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HomeMy WebLinkAboutBuilding Permit # 12/14/2015 00RTy BUILDING PERMIT o��t, O2 Om TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION q � Permit NO. g Date Received 7RA°RATED �SSACHUS�� Date Issued: �� LV IMPORTANT:Applicant must complete all items on this page P rint PROPERTY-OWNER Print MAP 210 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ,/ One family Addition Two or more family Industrial v/ Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain' Wetlands` Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Re pbscj- Identification Please Type or Print Clearly) OWNER: Name: 1 -)n(-(je kV-) Phone: Address: 1st 4 �i�GY� i�M �\ W, a L CONTRACTOR Name: `Phone:. 'Address:��r1 ' G � Supervisor's Construction License Exp: Date: / � I ' Home Improvement License: Exp. 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. ;`f otal Project Cost: $ � 0 0- FEE: $ I� Check No.: �1 Receipt No.: 2n � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund . r Signature of Agent/Owner Signature of contractor r t%ORTH -Town of Andovero No. ;,.;L ;Lot 4 '� h verass ®� cocHIC wocK. AORATE D `� LI BOARD OF HEALTH ME Food/Kitchen P E T LD Septic System ® BUILDING INSPECTOR THIS CERTIFIES THAT ............. ... .. .. ...... ...... . .... .......................................... • •*..• Foundation has permission to erect ........... buildings on .. .. .... .. ...... ...............® `` � Rough AP 4 to be occupied as .... cktop it" sem. .. . . Chimney provided that the person a epting this permit shall in every respect conform to the terms of the ap lication Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and PLUMBING INSPECTOR Construction of Buildings in the Town-of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMITI IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION (j T Rough �7 Service . Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathingr g Wall 1 ® eDone FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. (,ry g wo mn Ovoler' hd kme ........ „^ 1'x.7:,d F F ._ A'" ._`� +.�1� G.I N. Glp I�V01 b Job tdddte,...r Varve 1ho nwrv)h)tat the prf f^ivr es i ienCfnurud below Iveby er Wj¢ ii,f wiM anrl duthwitie You 1,m ILin iirah,tll ne"'("segury Imterial,i,kbor and vvoi V,frfan"'hir" N,iPfrsidll,f.rffv,,"ru c; and p4a0(t Iho irfilrrtn¢,frfnr'rfn ,re;;ur fiy'I to ul')feflt,rwlrrm;p.p+ep,ilfr.gaflnris two Pnd i"nif(htio mG,on piewi eta imfl fta cimribao Brand: ! r. } (WPIDOM SPECVF1 G@014S Quardity: NMI Iieirho k.rsw'r.E Metal 11v(. tjevmlfm tudau.,l'4"#.��ip.. GY,:ruf over hang rrrmpGkru ga;rreerm.„ 4";sok(:„,, friar Y'rnrn k=8rri.,@r Color: A, NO lror No °drvs 'NO 'Yes I"k) ",°ns NO Yee No Yat;le "to `(m No Double Hung . . „�...,.._ ,...,.ro..,, .. .„., .....,...� ... �..._. 1/3 Deposit s :rlm:er i ,.., _.,.... . _.,,,,.,..... ._., ...... ..n,. ..... ,., �.., .. .. ...... �.. .... ,1/3 Start of r,tob"s4 e.✓” r d,x drr6e1l...._.,_. ,_.. ... ..... ......... .”.....�.. .... _.. ._, ._ .w....._ ..w.w...,,... _ .. ovt l nruew tUponG arorrudaka 4uura$...... 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P Pr(L I f `af 3 DI0➢Rio Y 3 t r m Nor,R fur O' d u %' p N"h Y + r, i 1 d r ennY u 0 sy mi I, r ca i rn rirmn {ram rrl m r n .. t`^C(Yi•1 of m a ;a. -"W'. },m r„ r,-'r'uCi p om r,I r ,a!w d m Of SI G ir✓ t,ory.l"'W", ,vr V...�a1,c Y: .r .. .. l,'A Uhw �� I it 1rt rl ginmi`vl rranr (i Irf:r'!> C.✓w)(I tretely yfp v'iif Pratt ,,d a i,,,qu !r r,..."IMY,m hGB:dBp4rme of V'mp0ssl r�r;1[}`„CYC.3ldk".f:f.t*m,v10(:urirl©)„uda.C.fLr,rr irllYrf fhjj nrrLgf q t,,,Cm J(I ,,hP!:[d41^5rI "" 0lA mel'Ou rfr,a 301 r,,,6.0 rki l4..ml i,n .g",r tfrh/'.1PMt vml h;^rr 3<f( na(x'V r.1„r;.m.Y"reuffie eiryea„rarep e anfA Oft rr;uuwame4mr M my f ure prier to nr@evtfiWA opt Me hu6un rdwaahree.e day Oiler Hm¢,,fl r 0 if is kamrreJaaa9W,Cancelb Oran¢rrt,om9.be rcGam Oe wwd un g.We test ave Pfrom rigphl to ON*y ouml man, W.b dNog"SnD 'Y'HlS CONTRACT'IFTHERE R Y M.ANK SPAGES. a IN Wt CiVG S Vifi4ff RE 1 ramY fWyr p lrtm�,k � eifnlo have, igrm¢#rf�hair names this C a9aY asfl € f ya C7 z-5 aTt'PI Up �d...�.,f) .yd �..��y " ! 4 7s 'C1 e f r7f t X if rtt rr i wit), uie fYr, a ,uf _... - y7..,mr,n a(.,v«.� ,I, rat er,d i, u,,,rr,r„rr..r,rx�lr vlu erarr fPa"ur,er G¢Rf Fn rm llrr te9r” Qfr7/ ,r.JVf rfr .G F.{,fFr rren i',;.Rr r J�.^MR:Cr CCnryl` I Sigried ..... 'r hrSpp IM1r lP ue t'6d) t�^4 +.Pyr y7 , prl ura*mrMr ,! gP,(A!F nl frl nn,r T(^r: o'I al VPr a5w'rrtrr .,.. ..,._,._..._.,.._.._.. ......m......., 0....00_0..._... ._,_............. .............�,,,,..,,,......,, _......000..0..,_._...............,....._.�..... .,... w...........,..�..........w...,..... ......, ..�.,.,,.., ..._...,„.......,.....,�.................,. The C'ommonweal'th ofMassachusetis , - Department of.YndustriglAccidents Office of Investigations 600 Washington Sheet Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/.Plumbers Applicant Information Please Print Legibly Name(Business/Organization/fndividual): Rba Ks C'OVA�! Address: 0�5 r od�&/a Ci /State/Zip S { C�3 r-1 Phone#: ty : D ��� , Are yu an employer?Check the appropriate box: Tyle of project(required): I. a I am a employer with 14 4. ❑ i am a general contractor and I 6. E]New construction employees(fall and/oxpart-time).* have hired the sub-contractors 2.El am a sole proprietor orpartner- listed on the attached sheet.x 7• [�Remodeling ship andEl no employees These sub-contractors have 8. Demolition working forme in any capacity. workers'comp.insurance. g• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3.❑ I am a homeowner,doing all work right of exemption per MGL I1.❑Plumbingrepairs or additions myself.[No workers' comp. c.1.52,§1(4),andwehaveno 12.❑Roofrepairs insurance required.]i employees.[No workers' 1311 Other comp,insurance required.] 'Any applicant that checks box#I must also fill outthe section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insuranceformy employees. Below is thepolicy anrljob site information. Insurance Company Name: Policy#or Self ins.Lic.#: ,V c 3(6)A]Cj Expiration Date: E) G j 1`to rob Site Address:. 0 a'. Vo—o1 RCS City/State/Zip: Attach a copy of the workers'compensation-policy$eclaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A o£MGL o.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 rine 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 DTA for insurance coverage verification. fd'o Hereby cern under ie ins andpenalties ofperjury that the information provided above is true and correct. - SigLiature: Date: Phone#• Lop S- ,(Aq4-11N 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): I.Board of Health 2.Building Department 3.CitylTown Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: T A ® DATE(MMIDDIYYYY) CERTIFICATE LIABILITY Fb/29/2015 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). PRODUCER NAMEACT Linda Bogdanowicz Insurance Solutions Corporation PHONE (603)382-4600 _J 1601: (603)382-2034 F 60 Westville Rd E-MAIL ADb E .lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC tk Plaistow NH 038£5 INSURERA:PeerlesS Indemnity Insurance 18333 INSURED INSURER B Brooks Construction Co. of Lawrence Inc, DBA: INSURERC-XXCelSiOr Insurance 11045 254 N. Broadway INSURERD: INSURER E: Salam mH 03079 1NOURM F: COVERAGES CERTIFICATE NUMBER:CL1552621745 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 DFSCRIBFD 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 DD B POLICY EFF POLICY EXP LIMITS LTR INS MLO POUCY NUMBER MMfDD MMIDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,DO() X COMMERCIAL GENERAL LIABILITY bA AGE (Eaa o E�ccurrence PREMISESS $ 100,000 o A CLAIMS-MADE ®OCCUP, CBP8945793 /16/2015 /16/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY JECI F__1 PRO LOC $ AUTOMOBILE LIABILITY COMBINEDcNrfanSINGLE LIMIT Fa a �_ _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNEDIPIR ERT AAIAGE $ HIRED AUTOS AUTOS Medlcal 26=11ts $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATIONWC STATU- MIT EMPLOYERS'UABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE EL.EACH ACCIDENT $ 500,000 OFFICERIMEMBEREXCLUDED? N NIA 6836275 /16/2015 /16/2016 (Mandatory in NH) F.I.f11.4FASF-FA FAAPI OYFF S 500,000 If es,describe under __D RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more Space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Diane and Philip DiBenedetto ACCORDANCE WITH THE POLICY PROVISIONS. 123 French Farm Rd N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE Keith Maglia/CLS ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION, All rights reserved. IKIS025 f9wri i ml Tha 6C(1Rr1 namn anri Innn am rnnlafararl markQ of anr1R11 )ffrc4 of C;orrsumer Affnira to I3usinees Refill lation fi''CJME IMPROVEMENT CONTRACTOR w,;',"Registration: 101682 Type, Expiration; 6/29/2016 Supplement BROOKS CONST.CO., INC.OF LAW MARK DI PRIMA 2540 N. BROADWAY STE 110 SALEM, NH 03079 Undersecretary Bcmrd of Budding Regulations and Standards Uc.e nse: CSSL-099730 ii" � t P, �,F MARK DIPRIMA ni 1 18 HAWK DRIVK SALEM BVH 030' �am�b�� rorunnnu. 02/20/2016