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Home My WebLink AboutBuilding Permit # 1/14/2016 BUILDING PERMIT bF rtbRTry TOWN ® THANDOVER � .:. ...a•"•.." APPLICATION FOR PLAN EXAMINATION10 Permit No#: Date Received PRM TEP CHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATIONS /l r Print PROPERTY OWNER_ A/ d Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building ❑ One family ❑Addition "Two or more family El Industrial El Alteration ' "No. of units: c., ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other DESCRIPTION OF WORK TO BE PERFORMED: Id ntificat'on- Please Type or Print Clearly YP Y OWNER: Name: fCF " krLr "/ Phone ( t Address: ... 5 62e Contractor, ame: /—Z(/-Phone: / `� r'jw& rte Address: V Supervisor's Construction License: ' Exp. Date: , _ ;. Home Improvement License: 23 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F, wyI � Total Project Cost: $ - , FEE: $ Check No.:_ Receipt No.: NOTE: Persons contracting with� rentractors do not have access to the guaranty fund «,r, 3P "� 9,rr505 v ., "' r; ii"':� ITJI/' iIf,IFn... rr r !�/T /Pr /� /I7,%' ii/ki� Ulr ,... r „ COiJr l la r r I,lr f r%� /,l f�'� ll�fi�r /l,( 1 NORT -170exAH tiAnd V Etxti 9a 0 ~' h ver, ass COI MICKEWICK S 7 TEO f 1 U � BOARD OF HEALTH Food/Kitchen IN Septic System �, , ,,,,,, /;�y..� BUILDING INSPECTOR CERTIFIES THAT.............. �... .. .............. .. .... .................... .................... �� J � Foundation has permission to erect.......................... buildings on .. .. .... / ... ................................ Rough to be occupied as �.. ..... ..... . ................................................................... Chimney provided that the person accepting this permit shall in every spect 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 ` I IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC I T Rough Service .. ... .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occu2v Buiddine Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingr Dry Wall ToBe One FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth ofMassgehasetts De pcartineal oflr�dr�st�iaZAccideizts M 1 Congress Skeet,Suite 100 = 1uoston,MA.02114-2017 www.raaass.gov/dia !�•,.., SViv, okkexs'compensation insurance Buildexs/Contractors/Electricians Tlum]bexs. TO BE,FILEID MTHTHEPEPM[TTING.A.UTHORITY- please Print Le ibl Applicauffnfoxmation ! Namo(Business/Oxganizatiroon/ludivi/Built:) Address:— � 1� 6, ? s City/State/Zip: / �i Phone Are you an employer?Check the appropriate box: Type of project('equired): 1.M� �,, ._ em to ees full and/orpart-time,)."* 'J, �Now cOJ15trUCtlon I am a employer with p y ( I am a sole proprietor or partnership and have no employees working forme in 8. Re1x10 delirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3..Q I am ahorneowner doing allwozkmysel£[No workers'comp.insurance required.]t 10 Q Building addition 4.[]lam a homeowner and will be hiring contractors to conduct all work on my property. 1-will 11,[(Electrical repairs or additions ensure that all contractors either have wozkers'compensation insurance or are sole prop zz ; - -eto12:El Plumbing repairs or additions rs vaithrioemployees. — 5.Fj lam a general contractor and I have hired the sub-coiitractors listed on the attached sheet. 13.0 Roof repairs Thew sub-contractors have employees and have workers'comp.insurance.t 14 ❑Other 6.[]We are a corporation and ifs officers have exercised their right of exemption per MGL c, 152,§1(4),andwe have nq elnployegs.[No workers'comp.insurance required.] - Mny applicant that checks box4l must also fill out the section below showing their workers'compensation policy information. Homeowners wfio snliriiit Ibis affidavit indicating they are doing all work andthea 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-c6ri1rado'ls fiave employees,&l ifinst provide their workeis'comp.policy number. f am an employer Mat is piovid619 workers'compensation insurance fol'my employees'Below is the policy and joh site information. f /7rt 1 h Insurance Company Name: Policy#or Self-ins,Lie. _ / r G��,�7 02-;X 20/3 xpirationDate• #: ` �/ fob Site Address: 6 U Va G City/State/Zip: '41-L (`, Attach a copy of the woxlcexs' coxnpensolicy declaration page(showing the policy xtumbex and expiration date). atlo Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD.ORDER and a fine of up to$250.00 a day against the violator. A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. f do/Ze,evy cert--Z C7 de e n dpenaltzes of pejja�.)treat the information provided a�v is tru and correct. Date: SOt i nature: -7, Phone##: Official use only. Do not in this area,to he completed by city or,town of . City or Town' PermitlLicense# Issuing.A,uthoxity(circle one): 1.Board of Ifealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: P 6/9/2015 2 : 22 : 16 PM 8618 0 02/03 LIABILITYCERTIFICATE OF INSURANCE DAM WMWM5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMA71VELY OR NEGA7IVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONS71TUTE A CONTRACT BETWEEN THE ISSUING INSURER(4 AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOUR. BIPORTAIM If the certificate holder is an ADDITIONAL INSURED,the poficy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the tams and conditions of the policy,certain policies may mquire an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 01227-001cirr Prescott&Son Ins Agcy Inc P (781)322-2350 W _ (781)322-3893 90 Eastern Avenue sr Malden.MA 02148 NG ca s WJSURER A: A.LM.Mutual 1 Co 33758 MURED o D seg Roofing LLC NORRIER B O Baa 383 Billerica, 01821 ®' WSURERE: COVERAGE$$ CERTIFICATE N BER: REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI INDICATED_ NOTWITHSTANDING ANY REOUIRE]MBdiT, TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT V ITH RESPECT TO WMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE MURANCE AFFORDED BY THE PMICIES DESCRIED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ASID CONDITIONS OF SUCH POLICES_LIMITS SHOWNMAY HAVE BEEN REDUCED BY PAID CLAIMS_ L TYPENam POIIL9' EYP GENERAL LflABHM EACH OCCUPPEWM $ 04, GENERr&UAettry DAMFGE TO F&MIED fpvfflw�AME Do- •ampm FER9DN 1&.AiD'a+ s RGE1qWALAGGREGATE $ AcG ATELA6AHTs34'PLr PEI PI TS-6A AC--G $ CY cc AUTOMOSKE LIABILITY CO _ S1UGtEQ-M $ fEa d Y x r r�moH S SCHEDUQED I H ALL AUJFOS 8 AUTOSarm $ mm"L" ®ODllIR EAbTH $ '.. E%CESSum CLNUSN"'M lE EEATE $ 0139 R£fENHHIFI6$ $ �Tpppg XaF' `s I�Y LIABW.IHY A I DE�➢8 Y® NIA AYYCd600-70274$7-2015A 761P2095 711AMG E�Es t $ 1,0�•t100.Ot! L" EE,LISEASE-EA EMPLOYEE $ 1,000,000.00 rt� TlaTss H E L_ONSEASE-POUCY LWFT $ 1,000,000.00 DEMWTMOFOPERATPONSILOCA7MMfVB*CLES194,AddrxeroW Re=zwftSdwdAv.it wam sp=e Is - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DE3CRfflW PEES BE CANCELLED BEFORE THE EXPIRATION DATE THERSDF, NOTICE WILL BE DELIVERED IN ACC NCE WITH THE POLICY PR S. AUTHDRIZEDRUIRESEMA7WE ®1988-2010 ACORD CORPORATION.All rights nerved. i ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 4886 IVWNlissachusetts -Denartmcnl-!-,f Safetv Board of Bu41ding .Regudat�-)ms nm,-:,� S-landairds CSSL-099681 ilba jE ERIC DEMPSEY 7 RICIIARDSOMST BELLERICA MA 01st, 0512312016 Ofr ice of Consumer Affaars&BusillessIlegulliflon NOME IMPROVEMENT CONTRACTOR tz ,,.�,txpiration:egistrat!On:3/6/2016178026 LLC Type: DEMPSEY ROOFING LLC. ERIC DEMPSEY 7 RICHARD ST BILLERICA, MA 01821 undersecretary