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HomeMy WebLinkAboutBuilding Permit # 12/1/2015 %AORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#o Date Received ��ss•Acwus���� Date Issued: lZ ' r IMPORTANT: Applicant must complete all items on this page f F.f rr'krlLilJ$ r. /rr'f✓1.�� I ,rr rn y; �,: tr r���r''c- MAP rP/1REL t ZONING DISTRICT Histone Distract =f ,Byes no , r Sh'o r rr F � �= rMacfiin,e ., . -p Village yesr. :� nq TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family 11 Industrial .Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Welh ❑ Floodplain` Wetlandds ❑ Watershed Distract ❑(UVaterlSewer, DESCRIPTION OF WORK TO BE PERFORMED. Identification- Please Type or Print Cleary OWNER: Name: ksol-ns Phone: 0 w -� Address: Contractor Name �r ,��CPhone: rErnail t r � r Supervisor's,Construction License '� ��`� rr� rHomer Improvement License ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$1200 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. Total Project Cost: $ 0. FEE: $ Check No.: Receipt No.: 9'� e istered contractors do not have access to the uaran�x, rind Persons contracting yvi unregistered � OTI+ • � IaT � Signature_of Agent/Ovvner ®� Signaitare of_co,nfractor FORTH Town ofAndover2 fi ® i_ 'y 0 ® 46-ah z� o Ver, Mass, LAK� COCHICME WICK ADRATED �RMIT T LD P S u BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT ............ ........., . , BUILDING INSPECTOR ................ ..... ..... ..... ..IO........................ has permission to erect ... buildings oFoundation ..........®........ pp ... ..... . ......... .. JOWA..... Rough. tobe occupied as .......... . .....p-4... ,. . .. f!................................................................................ 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU�,�, l 11 S Rough Service .� .. ...... .. .. ...... ... ... Final BUILDING 1 PECT GAS INSPECTOR ccupancy Permit Required to Occupy BuRough Display in aons icuous Place on the Premises — Do Not Remove Final No Lathing at ' r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Inland Qtiality 1311ilder-s Date Estimate/t 28 meadow Ln INLAND Wcstlbi-d, MA 01886 11/30/2015 648 QUALITY BUILDERS GENffiAL CONTRACTOR Phone It 617-839-2659 u, r.,€ur,ar u� w�r,4c,r�[Erar. I)a�a�InlandQa�ilit)^f',��i1de�:.cGau� n4tiec.lul,uul(„)n,alUrl;nik➢ars.c ,trr Proposal Fon Name/Address Jason&.len F astrnan 84 Brentwood circle North Andover,MA Project Roof Description 1QB proposes the following scope of work listed below: 1QB will strip and re-roof the existing house and garage: -IQB will strip existing shingles to existing plywood -IQI3 will then apply grace ice and water 6'up the roof and around all skylights and valley's -IQ13 will apply all drip edge which will be white -IQI3 will use synthetic roofing paper for the remainder ofthe root. -IQI3 will install new ridge vent in main house and garage -IQB will supply and install new 30 yr architectural GAl'shingles per manufacture installation guide. -IQI3 will supply 20 yd dunnpster Payment: j Deposit c 3600.00 Final payment upon completion$3600.00 Thank you for giving IQI3 the opportunity to provide this quote liar you! 1 $7,200.00 `this proposal expires one month from the date written Total All work is warranted for materials and labor for a minimtnn ol'one year.This proposal is valid Cor one nnonth from the date above.The total listed above is the total cost of your project as outlined above.Change Orders will be written for all changes in the scope ofthe work.Each change order must be approved by you before work begins.Payment for all change orders is expected at the tinnc they are signed.(f this proposal is accepted please sign one copy and return it to Inland Quality Builders.We also understand that Inland Quality Builders reserves the right to delay completion of the work for nonpayment of any invoices.Signature 17elow acknowledges receipt of two Rights of Rescission terms included below. Signature Date /2015 Customer Signature Date l /2015 1nlaud Quality Builders Represenuaiwe The Commonwealth of Massachusetts Department of IndiustrialAceldents I Congress Street, Suite 100 F° Boston,MA.02114-12017 ... www mass.gov1dia sy. Workers,Compensation insurance Affidavit:Builders/Contractors/Electxicians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licantlnformation + I Please Print Legib Name (Business/Organizatioi0ndividual): l/t Address: _ City/State/Zip: ��°/� 1 (A 0�yla Phorte#: Are you an employer?Check flie appropriate box: Type of project(ie4uired): 1.�I am a employerwith • . 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. El Remodeling any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3.,❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10F)Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.FJ Erepairs airs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors withno employees. 12.Q 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'corq.insurance.t 14.❑Other 6.Q We are a corporation and its offigers have exercised their right of exemption per MGL c. 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 subi iif this affidavit indicating they are doing all work and then hire outside contractors must si}bmit 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 ha_ve ctors have emplo'es,tliey must provide their workers'comp.policy number. employees. If the sub-contra " lam an employer tliat is pidvidirzg woi kkrs'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name; Policy#or Self-ins,Lic.#: F-,S \3f, Expiration Date: u -1 �� .+��;� �,(c �-- City/State/Zip: k)-aK ltn� A C�) Job Site Address: u 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 DIA for insurance coverage verification. X do hereby certiif i 'e pains andp of per' iy tlaat the information provided above is true and correct. Si nature: i' Date Phone#: �j— `Z' Lyn 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#: INLAQUA-01 SWHITEHURST CERTIFICATE ® LIABILITY INSURANCE D 1111191201 YY, 11/19/2015 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). CONTACT PRODUCER NAME: _ __—_—._ -- --- Knapp,Schenck&Company Insurance Agency,Inc. (AI/°NN Ext),(617)742-3366 A c,Na):(617)742-2832 One India Street E-MAIL Suite 204 ADDRESS: - Boston,MA 02109 _ INSURER(S)AFFORDING COVERAGE _ NAIC# _ INSURER A:Arch Specialty Insurance Company +21199 INSURED INSURER B:Safety Insurance Company i Inland Quality Builders,LLC INSURER c: -- ----- 28 Meadow Lane INSURE D: Westford,MA 01886 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 ',AD L�SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVb POLICY NUMBER MM/DD/YYYY MMIDD/YYYY A x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE i$ 1,000,000 09101!2075 09/01/2016 0(Eao ED--- 100,000 CLAIMS-MADE X1 OCCUR BAG1024398 PREMISES(-Roccurrence) — �iI—' j MED EXP(Any one person) 1$ 10,00 �',, I ' I' ERSONAL&ADV INJURY$ 1,000,000 I GENERALAGGREGATE $_ 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: r2,000,000 PRODUCTS-COMP/OP AG G 1 5 POLICY CI JECT L 1 LOG $ OTHER: AUTOMOBILE LIABILITY I i COMBINED SINGLE LIMIT $ ! I I Ea accidenU B I�ANY AUTO 16220426 10/2412015'10/24/2016 BODILY INJURY(Per person) I$ 100,000 ALL OWNED ��(�,SCHEDULED i BODILY INJURY(Per accident)I$ 300,000 AUTOS AUTOS NON OWNED I I PROPERTY DAMAGE S 1.00,000 (Per accidentL_— — HIRED AUTOS _AUTOS S — EACH OCCURRENCE �$ UMBRELLALIAB OCCUR EXCESS LIABi CLAIMS-MADE I AGGREGATE i$ is DED R TENTION$ PER OTH- I WORKERS COMPENSATION _ STATUTE J_ER _ AND EMPLOYERS'LIABILITY Y 1 N E.L.EACH ACCIDENT 1$ ANY PROPRIETORIPARTNERIEXECUTIVEIr------- ---"- I OFFICERIMEMBER EXCLUDED? ' E.L-DISEASE-EA EMPLOYEE!$ (Mandatory In NH) I — If yes,describe under I E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS below I i i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers Compensation coverage is active and in good standing.A Certificate of Insurance will come directly from the carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE L®F IA ILITY INSURANC DATE(MM/DD/YYYY) �.� 11/19/2015 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 NAME: Helen O'Neill KNAPP SCHENCK AND COMPANY INSURANCE AGENCY INC. Pa/CNN Ext: (617)619-0204 FAX,rNo: ADDRESS: swhitehurst@kscins.com One India Street INSURERS AFFORDING COVERAGE NAIC# BOSTON MA 02109 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURERS: INLAND QUALITY BUILDERS LLC INSURERC: INSURER D: 33 MASSAPOAG WAY INSURER E: DUNSTABLE MA 01827 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 13583 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 POLICYNUMBER MM/DD MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMA '.. TO R CLAIMS-MADE �OCCUR PREMISES ED PREMISES Ea oceurrence $ MED EXP(Any one person) $ '.. N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- ElJECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ',.. ALL OWNED F SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ '... NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ '.. EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION xi STATUTE ERH- AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE YIN N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED7 NIA NIA NIA 6S62UBCG31060915 09/17/2015 09/17/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/iwd/workers-compensationlinvestigationsi. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN T' ACCORDANCE WITH THE POLICY PROVISIONS. 2r AUTHORIZED REPRESENTATIVE ( MA 01886 Daniel M.Cro�✓ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD \ Office of Consumer Affairs&Business Regulation t� OME IMPROVEMENT CONTRACTOR I, - J _egistration: 167038 Type: xpiration: 8/2/2016 DBA INLAND QUALITY BUILDERS DANIEL MCGONIGLE 69 ARNOLD AVE. LOWELL,MA 01852 Undersecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-094579 Construction Supervisor �� x DANIEL J MCGONICLE ' t ` ' 7 33 MASSAPOAG WAYS: ' N'41 DUNSTABLE MA 01827 (�,nn Expiration: Commissioner 10/23/2017