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HomeMy WebLinkAboutBuilding Permit # 12/9/2015 t%OaTH �- ® ¢ BUILDING IT gyp. , 1 LID ' TOWN OF NORTH ANDOVER .o.,. ...... APPLICATION FOR PLAN EXAMINATION , r Date Received o Permit NO: � "'#Argo� A SCWUS�C� Date Issued: z— IMPORTant must com lets all items on this a e r , r / / 1 » TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building ne family [iAddition ❑ Two or more family ❑ Industrial El AI ration No. of units: [i Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ..;. ,,.,, /,ir , rri ,r//a/o/gid ,r ,��//, ✓/,://,'!//i/f/r/f.,,/i,,,/,,, %/ral r�r i%i%/ii/%//�%�1,/�i%,/�l ,.rr ,,a. ri l,.rrr /.r// / r//1..//r,/ ,,,. //, .,,,,..,// /,. ,. .. f /, / c/ � ///I!, l.r „. ✓-t1 // /moi,,,„., iY 0.11lU x,11 i Y Identification Please Type or Print Clearly) OWNER: Name: Phone:t� I Address: , SII fl Il rrli �uf' l f hn / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ t0 FEE: $ Check Receipt No.: NOTE:NQie-rsons contr ctin wit nre istered contractors do not have access to g anty f'iind orl foy"T,' AM tkORTH town ot nctover - 0 . "s - ver, S9 I p L"", 1 �g COCKICNEW.CK V ` A®RITE® PP�,��y S U BOARD OF HEALTH Food/Kitchen twERMI D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .......................�:......... ....... rte..�..... .............................. .......,............ r ® � ( Foundation. has permission to erect .......................... buildings on ... ...,.. ... ...... .,.. .... ........ +� ��� 9 ���� Rough to be occupied as .....11+1 . .t.....�. ..s... ...... � ....`�. ........ Chimney ........ . provided that the person accepting this permit shall in every respect conform tot 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 `} PERMITIRES IN 6 MONTHS ELECTRICAL INSPECTOR �JTI Rough T TS Service ................... ......... ................:.................................. Final BUILDING INSPECTOR - GAS INSPECTOR Occupancy Permit Required to Occupy BuRough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing r all To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Sweepnman, Inc. 108 Main Street Building H North Reading MA 01864 Phone:(978)664-6642 Fax:(978)664-1298 sweepnmanOyahoo.com www.sweepnman.com Service Information Matthew Carnevale -------------–------------------—_------- r Work Orde 5 Greenwood East Ln Billing Information North Andover MA 01845-4622 Matthew Carnevale Contact: Matthew Carnevale 5 Greenwood East Ln Phone: (617)571-8238 Fax: Alt Contact: Alt Phone North Andover MA 01845-4622 E-Mail: quaftro–ft-225@yahoo.com Marketing Campaign ............. Wom Job Name ❑ Call Ahead Confirmed ..............Sales- RF�ep Type Class Carnevale,Matthew-2497 p TM Due on receipt Type Liner �Ipjj_ Liner Job Type PO# Route Scheduled Start En �ers 2*permit ne( ETimothyM 12/10/2015 08:00 AM 04:00 PM Item Quantity Rate Amount .......----------- LINER Liner for brick oven 6"hybrid 1 $2,390.0000 $2,39U0 Insulated at the bottom and around the top LINER - For wood stove insert 1 $2,290.0000 $2,290.00 Bricks will have to be removed from the back to fit the full 6"liner through the throat Permit Permit Fee 1 $250.0000 $250.00 Job Subtotal: $4,930.00 $0.00 Account Balance: $0.00 Total Due: $4,930.00 _System Info Home Heating Chimney Info__� System Chimney Cap -------–----- Job Notes and Instructions TM estimated this job from his prior company,customer search him out,please go and provide estimate for liner work This report is the result of visual inspection done at the time of cleaning. It is intended as a I have read this form and understand the convenience to our customer,not as a certification of fire worthiness or safety. Since apparent condition of my fireplace,appliance, conditions of use and hidden construction defects are beyond our control,no warrantee is chimney,and/or vent system. Furthermore I made for the safety or function of any appliance,and/or system,and not is to be implied. understand the limitations of this report as given. �c091510:21a Sweepnman, Inc. 978-664-1298 p.1 -y� ® DATE(MM1DDNYYV) ',..'.'... CERTIFICATE CF LIABILITY INSURANCE12/9I2015 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). PRODUCER NAMeACT Scott Leavitt, CIC, LIA MTMBrainerd Inc PHONE (978)667-9031 at Nn:(978)667-1D16 1A Andover RoadDOR AE-NAILESS:Bcottl@brainerdinsure.com DDR INSURERS AFFORDING COVERAGE NAIC# Billerica MA 01821 INSURERA:James River Insurance Compan INSURED INSURER B;SafetyInsurance Company Sweepnman Inc. INSURERC: 108 Main Street Bldg R INSURER D: INSURER E' North Reading MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER>faster Cert 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. ADDLINSR TYPEOFINSURANCE IVSD-WUJL POLICY NUMBER MmlooYEFF MM%DD/YYYY LIMITS LTR X 'COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ril OCCUR DAMAG E TO RENTED pREMI$ES Eeoc_unence $ 50,000 X . Blanket Additional I 000691690 11/18/2015 11/18/2016 MED EXP(Anyone person) $ Excluded ' Insured BV Contract i PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- ' X POLICY- JECT " LDC PRODUCTS-COMPIOP AGG $ 2,000'000 OTHER: 1 Employee Benefits $ AUTOMOBILE LIABILITY F11SINGLE LIMIT $ 1,000,000 BJANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED New #TBA 11/18/2015 11/18/2016 BODILY INJURY(Per acciderd)33$ AUTOS AUTOS i HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Par accident g UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS i I WORKERS COMPENSATION {{ AND EMPLOYERS!LIABILITY YIN STATUTE t ERH _ ;ANY PROP.RIETORIPARTNEWEXECUTIVE N JA i E.L.EACH ACCIDENT $ 1OFFICERIMEMaER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS belrnv E.L DISEASE-POLICY LIMIT7L $ t DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,maybe aftachedif more space is required) This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE Matthew Carnvale THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 5 Greenwood East: Lane ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA. 01845 AUTHORIZED REPRESFJVTAT(VE S Leavitt, CIC, LMA%S ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD INSD25 rmun11 ® DATE(MMIDD/YYYY) CERTIFICATE LIABILITY INSURANCE11/17/2015 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 D-JOHNSON INSURANCE AGENCY INC NAME: 7 GROVE STREET STE#201 PHONE FAX TOPSFIELD, MA 01983 MAIC Ext): A/c "° ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER B SWEEPNMAN INC 27 LOWELL RD INSURERC: NORTH READING MA 01864 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 27338068 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. ILTR TYPE OF INSURANCE INSD WVQ SUER POLICY NUMBER MM/L DIYYYY MICY EFF M/DD�Y LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE El OCCUR DAMIAGETO RENTED PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L-AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $-- POLICY❑JEPRCTO [7] LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-388139-014 12/18/2014 12/18/2015 STATUTE OERTH- AND EMPLOYERS'LIABILITY Y/" ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? ® N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION MATTHEW CARNVALE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 5 GREENWOOD EAST LANE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER MA 01810 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ✓� WI n LM Insurance Corporation t✓ fJ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 27338068 1 1-388139 1 14-15 WC I yogesh.patil®libertymutual.com 1 11/17/2015 5:24:28 PM (PST) I Page 1 of 1 The Commonwealth of Massachusetis Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 wwwmass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ri Address: A�o toe-L L City/State/zip: (A r I'a VLh hone e Are you an employer? Ch r6oate box: 1.9 1 am a employer withT7 4. R I am a general contractor and I Type of project(required): F, employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. F-1 Remodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.1 9. E]Building addition required.] 5. [:] We are a corporation and its I O.El Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.R Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.E]Roof repairs insurance required-] f c. 152, §1(4),,and we have no employees. [No workers' 13.9 Other S` Lk&, comp. insurance required.] Lbnzlm�w bAtr- *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. tContractors 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 thepolicy and job site information. Insurance Company Name: ace Policy#or Self-ins. Lic. 3ECZI=3::_2 Expiration Date: xcl? 2&1_1_1 Y Job Site Address: A _i�).WZM Gr 6�41� 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 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 certify and r .,t,,r_pa1n,v and penalties ofperjury that the information provided above is true and correct. 41 Sigpature: Date: 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 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts -Department Of Public Safety Board of Building Regulations and Standards C.'dfsaw�ti-�acdi�rn ��titp::i�a�r�r`�g�eci:kl4}` License: CSSL 100886 DAVID A BANCROFT 27 LOWELL RD—= '`;k North Reading MA 01864 .X ti Fxpi ration Commissioner 03/09/2016 COmmonwealth Of Massachusetts Department of Public Safety oil Siaa'ncs�ln hnici,ars C:Vjgificnie License: BU-026558 / q DAVIDABANCR40FT 27 LOWELL RDS 1 i North Reading NSA pi864 r Commissioner Expi ratioF7: 03/09/2016 :� /. ../._. ----._ 6 ill lilt..,,,/j,wIll?N/�r(,L, „C� . \ Office of Consumer Affairs&Busin@ss Regulation License or registration valid for individul use only ( #S7ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: d ,69istration: 160389 Type: Office of Consumer Affairs and Business Regulation ";�Pr .Expiration: 7/16/2016 Private Corporation 10 Park Plaza-Suite 5170 -4 5WEEPNMAN,INC. Boston,MA 02116 DAVID BANCROFT 27 LOWELL RD. NO.READING,MA 01864 Undersecretary Not valid without signature