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HomeMy WebLinkAboutBuilding Permit # 11/23/2015 ®F taoRr$ BUILDING PIT 4,'-p o ' a TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: �` ' Date Received " �RQ�aA7ED Ppp` y a �SSgCHUS�� Date Issued: °' IMPORTANT: Applicant must complete all items on this page LOCATION �<1 54� Print PROPERTY OWNER Prin 100 Year Structure yes (no MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building e family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 2rFKepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 1111 OV11,11,11 �rr,�i r•firrr,;r p r r'` � n�krai��.��r�:�I��f J��or/ !w'�v�u���r+�!�� �arirp�rl�r���%rU,r`eiil�'rl:a ririn>r�/��G,'ss�,i�rs�,�;r� � -�//i�,� rGNicr ;f��rf!rYad1!!%e4a¢IVlls�I�1v�'IN��eIPJD�fr,!;,r.�.�..f.r11111J1��/'FC„�III-;J;d-� �i+'..,�/�,��r�,'�.. > 1 ll Ip Iill 6r,hv r "i l, J / ESCRIPTION F WO K TO B RERFORMED: Identificat' - Please Type or Print Clearly OWNER: Name: ��l � � Phone: Address: r) Contractor Name: Phone: Email: Address: r ” Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: '° ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.0 OF THE TOTAL ESTIMATED T BASED ON$125.00 PER S.F. I Total Project Cost: $ FEE: $ Check No.: T7 Receipt No.: �� I NOTE: Persons contracting with unreg* t ed contractors do not have acces r ' d r 7,4,,,r. r.r�. ,, r � i J rr, ,„. ,�,. �;:r� ,,,fr ,.7 OM//f ,/ud //,/i0i r,/"T70 ,r , {, .r�r/I,/"ill//�Ir/i/„ 9/g... /,.7f/��/ k / f�ri. � r .,,,._. �s�u. ,. NORTH Town of 4 E _•.p ndover ® No. t o LA" ver, Mass, SQA COC.I.M.1c.`y1' S U BOARD OF HEALTH Food/Kitchen PER. T D Septic System THIS CERTIFIES THAT ......... ..... V4........ BUILDING INSPECTOR .has permission to erect.......................... buildings on ...............1.1 ....... �...... ............ Foundation p .... � Rough o be occu ied as .011-0400JA .. t��.. .... .... . ....04,6A...0......... 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT I IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTI 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 D all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 1A CONTRACT fr i . ITEMIZED INSTALLED SALES CONTRACT INSTALLED SALES SPECIALIST y NUMBER" CUSTOMER r STORE NO. STREET ADDRESS STREET ADDRESS i CITY STATE ZIP CITU,�� -- STATE ZIP TELEPHONE TELEPHONEI F � DATE LOWE S CONTRACTOR LICENSE NUMBER"" � DASHF BANK I F FA_EG 1 MA,MD—State License Number;All Other States Lowe's Employee Number, AL,CT,EL,MAMD,NV#45450 unlimited,TN#16066,only. This is a contract between Lowe's(as defined in the Terms and Conditions)("Lowe's"),and the above-narned Customer for the installation of goods at the Customer's residential premises(the"Premises")at the following installation address: STREET ADDRESS �! ,_ CITY` — STATE ZIP Additional Specifications: The Environmental Protection Agency (EPA) has requested that Mat'ls Lowe's notify installation customers that a lead based paint hazard may exist in dwellings built *Tax prior to 1978. See pamphlet EPA 747-IC-99-001 for details. Labor pp j Tax e, / Total *"where applicable labor is taxable; local tax restriction. i' , r , Work is to commence upon reasonable availability of Contractor which is anticipated to be [fill in date]. Estimated completion date is [fill in date]. NOTICE TO CUSTOMER All items listed in this contract and specification sheet(s)are to be installed under conditions agreed upon at tirne of purchase and at the price appearing on this contract form. This assumes sound existing substructures,superstructure and points of attachments. Extra labor or material incident to installation necessitated by defective substructures,superstructure,points of attachment,or the moving of fixtures or appliances to be billed at extra cost to customer. DO NOT SIGN THIS CONTRACT UNTIL COMPLETE AND YOU HAVE DEAD THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS CONTRACT. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDER- STAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS DAY.OF (Seal) Owner (Seal) (Seal) Specialist or Above Spouse Customer acknowledges;repelpt,of a,true copy of this contract which was completely filled in prior to Customer's execution hereof. If credit is extended to you,you the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction, See the attached notice of cancellation form for an explanation of this right. The Coninionwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations l I Congress Street, Suite 100 Boston, MA 02114-2017 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPlicant Information j� Please Print Legibly Maime(Business/organization/fndividu (Jal): �Sjin r&N Address: t" &ro,,LR (d!0. City/State/Zip: jJJt!'t #1A 1)1321 phone4h ?1T'4 se_V6J Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).'` have hired the sub-contractors 6. ❑ New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. p p p ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance•$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12[1 Roof repairs , insurance required.] t c. 152,§1(4),and we have no Viir employees. [No workers' 13- 6ir 4; W'07doe.. comp.insurance required.] fy,04ir 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit(his affidavit indicating they arc doing all work and then hire outside contraetars must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sut-contraciors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'camp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site infortttation. Insurance Company Name: Policy it or Self-ins.Lie.#: 1!� Expiration Date: Job Site Address: / [ 44{]/IJ �/ ,.,f• City/State/Zip: !V' ®( 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 WORK 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 cern unde th pains and penalties o r-ll er that the information provided above is true and correct. Signature: _ Date. Phone#: 17 �--- 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:_ Phone#: �4�®/�®® CERTIFICATE F LIABILITY INSURANC DATE(MMIDDIYYYY) 6/5/2015 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(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 CONTACT Scott Leavitt, CIC, LIA NAME: MTMBrainerd Inc PHOIAIC.NE (978)667-9031 FAIC No:(978)667-1018 lA Andover Road E-MAIL ADDRESS:scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC# Billerica MA 01821 INSURERA:Travelers Casualty Ins Company 19046 INSURED INSURERB:Safety Indemnity Insurance Co 33618 Kevin O'Brien DBA K C O'brien Construction INSURERC: 15 Shanpauly Drive INSURER D: INSURER E: Billerica MA 01821 INSURER F: COVERAGES CERTIFICATE NUMBERklaster 2015 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 300,000 PREMISES Ea occurrence $ A CLAIMS-MADE n OCCUR 6806424N45A1542 6/3/2015 6/3/2016 MED EXP(Any one person) $ 5,000 X Blanket Additional PERSONAL&ADV INJURY $ 1,000,000 Insured by Contract GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY n PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 0 accident 500,000 ANY AUTO BODILY INJURY(Per person) $ B X ALL OWNED SCHEDULED 6214435 8/19/2019 /19/2015 AUTOS X AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS X AUTOS Per accident Uninsured motorist BI split limit $ UMBRELLA LAB HOCCUR EACH OCCURRENCE $ '.. EXCESS LAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- TORY I OTH- AND EMPLOYERS'LIABILITY YIN ER ANY PROPRI ETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Lowe's Companies, Inc. and any and all subsidiaries are named as an additional insured as respect to the above referenced General Liability Insurance Policy and Commercial Automobile Insurance Policy, as required by written contract or agreement. This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION vendorinsurance@lowes.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lowe's Companies, Inc ACCORDANCE WITH THE POLICY PROVISIONS. and any and all subsidiares Attn: Vendor Insurance AUTHORIZED REPRESENTATIVE PO Box 1111 North Wilkesboro, NC 28656 S Leavitt, CIC, LIA/S ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 r?mnn5i nl Thn Ar r1Rr1 name�nr1 innn mre reniefornrl merle¢of Arnpn A rr ci all UUIUC U1 'k—OlLbUrIXF 1AILLAIES U JI)LI5111css r-�xgulmlull 10 Park Plaza- Suite 5 170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 168327 Type: DBA Expiration: 2/3/2017 TO 263049 K.C. O'BRIEN CONSTRUCTION KEVIN O'BRIEN 15 SHANPAULY DR, BILLERICA, MA 01821 Upilitte Addrvs5 iijid retisi'n cited,11,11ark jwsOn fOr change. Address �. ] Renewal [�] Employment -SCA 0 1 Lost Card .,Mce of Consumer Affitirs&Business Regulation License or registration valid for individul use only �'Zf§MOME IMPROVEMENT CONTRACTOR oeiore zne expiration aste. ii round return toaglstration: 168327 -, 'j Type: office or Consumer Affairs and Business Regulation W4M W'—"" xplration: 2J312017 DBA 10 Park Plaza-Suite 5170 BGstan,MA 02116 K-C.O'BRIEN CONSTRUCT$ON KEVIN 01BRIEN 15 SHANPAULY DR. BILLERICA,MA 01821 undersecretary Not valid without signature C) cc �7 Feb 24 13 07:18p p•2 ' Office ofConsamtrAffairs doBoAstsaRtgabtion E IMPROVEMENT CONMCTOR �stratlan:' 168327 - ration: M=15: K.C.O'Blt! NaTRUCTfO N" ' KEVIN O'BRIEN 17 TOM GRACE NbAY BiLiC lillA 01821 Undeasttreta r"Y N13ssachusetts-Department of Public Safety Bcard of Building Regulations and Standards :`-mtrucxi,in License: CS-Mize VIN C OBRIEt!F I5:HANP'AUL'Y DRIVE BII LERICA N[A=01622 5 Commissioner 0813112016