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Home My WebLink AboutBuilding Permit # 3/8/2016 .. ORT BUILDING C PERMIT TOWN TH ANDOVER 00 0r Perrrrit h0o; APPLICATION FOR PLAN EXAMINATIONit� Date Received gab . 49 " Date Issued:_ol cHU TI�TPO T 'T'.A licant must cogn fete all items on this a e PROPER"I` 1 I I R t m - Prlrit MAP NO: ; Historic District yes no Machin Shop'Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid tial / Non- Residential U New Building 19ne family [TAddition ❑Two or more family F) Industrial El Iteration No. of units: Ci Commercial epair, replacement I Assessory Bldg r l Others: I 1 Demolition [I Other 0 Septic lo,Well U floodplain FEi Wetlands 0 Watershed District -, Water/Sewer r ins m t ppgg yp Identification Please Type or Print Clearly) OWNER: Dame: C r :Y-e, r ( S Phone J., y " Address: 1 �-; .. , Ycmv f,.mm- ` 6.�� ° NTRACT R"Namw, t � i Phone. ° Atr � )t . " . Supervisor's Cohstru6ti'ob Lice' n' se: , ;. fin p. Date: Home Irnproyerrlent Li hs : Exp., Cate: ARCHITECT/ENGINEER Phone:_ Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED CO,WB mSED ON 12 .00 PER S.F. Total Project Cost: $ FEE: . Check No.: 0 Receipt No.: ti' NOTE: ,Persons contracting with anregistered contractors do not have access tm the guaranty.14nd S11,104IL rAg,000,10wfter !!r i nature of contractor p taoRTvj town of2 An overL • - 2AIver1 , dSSy COCNIC NE WICK IR%I-RATED Cl U BOARD OF HEALTH Food/Kitchen r. ER IL U Septic System THIS CERTIFIES THAT .................. .......................... .... 04%0 BUILDING INSPECTOR . ..... has permission to erect.......................... buildings on . ..... .....r. Foundation� ..., �.... ® Rough tobe occupied as ....... .. ..... . . ......INIA !. .................................... Chimney provided that the person accepting this 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 PERMIT EXPIRES ONTS ELECTRICAL INSPECTOR UNLESSC ST T 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. On Duty Chimney Sweep, LLC On Duty Chimney Sweep, LLC 19 Stodge Drive Estimate Ashburnham, MA 01430 US Date Estimate# (978)696-7933 01/22/2016 1489 info@ondutychimneysweep.com Exp. Date hftp://www.ondutychimneysweep.com Address Joe Francis 1520 Forest Street Extension North Andover, Ma 01921 Activity Quantity Rate Amount • Parts and Materials -Stainless Steel (304) Heavy Gauge Smooth Wall 1 2,000.00 2,000.00T Liner[6"x35'] • Labor- Breakout of existing the and disposal. 1 550.00 550.00 • Labor-Chimney Liner Installation 1 450.00 450.00 • Parts and Materials-Liner Insulation Wrap 1 250.00 250.00T • Labor-Wood Stove Installation 1 200.00 200.00 Thank you for choosing On Duty Chimney Service. Here is your estimate for work SubTotal $3,450.00 requested. Please contact us with any questions. Tax(6.25%) $140.63 Shipping $50.00 r Total $3,640.63 Accepted By !� � � Accepted Date A 50%down payment is re uired prior to scheduling or ordering of materials. The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia etorsffile Workers'compensation insurance WITH THE PERMI Builders/Contra A1TTHOPJTYCtr icians/Piumbers. Please Print Legibly A Iicant Information , .S a-Vi Name(Business/Organization/Individual): ah 1 i'Fl Address: M '0b(ftK, `��°„"., �� r^ � �6� C>'l�f�(..� Phone#: �Z�r�"' �m� City/State/Zip: �•3� Type of project(required): Are you an employer?Checlr the appropriate box: 1.��mployer withf/ tfull and/or part-time).* 7. 0 New construction �emPo Yees( 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required] 9, 0 Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12.E]plumbing repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs nn i These sub-contractors have employees and have workers'comp.insurance.$ 14.[,dither 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. ' t 1 F LSP 1/IS 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. t Homeowners who submit this 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,they must provide their workers'comp.policy number. I ant an employel•tllat ispovidil:g ivol•lfels'colltpensation insuranceft”my employees. Below is tile policy andjob site in fo1•lnation. Insurance Company Name: .G�t.i`C. 5'&5 5A 4 o � �( Expiration Date: Policy#or Self-ins.Lic.#:_�_ ' � v' City/State/Zip: " Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). on punishable by a up to$1,SOO-00 Failure to secure coverage as required under tutee enalties�nthe form of STOP25A is a criminal day ORDER and a fneeof up to$250.00 a and/or one-year imprisonment,as p day against the violator.A copy of this statement may be for to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cel tify lender'tltepaills andpenalties of pelf[tly that the iitfolll:ation provided above is true and correct. Date: 1 r Signature: Phone#: y L[,seonly. Do not write in this area,to be completed by city or tower official. Town: Permit/License# hority(circle one): i Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing InspectorPhone#: son: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who emrtloys persons enant thereto shallto do or on the grounds or building appurtenant because of su aintenance,construction h or be d emed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if-you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia DATE(MMIDDIYYYY) Ac")?"® CERTIFICATE F LIABILITY INSURANCE 10/09/2015 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: Michael Ware PHONE 978 343-4853 ac No: CHOICE INSURANCE AGENCY INC E-MAILo Ext: ( ) ADDRESS: mware@choice-insuranCe.C,Om INSURERS AFFORDING COVERAGE NAIC# 376 SUMMER ST. 25666 FITCHBURG MA 01420 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA INSURED INSURER B: LEBLANC BRYAN DBA ON DUTY CHIMNEY SWEEP INSURERC: INSURER D: 19 STODGE DRIVE INSURER E: ASHBURNHAM MA 01430 INSURER F COVERAGES CERTIFICATE NUMBER: 4864 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 REEICONDITION OF ANY OLACT OR OTHER DOCUMENT WHICH THIS CERTIFICATE MAY BEISSUED OR MAY PRTAN, THE INSURANCEAFFODD BY THPOIIESDESSCRIEDHEREN S SUBECT TO ALLHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED FF PAID`CLAIMS. ELIMITS INSR ADDLSUBR POLICYNUMBER MM1DD MMIDD LTR TYPE OF INSURANCE I EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS-MADE 0 OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY❑PE o D LOC $ OTHER: COMBINED SINGLE LIMIT $ Ea accident AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY(Per accident) $ ALL OWNED SCHEDULED N/A AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED Per accident HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ TH- WORKERS COMPENSATION X E STATUTE ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 100,000 ANYPROPRIETORIPARTNER/EXECUTI VE NIA A OFFICERIMEMBEREXCLUDED? NIA NIA 6HUB5B55440615 08/13/2015 08/13/2016E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance. The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govfwd/workers-compensation/investigafions/. LEBLANC BRYAN has elected coverage. 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. Cleghorn Plumbing 142 Clarendon Street AUTHORIZED REPRESENTATIVE Daniel MA 01420 Fitchburg Daniel M.Cro4ly,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Certified Specialist Gas 07/31/2018 r 1(i Bryan LeBlanc ID Number:170339 Unrestricted-Buildings of any use group which #7716 contain less than 3 ,000 cubic feet (991m3)of 'CERTIFIED - tcHIMNEy enclo$Pd.space. L KWEEPe Valid Thru — 4 J June 2016 e to possess a v u ='„�O�sachusetts state Building Code is cause for revocation of this license. m For DPS Licensing information visit: www.Mass.6ov/DPS On Duty Chimney Sweep Ashburnham, MA Massachusetts Department of Public Safety ® ® Board of Building Regulations and Standards License CS-106348 {�pSSt .uparvisc, k V BRYAN S LEBLANC 19 STODGE DR ASHBURNHAM MA 01430 expiration: Commissioner 10105/2017 3/3/2016 office of Consumer Affairs&Business Regulation-Mass.Gov The official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation Home Consiuimea V,,��glmts and Resoul-cos 1 kane VprovemeM ContMcfiN HI C Registration Complaints Registration 173166 Registrant ON DUTY CHIMNEY SWEEP Name BRYAN LEBLANC Address 19 STODGE DRIVE City, State ASHBURNHAM, MA 01430 Zip Expiration 09/10/2016 Date Complaints Details 1"10 c'011'qlahlts fiDund for fl"u�s re,,'Jisb-aylt,. You can also view arblitr@-1 -god Q�uri�ia Y. t ELE)�iL Mb @ 2012 commonwealth of Massachusetts. Mass.Gov@ is a registered service mark of the commonwealth of Massachusetts. 0" 1/1 https://services.oca.state.ma.us/hicAiedetails.aspx?txtsearchLN=75045 Date Town of North Andover ou for the following reasons: your permit has been se t back to y � Check amount incorrect 2 No COPY of current license _'`ile or exPred Insurance Binder not on fQn Insurance Affadavit Farm 4) No Workers' Comp please call with any questions 978-688-9545.Fax 978-688-9542 the Town of North Andover ensation Form and Schedule of Fees can be found on Workers' Com P � Department. Website under Building pe p Mailing Address: 01845 600 Osgood Street,Building 20,Suite 2035,North Andover, MA d