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HomeMy WebLinkAboutBuilding Permit # 1/4/2016 y0 R Yp•► BUILDING � IT ®��%OR TOWN OF NORTH OVER 0 - . APPLICATION FOR PLAN EXAMINATION ~ " Permit No#: ! p Date Received ArED Pfp` 5 �ss.�cHusE�c Date Issued: "" 1 IMPOKFANT: Applicant must complete all items on this page LOCATION 0,4, Print PROPERTY OWNER i . " ry Print 100 Year Structure yes ) n MAP PARCEL: tl ✓ ZONING DISTRICT: Historic Districtno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ii anise r� Arai ,rntrrn ,.. /, r a '�"� i ,r r,rr✓/ / r .r r 1 r r� rr�u��. n! 5 "rN J rJl(/ // / f >v fy V� �/,fUii k !!%liY. ,/�l/o;//,rd/ r f r. /.< l � She ;r of �� VXatIE� f.5'e�1e i���1 �1� 1'( 1 � � I%� fV,.AIIIY�iI, � J ,r i;'Vl a J � ,�/r7; � lix�,/r,lrrrl�`y �G✓, ril/i/��i�/. DESCRIPTION OF WORK TO BE PERFORMED: e x,l skrla cj x PLIA II01, 4 R2 L 6t Identification- Please Type or Print Clearly OWNER: Name: lure & ,ef- 4j!!! b Phone: � "�c'�( G�( f•n Address: 0/F, V5- Contractor Name: Phone: 60-. 3d, - ' Email: Address: u- r- -e-evs Pr-►v Supervisor's Construction License: C-!5 - 47 9 ci' Exp. Date: L.4 Home Improvement License: /O(w 7/ Exp. Date: / 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.A Total Project Cost: $ ( $ FEE: $ 9z .. m� Check No.: e') C Receipt No.: �. NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - i ✓�i„m �n/� ✓ri -A/,/� 'Town of Andover F NpRTN 0L No. _ soh ver, Mass, COC MICHRWICK ADRATED P'VP y S U BOARD OF HEALTH Food/Kitchen PERMIT T L �u Septic System THIS CERTIFIES THAT .A .......jkxcto .�r BUILDING INSPECTOR .. .. has permission to ere buildings on .. ...Q. a-! T Foundation Rough tobe occupied as ............ .. ........ ...W% ✓................................................................. Chimney provided that the person accepting this permit hall 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 M HS ELECTRICAL INSPECTOR ?C� UNLESS C® STRUC ST S Rough Service .......... ... ...... ............ ...... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. John Yforan Construction, Q.L.C. (Bui'fd:ng andW§modefing. 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 December 22,2015 Stephen J. Kohr General Manager North Andover Country Club 500 Great Pond Road North Andover, MA 01845 Dear Mr. Kohr.: This is a contract for the small pavilion on the golf course at the North Andover Country Club. Construct a 9' x 9' pavilion as follows: 1. Remove existing structure. 2. Install 6"x6"pressure treated posts on existing piers. 3. Install 6"x6"pressure treated beams above the posts with 4"x4"angle braces. 4. Frame roof with 2"x6"rafters and board sheathing. 5. Cover the roof with architectural shingles. 6. Install 2"x10"pressure treated seat on two sides. 7. Painting not included. 8. Disposal of debris included. 9. 1 will apply for permit. Payment schedule: First payment due upon signing contract. $2,275.00 Second payment due after old pavilion demolished. 2,275.00 Third payment due upon completion. 2,275.00 Total cost: $6,825.00 Signature okAuKorized Agent Signat�f,6 of Contractor Dad Date Page 1 State of Massachusetts Home Improvement Contractor License#102071 State of Massachusetts Construction Supervisor License#47989 NAT-24039-1 „�,., ,. � r, -. �:c:.:,� Via'` - �=�' �r�,:�,��u' �`'r,�z,ca,'',�e> ��v�� �� ., _ (('�+ I � ' ��'� ±' � \1 ) } � � � I r �k � ?��� � 3 �S` 1 I _ f .� 's � � \� r k j I �. s i �' � _ f_ _ } e E?^. f�C i c i �.C��1^�4 r.n a"� `�k”c�`� ____._____.___.,,_,. ______.___... ._.__.__ ;..__,._.___ _._.____^_---------� _.__._________ lam'__—,—_________._ .____,_..� _.__. ____..__.__.�__._ __._,..-__._.0_,_ __.______—_--_ I T— L -?N /Vor �NDiir i r �� 3� � /iii;✓r' ��j��i/j���/�����, 'E Flo '(v { The Commonwealth ofMassachusetts _ Department ofl'ndlustrig"ccidents 1 congress Street,Suite 100 Boston,MA 02114-2017 www.l'nass.gov1dia Workers'Compensation Insurance Aftxdavit:BuUders/Contractors/EZgctricians/Flumlbexs. TO BE FILED VITH THE PET<MTTJNO A.'UTHORtTY. Please Print Le ibl A licant Inforrnati0n t� ; NaMe(Business/0xganizatxon/lndividual): �/ '►N 2 Address: C, City/State/Zip: w g Phone Are you an employex7 Check the appioprlate box: Type of projecF�eqyir ed): emto ees full and/or part time)* '1, 0 New consron 1.�am a employer with � : p y ( 2. I am a sole proprietor or partnership and have no employees working for me in 8. ©memo delift any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself[No wozkers'comp.insurance required.]' 10 El Building addition 4.❑I am a homeowner and will bo hiring contractors to conduct all work on my properly. I will 11.Q Electrical repairs or additions Ole ensure that all contractors either have workers'compensation insurance or are s12. Plug repairs off'additions prop rietors with no employees. 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,0 Roof repairs These sub-contractors have employees and have workers'comp.insurances 14.El Other 6.❑We are a corporation and ifs of59grs have exercised their tight o£exemption per MGT,c. 152,§1(4),and we have na emplayegs.[No workers'comp.insurance required.] t:• *Any applicant that checks box 41 must also fill outthe section below showing their workers'compensation policy information. i Homeowners who suliriiiti this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. tContractozs 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-c64rad6rs have employees,tl ce must provide their workers'comp.policy number. workers'compensation insurance for my employees'Below is the policy and joh site X am an erriployer tTiat is pi ovidir1g information. Insurance Company Name: I�/°"�.�_�--- :44 Sc Policy#b or Self-ins,Lic.#: ( �,�� i 7 J Expiration Date: / 116 lob Site.Address: roSG�C7 �+���`�- P/�nk 6 City/State/Zip: ,f ) �l-t Attach a copy of the worl(ers' cornpepsation policy declaration page(showing the policy number and expiration date. e by a fine UP to$1,500-00 Failure to secure coverage as required under M e G. 15e's,§25 f lrm of a STOPnal �WO1RK ORDERon Iand a Erna of up to$250.00 a and/or one_year imprisonment,as p day against the violator..A.copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do Xiereliy cerci u der tr e pains andpenalties ofpeiftay iliac the information provided above is true and correct. Date: � � j Signature: Phone#k: 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.CitylTo'wn Clork 4.Electrical Inspector 5.Plumbing Inspector 6,Other Phone#: Contact Person: Client#:490547 JOHNHORA DATE(MMIDDrrM) 6/223/20153/2015 ACORD. CERTIFICATE OF LIABILITY INSURANCE 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). CONTACT PRODUCER NAME: USI Insurance Services LLC PAIC NHONE 855 874-0123 AA/C,No): o Ext 3 Executive Park Drive,Suite 300 E-MAIL ADDRESS: Bedford, NH 03110 INSURER(S)AFFORDING COVERAGE NAIC# 855 874-0123 INSURER A:Maine Mutual Group Insurance Co 15997 INSURED INSURER B:EastGuard Insurance Company 14702 John Horan Construction LLC INSURERC: 21 Evergreen Dr. INSURER D: Hampstead, NH 03841 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 CONTRACTOR 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. LTRADDL SUB POLICY EFF POLICY EXP RLIMITS OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY A GENERAL LIABILITY SC10955638 04/01/2016 04/01/201 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES EaoNcurrence $250 000 CLAIMS-MADE F—y] OCCUR MED EXP(Any one person) $5,000 PERSONAL BADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 POLICY PE LOC $ A AUTOMOBILE LIABILITY KA10955638 04/01/2015 04/01/201r idenSINGLELIMIT $1,000,000 INJURY(Per person) $ ANY AUTO ALL OWNED X SCHEDULED INJURY(Per accident) $ AUTOS AUTOS RTY DAMAGE NON-OWNED cident $ X HIRED AUTOS X AUTOS $ A X UMBRELLA LIAB X OCCUR KU10966638 04/01/2015 04/01/201 OCCURRENCE $1 000 000 EXCESS LIAB CLAIMS-MADE EGATE $1 000 000 DED RETENTION$B WORKERS COMPENSATION JOWC667818 04/01/2015 04/011201C STATU- OTH- AND EMPLOYERS'LIABILITY CH ACCIDENT $500 000 ANY PROPRIETOR/PARTNER/EXECUTIVEY/NOFFICER/MEMBER EXCLUDED? N/A SEASE-EA EMPLOYEE $500,000 (Mandatory In NH) Ifyes,describeunderSEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) FOR INFORMATIONAL PURPOSES ONLY CERTIFICATE HOLDER CANCELLATION John Horan Construction LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 21 Evergreen Drive ACCORDANCE WITH THE POLICY PROVISIONS. Hampstead,NH 03841 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S15615641/M15613375 LAKCA 1�( Massachusetts -Department of Public Safety Board of Building Regulations and Standards Constructinn Supervisor License; CS-047989 JOHN V HORAN ! 21 EVERGREENi)R Hampstead NH 03841 f Pi r at(vO n Commissioner 03/02/2016 r eru(!((alru(er�/l/n�'C f��l�r�lc/rcl�cll License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: is HOME IMPROVEMENT CONTRACTOR Type. Office of Consumer Affairs and Business Regulation � t� Registration: 102071 10 Park Plaza-Suite 5170 110W'-;Expiration:� 6130/2016::_ DBA Boston,MA 02116 JOHN V.HORAN CONSTRUCTION John Horan 21 EVERGREEN DRIVE HAMPSTEAD,NH 03841 Undersecretary ; Not f valid without signature