HomeMy WebLinkAboutBuilding Permit # 11/24/2015 BUILDING PERMIT �&oRTN
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit
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Date Issued:
IVIP®1�'I'.�'�". .Apphcant must complete all atems on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ..,One family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessor Bldg ❑ Others:
❑ Demolition Other
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pp DESCRIPTION OF WORK TO DE PERFORMED:
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identification- Please Type or Print Clearly .r'”
OWNER: Name: Car- ��v Phone:
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Address: �:� s°�, �,�° � �� � °: �o'�. � PAA k 8 L(
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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: $ FEE: $ ( b 06
Check No,: Receipt No.:
MOTE: Pei-sons contracting unre ' tered contractors rho not have access to the guarantyfund
Signature_of Agenf/Ovvn. _. ” Signature af_co,nracto. 1
---- --
111 own of tAORT.1 1 A
Andover
No. 2,0
C%o I 1h LAKE verMass,
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®S RATED
ll BOARD OF HEALTH
Food/Kitchen
PER T L D Septic System
THIS CERTIFIES THAT ,,,,,,,,1! .Or!!!� BUILDING INSPECTOR
............ .................................... ..... ..............................
IL
. . Foundation
has permission to erect.......................... buildings o ...... ... . . ......................
Rough
to be occupiedas ... .. ........... ....oTaftma...... ....................................... Chimney
provided that the person accepting thi 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 I 6 MO
S
ELECTRICAL INSPECTOR
UNLESS C NST S Rough
.... ................................................. FinalService
........
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy -3uilin 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.
Pelletstoveservice.com
The Alternative to Dealer Service Since 2003 51 Winthrop Street
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Suite#5
Pell�/.�+�jr,o Stove Rehoboth,MA 02769
ERVICE
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Carlos Guzman
30 Amberville Road
North Andover,MA 01845
Account Number 10034
Quote Number 100342575
Issue Date 11/20/2015
Due Date 5/18/2016
� 0
11/20/2015 Install Timber Wolf TPI35 PEllet Insert in to existing manufactured fireplace(insert supplied by None 1 500.00 500.00
customer)
11/20/2015 4"pellet liner kit with lower end double wall connections None 1 675.00 675.00
11/20/2015 INstall Englander PDVC freestanding pellet stove in basement w/OAK(stove supplied by customer) None 1 650.00 650.00
11/20/2015 3 PEllet venting for basement install None 1 450.00 450.00
Sub-Total: $2,275.00
Total: $2,275.00
Balance Owing: $2,275.00
Permit to be paid for by customer
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P
y
Page 1 of 1
The Commonwealth of Massq chusetts
Department of IndustrialAceldents
X Congress Street Suite 100
Boston,.MMA 02114.2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHOPJTY-
Applicant Information fl„ Please Print Legib
Name (Business/Organization/Individual): Pi�V�U 1 w
Address:_ '51, W C-NreA i�,
C
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(zTequired):
1FJ I am a employer with /�. : employees(full and/or part-time).x 7. Q New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑
10 F1 Building addition
4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole It.[]Electrical repairs or additions
proprietors with no employees. 12.[]Plumbing repairs or additions
5.F1 I am a general contractor and I haye hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance)
6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c.
14.F1 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.
T Homeowners who snbmif flus affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContraotors 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 jolt site
information. g Q
Insurance Company Name: L `
Policy#or Self-ins.Lic.#: 7 11� � r'� Expiration Date: V'7 i
Job Site Address: �� `� �'� i(�@ '��`" City/State/Zip:
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$250.00 a
day against the violator.A.copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance
coverage verification.
I do hereby certify under die pains andpenalties of perjury that the information provided above is true and correct.
Signature
Date.
j — 2c?__ I-5
Phone#:
Official use only. Do not write in this area,to be completed by city or town official..
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CERTIFICATE 4F LIABILITY INSURANCE a }y EAATE t� TT"'
_ _ 1/1 12tt}lc
THIS CERIIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON IRE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER,
IMPORTANT B the cettlflL ate holder Is an ADpT10NAL INSURED,the pdity(Ise)must be endorsed. If SUBROGATIONIS WAIVED,eubleet to the
tams and conditions of the policy,certain policies may require an endorsemert. A statement on this certificate doe#not confer rights to the
,art ho►der In--of such endorsement(s).
COMPLETE BENEFIT SOLUTION5jPAC ae...eW, ,�-,,, (@B j 443-611,
250837 P: F: (888) 443-6112 FffL
vats
PO BOX 33015
SAN ANTONIO X 78265 -St,-sA. —„in .i .
c1' FZ Ir,t __
rnsatng '..
PAINTCRAFT INC DBA PELLET STOVE SERVICE nu-gfto
51 WINTHROP ST UNIT 5 --
REH09OTH MA 027E9 --
COVERAGES CERTIFICATE NU1d9ER: REVISION NUMBER:
n415 IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED OELOM RAVE BEEII ISSUED TO THE IIISUREO IIAMED ABOVE FOR THE PCUCY PERI6
U401CATED. NOTINTHSTANDLIG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTT4 RESPECT TO WHICH TT41
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUC1ES DESCRIBED HEREIN IS SUBJECT TO ALL nt
TERMS,EXCLUSIONS AND CONINTIONS OF SUCH POUCIES LIMITS SHOWN MAY RAVE BEEN REDUCED BY PALO CLAe,LS
Z` nYtoram Lva .Dec.It"
MLKY�FAIa{A MIlCYLX7' LIMITS��
CODUERCIAL GENERAL LIABILITY t1GM OCC11Rq{hGt {
CLAAL!"ADC QocwR OAU,41 To at R71 _...__.
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CERTIFICATE HOLDER ^—� N---- CANCELLATION_ _
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SMOULO ANY OF TME ABOVE 0E5(:RI E3E0 POUGES BE CAFtCEILED
BEFORE THE EXFIRATIOtt DATE THCSCOF,NOTICE WILL BE
1V GD IN ACCORtaANGE NnTH TH�i OUCY PROVI90N,S�
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ORD CORPORATION
ACORD 25(2014101) The ACORD name and logo aro .All registered m r$e of ACORO rights reaery
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Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License; CSSL-105742
C"c 'IstFUctior � zV
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SCOTT MLLIAMSON
579 TREMONT STREET
REHOBOTH MA 02769
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