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HomeMy WebLinkAboutTENANT FIT UPBUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Permit No#: qqo -1 c Date Issued: 1 S IMPORTANT: Applicant must complete all items on this page LOCATION /01;0 OS. PROPERTY OWNER MAP 010,.— PARCEL. _57-- Print Print ZONING DISTRICT: 100 Year Structure yes Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 Addition 0 Alteration 0 One family 0 Two or more family No. of units: 0 Industrial 0 Commercial 0 Repair, replacement 0 Demolition 0 Assessory Bldg WOthers: 0 Other Pr 5 u, limi )fifto,„,i $( \',Fr , efg rigi 1 fr I trik)?, ,','Iloski,,,}1i,,,I,i'mok,',10)01,dt i DESCRIPTION OF WORK TO BE PERFORMED: pi., • rje9t.." 14--f I hi: A.- /2- e L3/,- ty• r / • A. 4—) irftd 4 Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: V 7" C „.( Phone: Email: Dp7:7;04, 5. a / / cc /7,1 Address: 5 /777e::, rt-42(1 ci,2J 7_4j 6 rt. ?- /2-7c Supervisor's Construction License: C ,5% 0„2 71/ Exp. Date: Home Improvement Improvement License: /02 SJS> 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. Total Project Cost: $ it3-6 Check No.: 41‘, NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Date Received FEE: $ 111 ••••••••••••• no Receipt No.: '7771,772FTWFR7P7SAF:47.177V7117:17'77FIWW, A/r e7,77/17' 77747773717/71YYW' ',7'-'71777711247 /4474;1'77vPI'W- naturecorotk entt wner "70,-4,?/4)',e- f%%,%,*, vbf r, 7';15:1,pirN Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Well 1 Private (septic tank, etc. L. Tanning/Massage/Body Art Tobacco Sales Permanent Dumpster on Site _.-- — . Swimming Pools 4" 0 Food Packaging/Sges II THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM /PLANNING & DEVELOPMENT Reviewed On S-?-t Signature_ COMMENTS A16xrt- 6DNSERVATION Reviewed on COMMENTS Signature /HEALTH Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature & Date ]DPW Town Engineer: Signature: A Driveway Permit Located 384 Osgood Street CD cD O i a CQ. O ED coCr SU OOco co C CD gi =� CO CD to CD 0 MEMO • Cn 0 0 Cl)0 CD 0 CD CD 3, CD Cn 0 0 ID O CD naa p o; paipn 210103dSNI mama VIOLATION of the Zoning or Building Regulations Voids this Permit. rt 0 CD 0 C) n 0 loan o} uolsslaued seq .LVHl S3Id112130 SIHJ D and J Construction 9 McKenzie Circle Tewksbury, MA 01887 978-452-0536 office 978-815-9363 cell Proposal PROPOSAL SUBMITTED TO : Care Laser PHONE : 248-469-5147 DATE: 4-29-15 ADDRESS: 1060 Osgood Street, N. Andover, MA 01845 EMAIL: maralg@care-laser.com We propose hereby to furnish material and labor — complete in accordance with specifications below, for the sum of: see breakdown below All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practiced. Any alterations or deviation from specifications below involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman's Co ensation Tnse. / r Authorized Signature $ , Office Manager Note: We may withdraw this proposal if not accepted within 60 days. We hereby submit specifications and estimates for: Renovating of interior to include: Painting of interior according to submitted paint schedule $3,800.00 Installation of VCT flooring according to submitted schedule $5,985.00 Installation of grey laminate on cabinets and drains and wood on front of counter wall $1,200.00 Installation of 5 new interior wooden frame doors with handicap hardware. Room #111 to be 36"wide and one partition $3,400.00 PS Cost of doors with hardware $325.00 Installation of 44" x 48" window with safety glass in room 102 $565.00 Acceptance of proposal — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of acceptance: 5/4/15 Signature: Signature: Receipt No,: isterat contractors do not have access to the guaranty fiend r8 Permit No#: Date Issued: Date Received licant must com Mete all items on this LOCATION /O,l O ©SCoesPROPERTY OWNER 1 i /jam Print / BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO IMPORTANT: A MAP 03 5. PARCEL12)2% Print ZONING DISTRICT: TYPE OF IMPROVEMENT 0 New Building 0 Addition D Alteration 0 Repair, replacement 0 Demolition A OWNER: Name: Address: PROPOSED E Residential ❑ One family 0 Two or more family No. of units: - a yes 100 YearStructure ru tyre yes no Historic District Village yes no Machine Shop 0 Assessory Bldg 0 Other Non- Residential ❑ Industrial 0 Commercial tw thers: DESCRIPTION OF WORK TO BE PERFORMED: ' C. L �J1.14- .. cLoa(LS ir., Sto." Identification - Please Type or Print Clearly Phone: Contractor Name: 271 fcop- 7; t Phone: S ? r' 5?—/ C- Email: n4�Ar F n,sn /) z�ot, C01,1 Address:� �le.4g. 77 w.. 4-c rre.} .M eisy Supervisor's Construction License: C.S` 4.2, 3 71! Exp. Date: o 8-76 a/ Home Improvement License: /o Z, �3� Exp. Dater ��sr�G ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST EASED ON $125.00 PER S.F. efY Total Project Cost: $ /V Sc5-8 FEE: $ Check No.: NOTE: Persons contractin wit Scanned by CamScanner 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Print Form Name (Business/Organization/Individual): D " e A S //Z c, 7/ E' N Address: % /I/G ?, it= !iZ c %r City/State/Zip: " l l,�s y „e) _ evil?‘ Phone #: 9 7r 7.5 2, Are you an employer? Check the appropriate box: 1. IRram a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] 'lease Print Legibly © Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. [iuilding addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then 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 -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my en:ployees Below is the policy and job site information. Insurance Company Name: f & t S 'Ail: , 4 7R,) r Policy # or Self -ins. Lic. #: %t 2 w 79 5'17," Expiration Date: ;,,2,921,�%‘ Job Site Address: / 9 £ 4S c( S -� City/State/Zip: Al 4 Ar cl�a,, z �. r 3 5�s� Attach a copy of the workers' compensation policy declaration page (showing the policy number 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 $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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u� er the pains d penalties o i erjury that the information provided ab ve is t ue and correct. Si ature: Phone #: Date: 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 #: PRODUCER Schaffner Insurance Agency 1147 Main St Tewksbury, MA 01876 Phone (978)851-2727 THIS CERTIFICATE IS ISSUEDDATE (MM/DD/YYYy 2015 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY CERTIFICATE INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE HOLDER03/02. THIS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. THE POLICIES IMPORTANT: lithe certificate holder Is an ADDITIONAL INSURED, the policy(les) 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). INSURED D&J CONSTRUCTION 9 Mckenzie Circle Tewksbury COVERAGES A Fax (978)640-9375 Ma 01876- CERTIFICATE NUMBER: (978)851-2727 FAX robert.a.schaffnerr✓mverizon.net A/C No INSURERS} AFFORDING COVERAGE INSURER A: HUDSON INSURANCE CO INSURER B : COMMERCE INSURANCE INSURER C: BERKSHIRE HATHAWAY INSURANCE INSURER D : INSURER E : INSURER F CERTIFICATE OF LIABILITY INSURANCE ASAM CONTACT NA E: PHONE -MAIL (978)640-9375 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, NN EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lTR TYPE OF INSURANCE ADDLSUBR GENERAL LIABILITY/ODPOLICY NUMBER ,POLICY EFF .MM/DD LIMITS POLICY EXP ® COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS -MADE ❑ OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PRO- ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ AUT03 NED P95558 ❑ HIRED AUTOS ❑ ❑ ❑ UMBRELLA LIAR ❑:OCCUR ❑ AUTOSULED NON -OWNED ❑ AUTOS HBD10006301 C . ❑ EXCESS LIAB ❑ CLAIMS -MADE 0 DED 0 RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N OFICMMBEXCLUDED? CFEWEEECUTIVti N / A (Mandatory In NH) R2WC592555 If yes, describe under DESCRIPTION OF OPERATIONS below -' ..,I' 11 /30/2014 11/30/2015 REVISION NUMBER: EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence NAIC # $ 1,00 0,000.00 MED EXP (Arty one person) $ PERSONAL & ADV INJURY $ $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ GENERAL AGGREGATE COMBINED SINGLE LIMIT _(Ea acclden0 g BODILY INJURY (Per person) $ 500,000.00 10/17/2014 10/17/2015 BODILY INJURY (Per accident) $ 500,000.00 PilleDa RaenDAMAGE $ 100,000 00 $ $ EACH OCCURRENCE AGGREGATE ❑ STATUTE ❑ ED 02/21/2015 02/21/2016 E.L. EACH ACCIDENT $ 100,000.00 E.L. DISEASE - EA EMPLOYEE $ 100,000.00 E.L. DISEASE - POLICY LIMIT $ 500, 000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISioNs. 9L860 VW `Aingsval 01340 eizua>p 6 11'