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HomeMy WebLinkAboutBuilding Permit # 1/6/2016 %AORTy BUILDING PERMIT w. TOWN OF NORTH ANDOVER01 1 - APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received 1 �,�A��,rEpe►Pp��y ssacHUS Date Issued: 1 I PORTANT:Applicant must complete all items on this page LOCATION �` �� m�y Lp CeR Print PROPERTY OWNER Print 100 Year Structure yesno MAP PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village ye 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 Mg—off" , t 0"i �. a/ rrw „1rri IIIOuI((P„6l((r(/ rla,/� ,/,O,,�r✓r�, � �,/ , ✓ ,. U („ C ly f L ///rll✓/ ,f„/!/ r, . Il / % I �6 ,W tern: stncfi/ Sept Well ,� „< ,� ,� � 1 r „ ❑CF,, , I” r /f ,,, r i l�/ /� al, r:�, r p„ e/ /i4 ,✓ �� ,r �f 0� � �r 'rl Ili ,�1 ar, �r ( �/iii, ,l;'c�, DESCRJPTION OF WORK TO BE PERFORMED: 90—vq�c,-Cc 1� Identification- Please Type or Print Clearly OWNER: Name: ' � m Phone: Address: t (&Aodcn,Lg=zN Contractor I&LIQ Phone: Email: , i B �, Address C41 Supervisor's Construction License: Exp. Date:: l�- 1201.7 Home Improvement License: ( Exp. Date: Z0 f ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ L'. ' P FEE: $ oil.Check No.: 0 Receipt No.: . NOTE: Persons contracting with unregistered contractors do not have a c s t the uaranty fund 1 I t%ORTH of Oakv \Andover No. -- �, h , ver, Mass,JAW- Coc"Ic"tw'C'( Zo O A- \ U° BOARD OF HEALTH Food/Kitchen PERMIT T ML D Septic System THIS CERTIFIES THAT. 7T�k4,1. ... 1`1'i�rBUILDING INSPECTOR ........... .. ............ . ............................................................. Foundation has permission to erect .......................... buildings on J 3 .'n!Arb 1, .W ,. Rough to be occupied as .....rod rVw .....V!�!.�!!:1! .�.lR+.'!...................................... ............. Chimney provided that the person accepting this permit shall in every respect conform to thterms 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 u Final PERMITEXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTION STA Rough Service ................. ............... .. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t0 Occupy Butldln Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Ory Wall To Be Done . FIRE DEPARTMENT Until Inspected and Approved"by the Building Inspector. Burner Street No. Smoke Det. G.L. Clark Construction Tony Delourie 177 Jenkins Rd. 1538 Turnpike St. Andover MA 01810 N.Andover MA 978-375-3425 978-230-1609 CSL#102350 HIC#164510 SCOPE OF SERVICES —Windows and Small Roofs %2 of Building only 1) Windows- Remove existing windows and replace with new construction Double Hung Vinyl weld widows with Low E and Argon. Energy Star Rated 2) Total Lg. windows 20 @ $700 installed each Total Sm. Windows 15 @ $600 installed each. $23,000.00 Both include cost of window and installation. Does not include any replacement of fixed windows. Re-frame all openings. Trim out all windows and sheetrock where windows were removed only. Owner to mud tape and replace sheetrock around window openings not due to window replacement or areas due to water damage. May be replaced at time and materials at owners request 3) Remove siding from sloped window openings and install new fascia and Architectural shingles and flash cheek walls.(2nd floor only) $2500.00 4) Rent boom lift.1 month Includes fuel $3500.00 3) Clean up and removal of all debris. Notes* Any changes to scope of work or changes due to any unforeseen issues may change the cost of the project such as Rot, Code upgrades or any engineering that may be needed. Or any changes the customer may make that will change the scope of work to be done. All changes to be done will have a change order to be signed prior to start of any new work to be done not included in original scope. a) All work will be done with the required permits and to building code. Homeowner will pay for permits. b) All extras will be done at time and material Total cost of proposed work. $29,000.00 Payment schedule $7000.00. Deposit $7000.00. Upon delivery of windows $8000.00. Upon start of installation of windows. $3500.00. Upon Installation of%2 of windows $3500.00. Upon completion of completion of windows Tony Delourie T Gregory L Clark The Commonwealth of Massa chusetts .Department oflndustrialACcidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERM[TTING AUTHORITY- Applicant Information UTHORITY.ApulicantInformation Please Print Legibly Name (Business/Organization/Individual): Address: - 177 ��V� F V\ 's � City/State/Zip: Phone#: �t If-3+'Z Are you an employer?Check the appropriate box: Type of project()required): 1.❑I am a employerwith employees(full and/or part-time).* 7. 0 New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required] 9. El Demolition 3.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5fif'fam a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.l 6,F]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.FJ Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who subniifthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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-contractors have employees,'tiiey must provide their workers'comp.policy number. I am an employer t1iat is providing workers'compensation insurance for my employees.'Below is the policy and job site information. f Insurance Company Name: 1 NA 18 k L)y$ A< C 6 Policy#or Self-ins,Lie. W' C_ — 1 D()—(, (34 ' 01 Expiration Date: Z � lob Site Address: S` ���tlPi 03City/State/Zip: (��-nd e�,J� t/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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 WORK 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. X do Hereby cert! under thepains andpenalties ofperjury that the information provid d above is true and c r'ect. Si natu c-_ Date: Phone#: r 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �9 CLARGR1 OP ID: DL DATE IFI I E(MMID1 E 112!2 015 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 pollcy(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 Phone:978-777-9394 NAME: Dan Hurley Dan Hurley Insurance AgencyFax:978-777-3306 PHONE 978-777-9394 FAX No :978-777-3306 Chestnut Green,Suite 24 A/c No Ext Seven Federal Street E-MA" Danvers,MA 01923-3620 ADDRESS:dan hurleyinsurance.com Daniel J Hurley INSURER(S)AFFORDING COVERAGE NAIC I wsURERA:Providence Mutual 15040 INSURED Gregory Clark INSURERB:AIM Mutual Ins.Co. 117 Jenkins Road INSURERC: Andover, MA 01810 INSURERD: 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 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 POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDDIYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DA AGETO RENTED A X COMMERCIAL GENERAL LIABILITY BOP0070029 04/23/2015 04/23/2016 PREMISES Ea occurrence $ 50,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 3,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ HIREDS AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ F AUTOS Per accident UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ '.. EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X WCSTATU- OTH- AND EMPLOYERS'LIABILITY TORY LI ITS ER YIN B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA VWC-100-6017451-2015A 04/24/2015 04/24/2016 E.L.EACH ACCIDENT $ 100,000 OFFICERIMEM(Mandatory EREXCLUDED7 Y❑ SEE NOTES E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) As per policies: Gregory Clark is exempted from workers compensation. WC Insurance coverage applies only to the workers compensation laws of the state of Massachusetts. CERTIFICATE HOLDER CANCELLATION TOWNNOA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1600 Osgood St. AUTHORIZED REPRESENTATIVE 1 Bldg.20,Ste 2035 (� N.Andover, MA 01845 \j� 1 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ( Massachusetts -Department of Pudic Safet, i Board of Building Regulations and Standards CiIIZ$LI Ij CLl{1rE Supervisor t "pf License: CS-102350 %:,r'I.ti _GREGORY L CLARK JR„ 177 JENIMS Rl =x l j ANDOVER MA 61810 j t" i 'L i'x � + )i ,1 Expiratk Commissioner 10/15/20 &Xe Was1aMC12111aealtI ala/&f,"1" Office of Consumer Affairs&Business Regulatioi HOME IMPROVI=MENT CONTRACTOR a Registration:;"a';1'64510 Type: Expiration 101/9/2017 Individual ` GREGORY L CLARK JR ; GREGORY CLARK 177 JENKINS RD. _� ANDOVER, MA 01810 Undersecretary