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HomeMy WebLinkAboutBuilding Permit # 12/7/2015 `AORTH BUILDING PERMIT ED TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION D Rr.1-4-n- Permit No#: Date Received "ArrD PX .&S CHUS Date Issued: IMPORTANT:Applicant must complete all items on this page ,� �� � � `„ �� �/,li 1�J�`li/�ri�i;//Gy,%���,/r/�l'lP��'�%�/�r/��r'�� '!.�Fw�l r , � ,l,/%/,;i ri ISM Y1 ffiP ��,r �f/�il/r�i b/Jrrl /�,���1L1/�������r/)�;//G�i�. /� � r/irb%/r//�/ .� �(�//�Gd .r c u TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ohne family El Addition 0 Two or more family 11 Industrial VrAlteration No. of units: 11 Commercial [I Repair, replacement 0 Assessory Bldg 0 Others: El Demolition 0 Other DESCRIPTION OF WORK,TO BE PERFORM:, / (Y Zk S V4 1 46444 Identificafign- Plea Type or Print Clearly OWNER: Name: Phone: Address: '5. *0 41" av/ 61 V, Bill' fqq 11111 "1"1""1"', .......0i I NY, 151 ffil eJ(Ient License , ,, / f%f ,, Ex G Date ! r faf i�w 'i% ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.MOO PER$1000-00 OF THETOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3r ee)c 41'r FEE: $ Check No:: Receipt'No.: NOTE: Persons cohracting with unregistered contra iVz ceess to the guaranty fand _144. if,contr8tctbr Town of ndover ? ..t _ 0 : 4C - z h Ver' Mass, T O LANE i COC MIC MI WICK � Q�RNTEO S V BOARD OF HEALTH PERMmIT �T� D Food/Kitchen Septic System THIS CERTIFIES THAT ............ . .... .®^:........ . s's: G01. ............................................................. BUILDING INSPECTOR 1....!"4r'J ... .. ............................... Foundation has permission to erect .......................... buildings on .... ...... .. GIM... �� c ��j� /,� Rough to be occupied as .......... .1�. ..... .e.�.. .. ............ ... ...... .. ..........T. ......��.Lid Chimney .provided that the person accepting this permit shall i very 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 E IT EXPIRES 6 MONTHS ELECTRICAL INSPECTOR LES ST CT10 ST S Rough Service .... ... ............................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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. Page If of pages .......... /,"0" 4,4FN PROPOSAL SUBMITTED TO: JOB NAME JOB# "v! ADDRESS �MrJOB LOCATION �ov E OF PLANS N9 AXA PHONE# FAX# ARCHITECT e hereby submit specifications and estimates for; 7r e", -- ------------- ea �0 A v L__,2 % Atak 4 r .............. 04( Co ,41f 6e, ------- .......................... ......... . ........... . .......... .............. .............. ................ .. .. ..... ............................................. Ve propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: $ A�o ow Dollars with payments to be made as follows: _). .......... Any alterailon or,devjauon from above specifications involving extra costs Respectfully will be executed only upon written order,and will become an extra charge submitted auzz�44, over and above the estimate, All agreements contingent upon strikes, acctdelats,or delays bayrynd our control "Ire/withdrawn by us if not accepted within Note—this proposal may days, Ricreptallre of PrOP05at The above paces,specifications and conditions are satisfactory and are 6, ra hereby accepted,You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date of Acceptance Signature A-NC3819/7-3850 09-11 00a wm 12 both AOL, � � . � �..� .m. .�.�.� 1 �_ . ............. The Commonwealth ofMassaehusetts : Department of lndustrialAccidents X Congress Sheet, Suite 100 Boston,MA 02114-201 : .� www.mass,gov/dia 1 yJOv 'Workers'Compensation Insurance Affidavit:Builders/Contractors/Elect. ciansfPlumbexs. TO BE FILED WITH THE PERMITTING AUTHORITY. A Please Print Le 'b licantInformationl Name(Business/Oxganization/lndividnal): Address: City/State/Zip: C!/) )/ , " -fi d Phone#: VV' 6 21-46, ' 7 2- Are you an employer?Check the approprlate box: 'Type of project(I@quired): L l i arua employer with , _ , employees(full and/or part-time) 7. 0 New construction 2.�]I am a sole proprietor or partnership and have no employees working for mein 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3,Q lam a homeowner doing all work myself[No workers'comp.nzsurance zequired.]t 10[]Building addition 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. 1-will ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14. 6.F1 We are a corporation and its officers have exercised their right of exemption per MGI,G. 152,§1(4),and we have no,pployees.[No workers'comp.insurance required.] 115 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who stirBmif tris 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 ha_ve , employees. Ifthe sub-confracfors have employees,&t must provide their workers'comp.policy number.' I am an employer that ispioviding workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: ExpirationDate: Policy#or Self-ins,Lie. fob Site Address: ?« e 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 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. p do It er�ehy cer�tif iu der the ai dPenattles of perjiny that the infor ration pjov1de7;4ff;;1,;nd correctDat .. Si nature: Phone# Official use only. Do not write in this area,to be completed by city Or torvn Official. City or Town: Permit/License V 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#: 11 /30/2015 3 : 01 : 38 PM 8620 0 02/02 DATE(MM/DD/YYYY) CERTIFICATEF LIABILITY INSURANCE11/30/2015 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 confer rights to the certificate holder in lieu of such endorsement(s). ACT PRODUCER 02916-001 NAME: Pantano Vonkahle Insurance a//cc N%'Ext: (781)581-3100 220 Broadway#220 EMAIL Lynnfield, MA 01940 ADDRESS: INSURERS AFFORDINGCOVERAGE NAIC INSURERA: A.I.M.Mutual Insurance Company 33758 INSURED INSURER B Charles Burgess INSURER C 3 Latch Road INSURER D: Chelmsford, MA 01824 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. ,LTR TYPE OF INSURANCE ANSR SWVD POLICY NUMBER (POLICY M DIDNYYY) (MM/DDNYYY) LIMITS '.. GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY E ( RENTED PREMISESlEa occurrence $ PR CLAIMS-MADE F—]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY ECT OC AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS HIR ED AUTOSTOS NON-OWNED PROPERTY DAMAGE AUTOS Peraccident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X TORY LIMITS OER '.. AND EMPLOYERS'LIABILITY ANYPROPRETTOR!PARTNNER/EXECUTIVEY/N E.LEACH ACCIDENT $ 100,000.00 A OFFICER/MMB EREXCLUDED? N/A VWC-100-6019601-2015A 11/14/2015 11/14/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 D SCRIPTfft n OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The workers compensation policy does not provide coverage for Charles Burgess CERTIFICATE HOLDER CANCELLATION Town Of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - - -k. '� : ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 4542 Massachusetts -Department of Public Safety. Board of Building Regulations and Standards construction� Pei-Visor '.. ei -»ir License: CS-068820 rr CHARLESJBURES - 3 LATCH RD Chelmsford MA 8152 n. `4l aria" , a Expiration Commissioner 01/13/2017 c � C��e�poo�zwaarrcuea��a�C�/���cd�cc�rtdeCly Office of Consumer Affairs&Business Regulation NOME IMPROVEMENT CONTRACTOR Registration: -.124728 Type: Expiration 8/14/2017 DBA C.J. Burgess Charles Burgess 3 LATCH ROAD CHELMFORD,MA 01824 Undersecretary