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Home My WebLink AboutBuilding Permit # 12/3/2015 �ORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#-. Date Received- 0'?A'rcD C Date Issued: !MPOIZTANT: Applicant must complete all items on this page 0 54 M'p, ��IN, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building [I One family 0 Addition 11 Two or more family [I Industrial [I Alteration No. of units: 11 Commercial [I Repair, replacement 11 Assessory Bldg [I Others: El Demolition 0 Other U t �,ON, S 4if "etlarids ❑ WAN A pis DESGRIPTIONOE WORK TO BE PERFORMED: 0 coop... (4 Identification- Please Type or Print Clearly OWNER: Name: 144f*i &�jkbwVectA Phone: Address: arn& PR Contractor, bo,ne: )"N r r% e P r, ,ehse�N 11 'N s os a ' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;B UL DING PERMIT.'$12.00 PER$9000,00 OF THE TOTAL ESTIMATED COS T BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: b " 2 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Sig Itra FORTH To' wn ofAndover ? *. ® '• ' "sJ o : LAK. h ver, ass, Q coc"Ic"awic,( 1' 14 ATeo U BOARD OF HEALTH Food/Kitchen PE MIT T %O LD Septic System THIS CERTIFIES THAT .. .,. � [ BUILDING INSPECTOR has permission to erect Foundation p .......................... buildings on ...G ....... ........ .......................... Rough tobe occupied as .......... ..... ......... ....... ................... ......^............................................................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR (� UNLESS I T Rough Service ................ .... ........ .... ... ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required toOccup-P Buddtnz 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. zo Thomas Burke & Sons ®offing & Gutters AFamily Business Since 1941 781-246-5622 vwvw.BurkeRoofs.com P.O. Box 2152 Wakefield, MA 01880 CONST. SUPERVISOR LICENSE 98861 FULLY INSURED HIC LICENSE#102540 Contract price for labor and materials to re-roof roof by removing the existing shingles and re-roofing , over 3 OL,B felt by using Certianteed 3 O year architect roof shingles. To install Grace Ice and Water Shield to lower Si I - feet of all roofs and in valleys. To install an aluminium- drip-edge luminiumdrip-edge onto all lower roof edges. To replace any broken or rotted roof boards where needed. To open all flashing and to re-flash where needed. To remove all trash. `/4 Wyf�A)/ Total Cost: $ 'RTF , The first payment of Is due as a dep osit. The second payment o _5 6,V � Is due when the materials are delivered and the work is started. The third payment of$ Is due when the work is 75% completed. The balance of$ OOO. Is due when the work is complete and the trash is removed from the yard. Owner Contractor - Please make checks payable to Thomas Burke Please cover articles in the attic with sheets or plastic Due to the dust that can filter in. btReferen�es available upon request. �aXe of insurance available upon request. rB�rter Business Bureau 508-652-4888 �tObbb.or g The Conrnronwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia llrol-kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ..-/ Please Pt int Legibly Name(Business/Organization/Individual): { Y7rp?/t-� 1�u , Address: y PAAM Pt G_ 1..AVIV c City/State/Zip: e l'U St l`' N I C 3 Z7 Phone #: '711 [2.n re you an employer?Check the appropriate box: Type of project(required): IV I am a employer with _employees(full and/or part-time).• 7. r_1 New construction I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.) 8. ❑Remodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 1 am a homeowner and will be hiring contractors to conduct all work on m roe I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are property, y 11.[:]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13. Roof repairs 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]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. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this boa 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. 1 am air employer that is providing worlrers'corrrpetrsatiorr iusurarrce for my errrployees. Below is the policy and job site information. Insurance Company Name: I?R tV��kf_S Policy#or Self-ins.Lic.#:_i '��y Orjk33MC �j r13 Expiration Date: ��—/r' `� Job Site Address: �� /�p� Q �� - City/State/Zip: ✓�VI�Gb 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. ---------------- I do hereby certify lender he pains and penalties of perjury direr ilre irrforrtratiorr provided above is trite and correct _--- S 1Qnatu re: e. Date: Phone#: -7 e `7 1F',sof use only. Do not write in this area, to be completed by city or town official, Town: Permit/License# Authority(circle one): d Health 2.Building Department 3.City/Town Cleric 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Per on: Phone#: �+ ® pp pp ® DATE(MM/DDIYYYYI CERTIFICATE OF LIABILITY INSURANCE10/30/2015 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 conferlrights to the certificate holder in lieu of such endorsement(s). PRODUCER , CONTACT , NAME Office Account FAX Cassidy Associates Insurance Agency PHONE(A ,No,Ext). (978)777-8880 (AIC,No): (978)777-9280 67 High Street ADDRESS INSURER(S)AFFORDING COVERAGE NAIC q Danvers MA 01923 i INSURER A Penn America @ Surplex INSURED INSURER B:Citation Thomas B. Burke I INSURER C:Travelers 25 Bishop Lane INSURER D j INSURER E Lynnfield MA 01940 INSURER F COVERAGES CERTIFICATE NUMBER:CL1592211108 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 TOIWHICH 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 INSPOLICY EFF POLICY EXP R LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMlDD YYYY MM DD YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S I 1,000,00C DAMAGE TO RENTED 100,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S PAV0055309 S;i2i 1G16 3!1212016 ME D E XP tAny one person) 5 5,000 PERSONAL:ADV INJURY i 1,000,000 GEN'L AGGREGATE LIMIT APP!ITS PFR )WNERAI_AGGREGATE $ 2,000,000 '.. PRO X POLICY 2,000,000 .IECT t i)c PRODUC CTS OMPsOP AGG S OTHER 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 1,000,000 iFa acc,dent) B ANY AU TO BLODIY INJURY,Pe(person, 5 ALL OWNED D SGHIcDULt AUTOS X AUTOS RV1I58: i 'GIS 1°i 7!2015 BODILY INJURY iPer accident) 5 NON OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS .Peracadonu ;.. UMBRELLA LIAB 0GCUR EACH OCCURRENCE .. I i EXCESS LIAB AIMS-MADE: AGGREGA FE 5 DED RETENTION> 5 WORKERS COMPENSATIONX PER 0TH- Y/N '.. AND EMPLOYERS'LIABILITY STATUTE ER IN) PROPRIETOR/PARTNERtEXL,:,_LIVE NIA E I EACH ACCIDENT 5 100,000 OFRCER/MEMBER EXCLUDED,' y C (Mandatory in NH) tiK(180:?37M09S1d ;,/8%'015 9;t3i016 EL DISEASE EAEMPLOYEE S 100,000 '.. II yes describe under DESCRIPTION OF OPERATIONS -sow E L DISEASE-POLICY LIMIT $ 500,000 r DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached it more space is required) Sole proprietor not covered by workers compensation. Coverages, exclusions, terms and conditions as set forth by the actual policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- All THORIZED ROVISIONS-At1THORIZED REPRES =t t7 0c '1988=2014 tGO PO TION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 ()ffice of r',.nsumer:Wairs&Business Regulation ,.,. VX, ME IMPROVEMENT CONTRACTOR Tistration: 102540 Ype: piration: 712/2016 DBA THOMAS BURKE ROOFING&GUTTERS Thomas Burke 4 PARTRIDGE LANE �a EAST KINGSTON, NH 0382; t ndersecretar% License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature � '`I�dSSdGt1U�'. tt'i Cta, tilt+ 1 ;>� �Ui74. �3�P"y ;_icense CSSL-098869 Thomas B Burke 4 Partridge Lane East Kingston NIf 03 piration �,,itirnissionar 03188/2017 Restricted To: CSSL-RF-Roofing Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Ucensing information visit: www.Mass.Gov/DPS g '