�1JI f / t i f f1� r f I c � i r: r 1 -✓ PF�,OPERTY OWNER � � r , Ef Pnnt 100 Year Structure yes no � ...............'�O X PARCEL � r ZONING DISTRICT�Histonc Distract yes no Mach�rie Su,op, � age y� TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family ❑Addition [I Two or more family ❑ Industrial ❑Alteration No. of units: •O'Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic <; ❑Well ❑ Floodplain ❑Wetiands ❑ a ers a is �„W,ater/Sewer ; ,, DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name P n t hoe ' - A`dd ress 5 f J ✓ 4 FI f r 1 f Supervisor's Construction L'Icense��.� f f r t r P Homeflmprouement LicOn scja2 ,, Date 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: $ Z C�C� � � FEE: $ . �� _ ��:� �� Check No.: Receipt No.: �Oq NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund nature Of contracto"r `Signature of Agent/Owner g -- _- ----- rim tkORTH _t own of Anc'lover ® 0 ® ® T h ver Mass, h► O LAKE cocK�cMewicK �1. RATED P .(5 U BOARD OF HEALTH Food/Kitchen PEKM LD Septic System THIS CERTIFIES THAT , ,`„ ............... BUILDING INSPECTOR ........... .. . ..... .... .. ........ .......................: ........... has permission to erect . buildings on J115 Foundation Rough tobe occupied as .......Sim. ..... . .. ..... ... .............................................................................. Chimney provided that the person acceptin 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT I T ® ELECTRICAL INSPECTOR UNLESST R Rough 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. G.L. Clark Construction Tony Delourie 177 Jenkins Rd. 1538 Turnpike St. Andover MA 01810 N.Andover MA 978-375-3425 978-230-1609 CSL#102350 HIC#164510 SCOPE OF SERVICES—Entire Roof. 1) Roof R&R 64 sq.2 Layers of asphalt roof shingles with IKO Architectural shingles. Install 6ft of ice & water shield along entire perimeter of roof. Install Synthetic underlayment over remaining roof deck, and install new 8' white drip edge. Extend fascia and rake up to 18". Wrap in white metal. Replace up to 64sf of plywood at hatch entrance due to rot. 2) Clean up and removal of all debris. Notes* Unless noted above any changes to scope of work or changes due to any unforeseen issues may change the cost of the project such as Rot, Code upgrades or any engineering that may be needed. Or any changes the customer may make that will change the scope of work to be done. All changes to be done will have a change order to be signed prior to start of any new work to be done not included in original scope. a)All work will be done with the required permits and to building code. Owner will pay for cost of all permits needed. b) All extras will be done at time and material Total cost of proposed work. $ 22,400.00 Payment Schedule $7500.00 upon signing of contract $7500.00 upon start of project $7400.00 upon completion of project. 'Tony Delourie Gregory L Clark CLARGR1 OP ID: DL � f TI I LIABILITY INSURANCE DATE(MMIDDIYYYY) 11/12/2015 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 pollcy(les) 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:978-777-9394 NCiAGMEACT Dan Hurley Dan Hurley Insurance Agency PHONE Chestnut Green,Suite 24 Fax:978-777-3306 AIC No Ext:978-777-9394 FAX No: 978-777-3306 Seven Federal Street ADDRESS:don hurle Danvers,NIA 01923-3620 yinsurance.com Daniel J Hurley INSURER(S)AFFORDING COVERAGE NAIC M INSURER A:Providence Mutual 15040 INSURED Gregory Clark INSURERB:AIM Mutual Ins.Co. 117 Jenkins Road Andover,MA 01810 INSURER C: INSURER D: INSURER E: INSURER F: COVE RAG ES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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. SR!ITR TYPE OF INSURANCE POLICY EFF PO IC E P !NSR WV0 POLICY NUMBER MMIDDIYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ,A X COMMERCIAL GENERAL LIABILITY BOP0070029 04/23/2015 04/23/2016 DAM GE OR SES Ea NTED occurrence $__ 50,OD0 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:. GENERAL AGGREGATE $ 2,000,000 POLICY PRO- PRODUCTS-COMP/OPAGG $ 2,000,000 JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO ALL OWNED BODILY INJURY(Per person) $ SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ DED RETENTION$ AGGREGATE $ -- WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X WC STATU- OTH- E3 ANY OFFICERIME BOER EXCLUDED?CUT VE YIN NIA C-100 6017451-2015A 04/24!2015 04/24/2016 E.L.EACH ACCIDENT ER $ 100,000 (Mandatory In NH) SEE NOTES Ifyes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) per policies: Gregorx Clark is exempted from workers compensation. WC Tri._-5urance coverage applies only to the workers compensation laws of the ,5taxte, of Massachusetts. CERTIFICATE HOLDER CANCELLATION TOWNNOA 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. 1600 Osgood St. Bldg. 20,Ste 2035 AUTHORIZED REPRESENTATIVE N.Andover, MA 01845 O 1988-2010 ACORD CORPORATION. All rights reserved. ,ACCORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 = Boston,MA 02114-2017 .�` www.mass.gov/dia fidavit:Builders/Contractors/Electricians/Plumbers. Workers'Compensation Insurance Af TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le:=ibly Name(Business/Organization/Individual): -1 Address: J'Z7 �ut\L--�-+n -'s vLA City/State/Zip: Phone#: �� —:5 X_ ' Z Are you an employer?Check the appropriate box: Type of project(1•equired): 1.❑I am a employer with employees(full and/or part time).* 7. Q New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9, Q Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12. Plumbing repairs or additions 5.ER�am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have nc.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,tliey 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. n p Insurance Company Name: A t � Id � ��L2 vA<� C& Policy#or Self-ins.Lie.#: C_ r DC) (;201 7 5 "Z Dt Sr Expiration Date: 1 I I Job Site Address: 1 S� OR�� 03 City/State/Zip: �� A-Ad-c Q� U�L.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 WORD 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 certi under the pains and penalties ofper' ly that the information provided above is true and correct. Z/ Si natu c- Date: `Z Phone#: Official use only. Do not 1prite 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#: Massachusetts - Department of Public Safety Board of Building Regulations a„c; a ndards Constructor, Supervisor _ 1 License: CS-102350 , roti GREGORY L CLARK JR s- 177 JENHINS RD' a ANDOVER MA 61810 EXpIPa#itOrl Commissioner 10/15/2016 U/ae a»i-nrc�ecaectlf� 11011Z,"Jackrael Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: 164510 Type: Expiration: 10/19/2017 Individual GREGORY L CLARK JR. GREGORY CLARK 177 JENKINS RD. { y ANDOVER, MA 01810 Undersecretary