HomeMy WebLinkAboutBuilding Permit # 12/18/2015 BUILDING PERMIT a�a
TOWN OF NORTH ANDOVER ° .�n
�+, APPLICATION FOR PLAN EXAMINATION
Permit NO:� °�' Date Received °,�
I,� 9 S �5�
Date Issued 11• L ft
IMPORTANT Applicant must com fete all items on this page
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PR9PERTYOWNER
w1AP NO / rPARCE���' / 26,NIJVO DISTRICT Hlstoncplsinct r r/r Yes (,m.�' r
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
❑New Building ❑One family
!Addition ❑Two or more family Industrial
CI Alteration No.of units E"Commercial
n Repair,replacement I I Assessory Bldg n Others:
7 Demolition ❑Other
USeptic=., Well QFloodplam I3Wetlattsls-; C7 a/Ilafershed Dist
•�16J)ALlq VIS`}.A.i��.1 i60
Identification Please Type or Print Clearly)
OWNER: Name: DC (�t Phone: Yn
Address: �.. CU �(( , IL 'G-LI(? f•, I7 Y1 Y f)
G'Qfl� fy'J'002me`
I� �! /irrr irk/lf%// it��//r// r/i1i /�/I✓� �///'ii �/irrt Or �/i//G��/� �/r��
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Fjoroe
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ARCHITECT/ENGINEER Phone:
Address: Reg.No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Protect Cost $
5 'I'''I ,v)() FEE:$
Check No 1 Ok f2 Receipt No u
NOTE Persons co"Ovedng ilhunregistered contractors do not haveacces o theguar ty/isnd
Sigriatu e,pf AgerA4fflWlie'rL.410
i;/Orr—
ii,,r,/i� Slynatt re;o(eonfraetgrr
...._.._ ..._._....
Town of & V%ORTII
Andoverr
No. ver,Mass, I ce IKAIS
��f,9 pOanre°M�va4,�5
3 U BOARD OF HEALTH
P Em R IL Food/Kitchen
Septic System
THIS CERTIFIES THAT.......................................................r...'.... ........................................... BUILDING INSPECTOR
.................
has permission to erect..........................buildings on.. .. .. ...✓ ° e..Zat.! nundatron
yo Rough
to be occupied as...... � ......... .... .... .. !did..XAt..................................................... chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Finar
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 M® THS ELECTRICAL INSPECTOR
UNLESS C®NSTRU I S TS Rough
Servire
............ ............................................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Reguired to Occupy Building Rough
Display in a Conspicuous Place on the Premises—Do Not Remove Fnal
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector, Bumer
Street No.
Smoke Det.
DJD.1.5-BO-G-0032 P.g')'I of 9
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0FrF,ROR 70 COMPL.E'T1.;BLOCKS 12,17,23,24 B 30 1).15 80-0091
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/FOR SOLICITATION '
INFORMATION CALL
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_000 D Iwcr>'lo I I I/14L015 �� 1 000000 I A $44,14'650)() 1 '944,746,50
1'�UItNI'I'UI2E AS INDI('A'I'flil ON A'I'fAC;HGD
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DJD-15-60-G-0032 Page 2 of 9
21. 12 21
TFM NO. 6 _(UL_ 1P -^VIuANI TY i AMOL JT
32u.OUANTI t'!IN COLUMN 21 HAS FEIN i
BECENFO [:]INSPECTED [:]ACCEPTED,AND CONIORNIS"-O THE CONTT I3ACT E%CE'T AS NOTED'.
32NATURE OF AUTI101iIZED""""ENT2c DATE 324_PRINTED NAME AND I TIE OFAUTHORILED GOVERNMENT
REPRESENTATIVE REPRESENTATIVE
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iLO MAILING ADDRESS OF AUTHORIZED GOVIRNMENT IPFPRFSENTATNE REPRESENT NVEUMFEH OIOI AU'InORI)EO GOVERNMENT
32g.EMAIL OF All'I FO-VTR IeM RE FB6ENTATIVI
33.SHIP NUMBER 34.VOUCHER NUMBER AMOUNF VEI31 IE 96.PAVMEN'F 3l I" NUMBER
--p '.CI ECK
^'-I COR13E(:FOR F COMPLETE [JPAR'HAL FINAL
JO IP ACCT FINAL I _ '-
FIR OUNT NUMSEI2 39.SIR VCCCHER NUMBER 40.PAIDBY
1a.I0ERTIFY THIF ACCOUNT I9 COIiHEGT AND PROPER FOR ENT 29-RICEIVED BY(P-0
III SIONATDRE ANUTITLEOFCEHTIF NGOI-FICER c.DATL _-
42b.RFOEIVEUATfLocel/w)
.OATI RECD IYV/MM/DUf 42tl.TOTAL CONTAINERS
STANDARD FORM 1449(CIV,MIDI BALK
WD-16-80-6-0032 P.g,,3 of 9
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DFA-SAP-MA 121X DHA Rin,liNd Aqui,ilio,,U se MMflx(MAY 2010)............
4 Lio nC Aunchmc.iii.................................. , ''. .........................
;the Commonwealth ofMassaehusetts
Dquvtment of IfUlm rialAceidems
X C ngv'ess Street,Suite 100
Briton,mass. ov1dIa27
www.mass.gao/d8a
Workers CompensationIasuranoe Affidavit:Builders/Cant actorsZElOot}dcians/Plumbers.
TO BY,MED'4t'ITTITM,ETs'RNDTTBVG ADTFOBITY. Plea se Priu£Lo'bl
A 11—tIuformation .
Name(Buamess/organizattodrnatvianstY._� 1 O h 5..;_.��� �-T
City/State/Zip: Phone 0:- �7 S_
Areyon nn mup/oycrl Checkthe appiopriafebnx. Type of project(h'egnil'ed):
22 7.0 New constmction
1�I om s employer with�ymnPloyaes(TuIl and/orparttlma),*
2.[�Iamasoleproprietor orpartncrsh[p andhave ne employees Working furmein 8.�Aemodelirig
auy capaeiry.LNoworlcars'comp.iruvraeme requimd.] 9,❑Demolition
3.QIm¢ahomeevarer ddngah work mY,,,No workem'comp.h�surmeoregvrtcd.]t 10 E]insilding addition
4.QIm albhhhrcontmk etom to coennsdeutciot ettworkeono my Propery.Iwill BIeatd-,drpais or additions
thtll ant
d
D-
5.[]
_p p-- Pl yeea: 1�,[}Plumbing repia oxadditions _.
5. I s,_1 .,d•rdIhaye7ur dike b rimcto sated th ti hedsheeC 13.�]Roofxepalxs
these sib-contractorsltave employees and have workers'camp.mau-'$
6.0 We am acorporatipnand its gH,rgenshave excrcisedtheirright ofI—ptI.U`MGL c.
14.(]other
152,§1(4),aadwoh¢vonq.employees.[No workers'comp.i¢smance inquired.]
eAny applicaN.that checks tioxikl mustalso filloutibe secllorthelowsbowingtheirworkem'compeosationpolicyi xmerion
t 8omcowncm w&os'ntimitk6isaffidavitindicating they me doingallworkendtheuhva outside couhactorsmustsubmitanew af'Hdhase evtit rys have h.
I
c
on,
ct"," checkthigbox stattachedanadditimal alreetshowingthe mm�e ofthesnb-centractors and stale whether Drool.
ploy Ifth b.� f 5 omplaye,'-s they muitpmvide Weaw lee' p policy numbm.' -
Z ces.Below a th pal cy and,7ab sat
Tarn an employer tl:atisprovidingworkers'cornpeasahon ansau•ance}orrrye Ir Y
information.
Insurance Company Nemo_�Ce�i�-l�.�lca`n—L'blSklra"�'C �_ ���---�—
FxpieationDato;_
Policy#ar Self-ins.L]c.#:
rob Sita Addreaa:_ Imo a o
Attach a copy ofthe workers'ebmpensation po]icy declaration pagu(showing the policy number and expiration data).
Failure to secure coverage as required under MOL a.152,§ZSA is a criminal vielati)npunishablo by a fins up to A1,500.00
and/or one•year nnpxisonment,aswell as civ31 penalties hrtha foam oLa STOP WORK ORDER and a Fane oPup to$250.OD a
day against the v]olator.A copy o£this statement may be forwarded to the Office of Investigaflons oi'the DTA forinsmance
coverage vertftcatiou.
Ido la�e'uy certify ander Fy¢patrxs andpenaliies ofpmjutythatike tnfarmNdonprovddedabove istraeand correct.
i nature:
O�eiadnse ondy.Do notwrite do Ills area to be completed by city or torus�ciab_
City or Towu:_ —
Persnit/Lisaa-a#
f,,WngAnthority(chole ono):
1.Board ofllealth 2.BuildingDapartmen£3.City/Town Clerk 4.Metrieal Inspector 5.PlnmbingInspector
6.Ott—
Phone#:_
CERTIFICATE OF LIABILITY INSURANCEDATEIMM/DDTYYVI
T TIFICATE 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
PR D ERA FI ATE H LDER
IMPORTANT:If the certificate holder IS an ADDITIONAL INSURED,the poli
he .Y(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to
terms and connsditioof the policy,Certain policies m,yreq,ir,and endorsement.Astatement on this certificate does not confer rights to
the certificate holder In lieu of such .d.—Daunt(ii).
PRODUCER CONTACT
AME:
LTE INSURANCE AGENCY INC PHONE FAx
85 WE,MING'fON ROAD (A/G,No,E%1):
E-MAIL
EURLINOI'ON,MA 01803 ADDRESS:
]]6SP INSURERS)AFFORDING COVERAGE NAICN
INSURED INEURERA:A
LION SERVICES INC INSURER B:
INSURER G:
INSURER D:
11 MCDONALD ROAD INSURER E
WILMINGTON,MA 01887 INSURERF.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
AlEOR111 MY THE POLMIES 11111TIED HEREIN 11 SUBJECT To ALL111—11,—UETON1 AND C11,111111 11 111H EuDLIES.LIMITAITMARM-11EINAE.LCEDDY
INGR AD. Us NS
P(Mnno(M1--1Y1 PInluwmvvvvlMR
E
R GENERAL LIABILITY 11H OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CLAIMS MAGEJAMABE TO REN
OCCUR. R MSES(Ea occTED urmnce) $
ED EXP(Aly one peacn) $
ERSONAL B ADV INJURY $
GENI.AGGREGATE LIMIT APPLIES PER: SENEGAL AGGREGAtE Is
POLICY OPROJECT EJ LOG RODUCTS-COMP/OP AGO $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANYAUTO LIMIT(Ea accident)
ALLOWNEDAUTOS BODILY INJURY $
SCHEDULEADTOS (Per Person)
HIRED AUTOS BODILY INJURY $
cidenl)
NON-OWNED AUTOS PROP S AMAGE $
(Pe accident)
UMBRELLA LAN OCCUR EACH OCCURRENCE $
EXCESS LIAS CtAIMSMABE AGGREGATE $
DEDUCTIBLE $
RETENTION$ $
A WORNER'S COMPENSATION AND x TU H
EMPLOYER'S LIABILITY YM UB-OG16B465-15 0ILD"Dt5 0]/1612016
ITY cwDEUt UTNE O N/A E.L EACH ACCIDENT $ 1,000,000
(I A1.,.1 Me E.L.DISEASE-EAEMPLOYEE$ 1,000,000
E.L.DISEASEPOLICYLIMIT $ 1,000,000
DESCRIPTION OF OPERA TIONS OCATIONSNEHICLES/AESTRICTIONS/SPECIAL ITEMS
I., II—ESUBPETLP
CERTIFICATE HOLDER CANCELLATION
OZZY PROPERTIES INC DUNDEE OFFICE PARK LIC, SHO ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV
C/O OZZY PROPGRI IIS IN ACCORDANCE W ITN THE POLICY PROV
1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE
NORTH ANDOVER,MA 01845
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP R nghts ieserved.
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JAIME LAYON
71 MCDONALD RD
WILMINGTON MA 01867
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ILAYON
11 MC
DONALD
Wilmington MA iij ;;t
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