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HomeMy WebLinkAboutBuilding Permit # 3/22/2016 BUILDING PERMIT AoV D o� 1 ,t,.� ,bgq'O 6 TOWN OF NORTH ANDOVER o - APPLICATION FOR PLAN EXAMINATION `, p Permit No#: Date Received ��ssaceaus���5 Date Issued: : 0 IMPORTANT:Applicant must complete all items on this page J � LOCATION l /° Print PROPERTY OWNER leblG 00-A—)VP Print 100 Year Structure yes no MAP PARCEL: 6�32ZONING DISTRICT: Historic District yes no 'Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 101 e ell ® ood fi I n Weil-and ;' ied 'sicF e eue DESCRIPTION OF WORK TO BE PERFORMED: koo ,,� hotl f e `., P XG y/�r 61S Identification- Please Type or Print Clearly OWNER: Name: 3' t`-G Phone: Address: Contractor Name: Phone: 7rfn Lr.7,5 77,",�- Email: 11or) � Address: AeS-� i— Supervisor's Construction License: 37 Exp. Date: 101KY .267 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. Total Project Cost: $ 1 00 60 FEE: $ 1 ii el Check No.: I � 6y Receipt No.: NOTE Persons contracting with unregistered contractors Flo not �have acc s to the guarantyfund ggm ' AORTH Town ofAndover2 ' L O �� 0% No. 20P ® }Y. - .# h ver, ass, .3 -22 /& COC MIc"I - ®ADRATED S U BOARD OF HEALTH Food/Kitchen PE 'r% M- IT T LD Septic System THIS CERTIFIES THAT ow.......... BUILDING INSPECTOR has permission to erect buildings on .. /- /Pa QA'f _9V0(__ Foundation ............. ........................ ................................................. Rough to be occupied as i°:A: ..... .. .... . ........ .............................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terrhs 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 IN 6 MONTHS ELECTRICAL INSPECTOR CONSTRUCTIONUNLESS STARTS Rough Service ................ Final UILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy BuRough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Page_ No, of Pages Roofing Jerry P. LeBlancACCEPTANCE • Siding • Gutter 9 Atkinson Decot Road Construction Supervisor Specialty License ° Painting LiCense:CSSL-099633 Restricted To:RF WS • Carpentry Plaistow, NH 03865 Tr#:5177 Expires: 1011512015 Windows Home (603) 382-0817 Home Improvement Contractor •Snowplowing Cell (978) 838-7740 Registration:149881 Expires:2/16/2016 PROPOSAL SUBMITTED TO ` PHONE DATE 120 t 17 s s � STRE � I JOB NAME ✓ l CITY,STATE AND ZIP CODE JOB LOCATION ARCHITECT _ - DATE OF PLANS 10B PHONE We hereby submit specifications and estimates for: , i tea t _ - r -��-✓mil H� +�L fr<Z!�</s�_ I�_�r�aC -- rrti 5 -6�•ee r Start within days — �-- �'1... ,✓G_ �'�r�--_—___ Complete in 30 days. We Propose hereby to furnish material and labor—complete in accordance with aboveXP, -,'icotions,for the su o SCJ �O�©Z Payment to be made as follows: dollars 9 d 44t: All material is guaranteed to be as specified.All work to be completed in a workman- like manner according to standard practices. Any alteration or deviation from above Authorized specifications involving extra costs will be executed only upon written orders,and Signature will become an extra charge over and above the estimate.All agreements contingent 61- upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Note: This oposal may be and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within days. pensation Insuronce. ca of -The above prices,specifications and con itions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Signature Date of Acceptance �lJ�� Signature The Commonwealth of Massachusetts Department oflndustrialAccidents d X Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/ElE lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ir Address: � /�C�ir�a City/State/Zip: ! Phone#: q X �L) -S'_775< A.re you an mployer?Check the appropriate box: Type of project(required): 1.IL'��J1�aamm a employer with employees(full and/or part-time).* 7, ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑DemoIition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑4.F1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.❑P 1 bing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13. of repairs These sub-contractors have employees and have workers'comp.insurance.# 6.❑We are a corporation and its officers have exercised their right of exemption per MGL G. 14.F1 Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for•my employees.'Below is the policy and job site information. Insurance Company Name: ar Policy#or Self-ins.Lie.#: S� b!/ 0 �`� 1 q/!;7— Expiration Date: Job Site Address: J 1 / aS'� f r$I /��rt� y�✓ City/State/Zip: 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. Ido her ehy certify under the pains and penalties of perjury that the inforrnation provided a ove is true and correct. Signature: Date: f Phone#: 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#: GE LE 1 JONEILL DATE(MMMD/YY" CERTIFICATE OF LIABILITY 1211/2015 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). PRODUCER CONTACT NAME-- Durso AMEDurso&Jankowski Insurance Agency PHONE 978 688-700D a No.(978)688-7001 11 Saunders Street c Nc Est:( ) North Andover,MA 01845 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Preferred Mutual Insurance Co. 15024 INSURED INSURER B:MSA Group 14788 Jerry LeBlanc INSURER C:Hartford Insurance Co. 9 Atkinson Depot Road INSURER D Plaistow,NH 03865 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 CONTRACTOR 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 iNSO WVDI POLICYNUMBER MWDD MM1DD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 300,00® CLAIMSdMADE ®OCCUR BOP0100717134 06/0912015 05!01/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any oneperson) $ 6,000 PERSONAL&ADV INJURY S 300,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 600,000 JEC�( POLICY❑PRO- F LOC PRODUCTS-COMPIOPAGG $ 600,00 OTHER: $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ 500,000 accident) .13 ANYAUTO B1132755S 01/04/2015 01/04/2016 BODILY INJURY(per Person) S ALL OWNED D �( SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPER O GE S X HIRED AUTOS X AUTOS Peracciden S UMBRELLA UAB OCCUR EACH OCCURRENCE- 5 EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTIONS I$ WORKERS COMPENSATION PER ER AND EMPLOYERS'LIABILITY C ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA 6S60UB2E34123415 08/06/2015 08/06/2016 ELEACHACCIDENT I$ 100,000 OFFICERIMEMBER EXCLUDED? 1 PLOYEES 100,000 (Mandatory in NH) E.L.DISEASE-EA EM IF yes,describe under 5001000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY OMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached 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. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. �:ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts;'Department of Public Safety T Board of Building Regulations and Standards License: CSSL-099633 Construction Supervisor Specialty y JERRY P LEBLANC 9 ATKINSON DEPOT ROAD PLAISTOW NH 03865 `a - I • is Expiration:` Commissioner 10/15/20.17 ` `=�lIG' ((7(1 fl777I1 CJ7/(/L'C(C��p/�J/�/�C(J,IC(CfL((JCI Office of Consumer Affairs&Business Regulation r-OME IMPROVEMENT CONTRACTOR =`egistration: 149881 Expiration: 2/16/2018 Type: Individual JERRY P LEBLANC JERRY LEBLANC 9 ATKINSON DEPOT RD e ,PUMSTOW,NH 03865 Undersecretary