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HomeMy WebLinkAboutMiscellaneous - 50 JOHNNY CAKE STREET 1/4/2016 V%ORTH BUILDING PERMIT 011 TOWN OF NORTH ANDOVER 0ti APPLICATION FOR PLAN EXAMINATION PermitNo#: Date Received 4-J I �SSAC US Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION SZ) 3t)KA TA COAel— Print PROPERTY OWNER JQkt'f- ' Print 100 Year Structure yes no MAP 6 I PARCEL. 58 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residgntial Non- Residential ❑ New Building One family D Addition 11 Two or more family 11 Industrial H-91feration No. of units: 11 Commercial epair, replacement El Assessory Bldg [I Others: 11 Demolition 11 Other gggl�e qq-g mmw DESCRIPTION OF WORK TO BE PERFORMED: �AOJS C-ek�Qt%%A- %, I a. U-N Vo(wyej Identification- Please Type or Print Clearly OWNER: Name: Phone:91-*Y) Address: Contractor Name: WV 4,Q Phone: Email 5)oj,^w-(r i n Wk- "Un Address:'J PQ f2 o%i iq�- Supervisor's Construction License: Exp. Date: r, Home Improvement License: 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.F. Ad) Total Project Cost: $ q% FEE: $ Check No.: L �� Receipt No.: NOTE: Persons contkettind with unregistered contractors do not have access to the guaranty fund o rirl �OR7 6y i own of ndover _ h .r ver, a k 2-0' O LAME COCNICKE WICK x.95 RATED 5 U BOARD OF HEALTH r t:.. Rg1T T LLO Food/Kitchen Septic Systemtit ` e THIS CERTIFIES THAT .. d1*WBUILDING INSPECTOR .... .... ... Foundation has permission to erect .......... buildings on ............... ` `m.... ............. ....;. ....... ... .. ............. Rough Ak to be occupied as '�. .. !. .. ... ... ..��!! , � S! ..... .... .r..... .. ......,�....................~.,.... ............... Chimney provided that the person accepting thl permit shall 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 PERM* EXPIRES I 6 , Tu ELECTRICAL INSPECTOR LESS CTIO 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. e i Feeo�oflsse➢ No ow A dlvi8ea afTtdeh�Sorg � I 40 uallatclaw%IFAX 41t� CONTRACT � pop eRoaaMoop '� a►saPM Me Moetray (978??A&0197 larA ZOIS 420781 0=4 SO Joltagy Cake Lane IJ SO Johagy Cake We r— NottB Andover,MA 01845- Nw%Attdom,MA 01845- C� JO DESCRIPTION AMSRALIIQtkPeovtdetaboteed msommeaarr«Qt a ,ama+�rl a 76tswakaia6o pent6rtaed taaoaonttwbtlm mootapedal mdsmtd dta�o tdtsmastmn dmtyaurlmaaswiU bs ts8abnbceltbasl tevol of elteadiadaorefrgmtbyr.Mate�bmeemedmsmiyavts�cc®tcd�e�Rraanm�ao�erproaunb.Ply '. eRas tbt�toandeatrtestmeemettte�, .etemdast 8ptagtsaadotbrin3xatedarms(vntndovo ero aotgmtnatiy sddtea=4M&wSlttq*eMwmkb*dmaa.AtedeedoaiAoft wiH==.but the=W aombetofab baotpmad. Atom aompteNmofdmwtmihaim taa wort:,=dot nmeddhtood can todw h=wwm,a MW blowsy domaodlarooat�ttaw mflbr eaetytbvrs�beaoodnsmdby tlmmasszoo dm mb(y�tta tadooretrquaU(y. 26It0.00 AMMALEWADUM(4)wodde8b= $340.00 DAA!>1Dtiii:Fravhlafsb�eadatatpiebto kWsp a 12'tsyaafR.38 uatUad Sbm�efsbmm(l4a)sgttmo@et tbrdmamisg Mom 130080 ATftCFLA7'.Pmvtdotaboraodamtd*tobtaAea8•taywofW28Clmt1Cdinfos m*dm(1072)sgomo6sotofopeaoft tIrC68.64 j KKEEWALI.S ftDvi6MormdmdmidstoW Hl•FBKftwseakigidt%mgfenbomdbmbdmto(2w)sgmo0xtor bswwtl ansa. s7a9m ATnCACCS&RafttobwaadmmWsto&own(1)eat'=vcd.insubtlb8onverbortbamdaeoxn amtr.AWAU 0atatrbeedpb'%oodwiDbo' l,'awmddoopuftwhbiadaeak lWwMdlowdmaovarah*Vdvm6w4Wp*gm mditobbdm8s. !137.65 ATRCACC1i8S:Flaw tdotoborwdm*irWstoamlmM to q=Weatastoaaa&wm.7hoapmdMwMbodandwhb manmdslsslmfrarmdmmmdsft FhdsbumfmgInd pahftaIsaothalo" 5170.00 V139'f11.A7it}It:Pma[dslabotmtd amtatalsro taoail(2)hss�desedmdmuubmawitbsolf$asoosdod Qepppvactmastamst e�g6asbmanSoW: 2237.50 VPNTQAMM.Ptatrhlotatmodmaomistsmiodlnow. $120A0 RASMaNTCEaatMPwfttebw=d ZbutatFonmebopmtaxlar of flet bmumat ceft8 at tba tame sU S171-% t?ederai 1D A 050ti058ffi RI$ji',Ea RlQotgrscP Rag'aftlfeUSS MA ttatt�ot Ramie a No tf0970 AdMdn dlblds<b t3 60Siita advandl,aatom,AlAQ20t� CONTRACT FAX> .63iS Peps 2 PROGRAM CMA43ES � wrzoim vrnuR°°iu -GURCILM Mum hb Mcchw Mr)2D8.0197 10)26/2015 420781 00004 RUN ow awasw 50 Jabnay Cdw Leu 50 JobmW Cdo Law North Andover,MA 0184S• North Andow,MA 01845- JOB DESCRIMON R188YouwHlantytbebModtboWssaotatt t wu*. awaUSUameeuCotombbQnoffm7S%bmnftnatocmeed= Mt>Qroeimsderlw.wdwft=Wwcfl0VAfcrtbo Ak$cdb* eNureyuPtoft tSMMWamadgdood$Mifsnttp opdambyftwdbw, Fordm nft end Mftofywbamh batoarairgaeJitq.wa wttl be ooh a tdamdoardtegaosdc offt fiveaabteda How In your6�obotbbefao�owottbbe�m.eada8aedmweatlteeb mwaekboompkm WewBiekseomhtcte&tia=esm taf dwcsmbmthmw>blycfyaaehmftM mandwWbmW.7M huavatw0fWQWdbedasemttoy=TaWa0owabk wadmdndmlnorslI bS3,ltQ 190.00 Toteh $4X7A9 pmaratn Immmum $3.110.00 CuahumTotd: $1,487.09 we a�Ktmeev to t amaaaae•cetwtetn a�tnah Dawe >m�rAoa not eur or "*One Thousud Four Hundred FIt1y 4Wm&89M00 Deli= i1�087.N ANr e�tstsata �c�i aotmsnaoa�maearewear acavvan olaaas mem /D Lb�.i" SD ona � � iuou" °rtoim itorNam=a0o a OWNER AUTHORMATiON FORM Iiihe M cIF1 ra o ow wofdo ptope4 bo&d at dgo Xo1 Ca--Ks (P OP*Aditn) hmewmftft auagedstarI Bt�rw ootonmybel�Eooft9nalm pm twdtopofamwo*onnWpmp*. I..-- Am Oaf ' The C'orrtme>ttweafth ofilla .sachusells Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,:I1A 02114-2017 www.mass.gov/dia Workers"Compensation Insurance Affidavit: BuilderslContractors lectrie ons/Plumbers Applicant Information Mease Print Legi>'tly Nattle 1tY_r Y'e&LA6-R Address: 00 13oX M _. -.._ Ci /State/Zi : m 1 6 Phone et 9 A-9 IS-b <3,491 3 Arc you an cinployer' Check the appropriate box: of project(required), 1. I ant a employer with 5 4, f air€a general contractor and 1 & [ New canstnudcn employ�cc%(full and/or part-tinael.* have hired the.sub-contractors ?, I am a merle proprietor or partner- listed on the;attached sheet. 7. RcmcttJt lit,g ship atnd have no employees These sub-contractors have b, ®Demolition working for me in an c acity. employees and have workers' b Y -� 9. ®Btrilduai;a€tJc3itican [',to workers'crrtnp,insurance acme+.insurance-'requiretf_] 5- We are a corporation and its MCI Electrical repairs or additions ffi ocers have exercised their I I.�Plumbing airs or additions re 3.� 1 am;i homeowner doing all work, P myself. [No workers'cornp. right of exemption per MGL 12.[]Roof repairs insurance required]{ c. 152,§1(4),and we have no enap y Ise="o. Nworkers' 1_� [ Other " i= comp,insurance required.] 'Any applwant that cheeks txoc dl nu'm also till out the-ecBuri 6k�kw showing their wofkcre'comps enation policy inforinatinn, r Hmnevwnm,i6ki sulmnit this affidavit indicating that'are doing all work ind ihm hire out.-aidc cownctors must submit a ncxi affidavit it indicating such. Tonttacto.s that check this box trust attachnl 31 ad itioml to at sh<rtaint the ttame of the sub-connimots and state whether or not thosc ctrtitics have t.�tupto ma If the sur`contra€ton how c^nployctis,t_?tek Mint finmide 6tir w(rke",corgp policy uunrtm, t use r employer thax is r[avid#ng»takers'cute rartatinn insures»cr fi r m}a»rpto}ees. Belon,is the:police and job site information. los irmice Company Natne,_ 4k_, Policy#t or Self-ins. Lie.#: r1_} Pi(�,P tkg3�21 Expiration Date,_VPj.3 C)1.1t Joh Site Address-'45% '�D'ht'1("q [( `� �LY�- it};State Zip. &w n q ' rtttaeh a copy of the workers'compensation policy d"laration page(shoeing the policy nnmkr 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 51,500,00 and/or one-year imptisonrrw nt,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 advisees that a copy of this st.atenmit may be forwarded to the Of€icc of investigations of the)SIA Etat insurance cov4rage verification, I du hereby certify under the pains ansl penoftiev of perjuty that lite i»fortrurtio»provided above is trate and correct, stun rttrn: ,ri r` - _.f t~--I` Date: Phone H: 'U. 3413___ Oficial use only. Do not write in this area,to be completed t`iy cr'h'or townr�fftt sal, City or flown:_,.,x permit/License Issuing Authority(circle one): 1.Iioatrd of Ilealtlt 2.Building Department 3,C'ityfFown Clerk 4.!•lectrical Inspector S.Plumbing ins,"or d.Cather Contact ersou• Phone CERTIFICATE OF LIABILITY INSURANCE =111wm THIS CERTIFICATE IS ISSUEID AS A MATTER OF INFORMATION QNL'f AND CONFERS NO AJGKTS UPON THE CER'rIFICe TE HOLDER.THIS CERTIFICATE DOES NOT AfFIRMATIVE'LY GR.NI GArNELY AfAt',Ib,EY.TFND OR ALTER P*E COVIK#GE APrrOROED€3Y THE POLICIES BELOW.THIS CERTIFICATE OI INSURANCE 00'tS NOT CONSTITUTE A CONTRACT HTIWEEN T4E 15SVIN5 INSUAER(S,,AUTHORIZED REPRESENTATTVE OR PRODUCER,AW)YNE CERTIFICATE HOLDEA IMPORTANT:If the cotlfcate hokW rs an ADDITIONAL INSLiRED,R* kyfws)mxcst tae er4gMed.it SVBR67GA IOON IS WAVED,Sub}Rct to the tarmi;and conditions of the po4lry,certa,,n pc4cies may myv",an+mdorsenwnt.A statement on to-*eettiflxatc cl4oi not confer rights to the eeAftate hsadet'in 14au of s KiT orsC TEnt(S), _ Clayton Martin J Ins Agency Inc Bar t�Y Ash s3rT2d Rtsk 54 Ts e s 1849 Northampton St PO Sox 589 (8300}£ e5kr0 .T (866)215-8118_ Holyoite MA 01041 �e�,� P01icyS-"S@> 14ipt-- lk7w3 te'Yv;9)A+-'{h^�".y is f4`tic ;E $ws r... Gavtttfcr ftTsn1�13aTt f0c NSAREAa Pt?SOX 344 fpa*iek M.A 010 CQ CERTIfiCATE tAlt�tB t: NARION NUMBER: IR IS 75-CE.RTEEY TrAT THE fAOd.tCIES 4F N UP"CE LISTED RfLOVV NAVE @EEN-aSS 0 14 T99 K$VAED NAMiD ABOW FOP THE I ICY Fit.OD IINOKi,Ttb,NIOTV tTNS'rANCDING ANY RE001REMExa7,rE OR 00I,4D+I1k'} AW CONTRACTOR(7HM DOC ImENT WrIH RtSPES T TO W4, CH THJS CERTIFTCA,TE MAYBE ISSUSD OA MAY PSR AN,THE 1€SLIRANC E AcFOI DED BY THE POLICIES DESCRIBED 1,EREN IS 4J�i fiT TCT l6L S'}'c TcR>.45, EXCLOStc 4S AW)COW1111ONS OF SxCK€OLCfES.L€#.#I'TS S83WN MAY HAVE BEEN PX-D ED BY PAID O.AW1 . LTv Tal L'nu4 1.19 ,p.,s. ISA Ky MAAS;E 2 c+ atw rr a �s s r e w'sts,1sa C.aA <5tu,?tn !tfi v?2 L_i t.=G 6.JtC t+4n -c' x? ?kR�P�.4S.R ASV#.'h.AzY St-Al 14^E.&€'.".4El=.Lw f PiA.7G'r' 0 'EGt Ilia,- 0 AIYt' 11A8a.IT'r 3L., i«a k='ie9a`-tt g H AM AiTO A" f. Sty-EE'ts'!7 _ .. S A,705 B,7Lsa.Y 1.!,344',crx ac�.keost, :o:;€:oe.Urcg El Ncr: •xti.:� Tt�acut>-e by-its lT%t PIx"F9s'tt'!3 S tk4 ouLA Lila U aact. EA'.iC I R,A"Ffti:.{ S ... €3tc£:t4 L" $ l.SiiiFi�Ya.4+E T::�Bbaf Y4asg5tR$CYti� : _ .. £..I3irE`YL3oER lV1Ct 6M}l4T' 4 fYY i:z; ANY -,`I ,y s_.. .,,I E.tE�i.-:.ae:�.�wl 5 SX)27E1 + 0"M ixcLLr�r us MAARP-IM127 ..Ax;"015 10!xj2016 si fcc,�cst+ u'.�e �SC `TR'SP+Qf f :itAT[4Pa5-G+BPA+: c.L'�?5E,t`4c.•P?i L'4'i Y�.. $ 'C`'sl'� {{ El 0 1 ._ 1 L k'ma ;S Tfh.LEa! tY3.: -Y-sA'xx:.7d+3.9s..gt2.ec si3ca 3 Y{sne�.l - tst :✓aGry Esr=�r.Sa=m Y,o--Yr �,s sv v%rse.tda: C -MCATE t'd MER C t? St+("D ANY° THE FIS{D'','f=fjsSCa`FT3ELD W�°t_� S 6E,C.AV�'_.Et:.3•:&'BL,T:CRG ctoa tAt Tlfw eXPAT.£W DOTE THEA 0F,407 WX s€Q£i',VERE-6 0 C4rttractor$YC9s h ZC,Z AV-,Z 4YTTs{T4E Poo C Y Pew,cti7t{S. 50 Washington Street Westborough,MA 41581 ACORD 25(2010/05) BRAC 3138 ACCO ®® DATE(MM/DDI � /� CERTIFICATE OF LIABILITY INSURANCE 7/7/2015 15 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 CONTACT Nancy Usher NAME: y NE Martin J Clayton Insurance Agency, Inc. AC,No,Ext: (413)536-0804 FAA/C,No):(413)534-7874 1649 Northampton Street AAIL DDRESS: -P. 0. BOX 989 INSURER(S)AFFORDING COVERAGE NAIC# _ Holyoke MA 01041-0989 INSURERA_Nationwide Mutual-Harleysville NATIO INSURED INSURERB:Allied World Natl Assurance Co Gauthier Insulation INSURER C. 44 ESSEX ROAD INSURER D: INSURER E: IPSWICH MA 01938 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL157701379 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. INSR'-- TYPE OF INSURANCE ADDL SUBR POLICY NUMBER (MM/DDY EFF MM DD EYY LIMITS LTRIMS X COMMERCIAL GENERAL LIABILITY $ 1,000,000 EACH OCCURRENCE -_-- � DAMAGE TO RENTED _ - A CLAIMS-MADE LX-1 OCCUR �_PREMISES(F. occurrence___ $_,-__-____ 50,000 �- X GL43487F ( 7/6/2015 7/6/2016 MED EXP(Anyone person)___- $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 _GEN'L AGGREGATE LIMIT APPLIES PER: GEN_ERAL AGGREGATE $ 2,000,000 PRO- 2 000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: I $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ -(Ea accident _ ANY AUTOBODILY INJURY(Per person) $ ALL OWNED SCHEDULED i n AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS _{Per accident $ X UMBRELLA LIAROCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $_____1,000_000_ DED RETENTION BE020792125-194985 10/18/2014 10/18/2015 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N 'iLER1 STATUTE! ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 0FFICER/MEMBER EXCLUDED? N/A ---- H A ___-- - (Mandatory in NH) "-J E.L.DISEASE-EA EMPLOYEE If yes,describe under - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET WESTBOROUGH, Mani 01581 AUTHORIZED REPRESENTATIVE Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD lVP?'di`b§tbd with pdfFactory trial version www.pdffactory.com B ,*ref of Building g�ufttiOns and Sta d d �:�sarerz-¢'ncraa'+aaa.as<;Ps�- License:CSSL-1Q2%2 KUkT R GAIL" P.a Rat 3" J*Wkh MA 01SQ* v r, �,wSrtr,v,,,ir1 ; Ja YRdt.6 '411 1\ &11a11SJr7CxY(j'e1n Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration. 173410 Type: Individual Expiration: 10/1/2016 Tr# 257812 KURT GAUTHIER KURT GAUTHIER _... .... . ...... ... ... ......_ P.O. BOX 344 _.._____ __..._... __ ......._. ___...._._._ . ..._... IPSWICH, MA 01938 _._ ..______ .. ........ ...._..__ ,._................... ........... ... Update Address and return card Mark reason for change. Address "......i Renewal ;- Employment Lost Card SCA 1 C, 26M 06111 ...._., r>/1tf Y.rnnei z,artrtC�G��lrja�:uzr�rr:elt'r s p Office of Consumer Affairs&Business Regulation License or registration valid for individul use only P before the expiration date. if found return to- 511 �30ME IMPROVEMENT CONTRACTORR n i t Registration 173410 Type: Office of Consumer Affairs and Business Regulation � piratian: 1011!2096 individu 10 Park Plaza-Suite 5170 C xal Boston,MA 02116 KURT GAUTHIER KURT GAUTHIER 44 ESSEX RDS �- IPSWICH,MA 01938 _ ._ __ _......._._. Undersecretary 'ot valyd wi out srgnatnre