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Home My WebLink AboutBuilding Permit # 4/13/2016 BUILDING PERMIT ®sarH TOWN OF NORTH ANDOVER - APPLICATION FOR PLAN EXAMINATION Permit N®#: � Date Received � � sop,? Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION 6� Print bno PROPERTY OWNER �eP,`1-, %�� C�>Print 100 Year Structure yesMAP PARCEL: 2—� ZONING DISTRICT: Historic District yesMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building P?One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial b�--Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Weil ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Wafer/Sewer; . . , %.. _� r DESC IPTION OF WORK TO BE PERO RMED: Identification- Please Type or Print Clearly OWNER: Name: z Phone: � � �2W'- Address: Contractor Name: °�o�r �� ✓� c Phone: Email: R& <' c? x e Ali e0 � Address: le Supervisor's Construction License: 7led 7 Exp. Date: Home Improvement License: / '� ��"� Exp. Date: �� 3 C ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ � Check No.: ' Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund nature�of �,� SORT H t i 2 i ndover h Vel° a•SS . No. blvi.,, 2kl� -r4-7,h Q LAKE COCMI CKEWIC. RATED UBOARD OF HEALTH Food/Kitchen ' PER ]�F� Septic System % tj a ®� BUILDING INSPECTOR THIS CERTIFIES THAT ...... .. ..................... .............. .......................................... .............................. ...... Foundation has permission to erect .......................... buildings on .. .o.L.. . . . ...... .,............ . ® Rough to be occupied as p. .. chimney provided that the person accepting his permit shall in every respect conform to the i�rms oft a 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. (64% US PLUMBING INSPECTOR Rough Ir VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT I 6 MONTHS ELECTRICAL INSPECTOR UNLESSI RTS Rough Service ...... . ..................... . . .................................... -Final BUILDING INSPECTOR GAS INSPECTOR ccupanc-p Permit Required to Occupy Building Rough Display in a Conspicuous, lace on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. " q Page# of page Carpentry & Remodeling 1.0 Hide wav Lane Methuen, MA 01 844 Lioonscc &-, Insured 78- 87-6416 odelyourhouse@yahoo.00m "PROPOSAL SUBMITTED To JOB NAME JOB# 0 ADDRESS JOBIOCATION DUE DATE OF PLANS r o PHONE l6P �t � 'Al# ARCHITECT CA gO l '^u JaS o hereby submit specifications and estimates for. ""W r " t /V V k��' �9✓$o#m'^e A i(xP J W �" d ti R'M 4 14)e51411 4 Yp^an gg w. x J"- d r xare g �W s'�" a k, r e propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: $ � Dollars . with payments to be made as follows: D /tT P x�r• '" Lin"-J 1r.*'rt�,.�r r� x d �""".m" ",,.�r" � /m" x."e" w,' � Any alteration or deviation from above specifications leabons involvmg extra costs Respectfully 1 � will be executed only upon written order,and will become an extra charge submitted over and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature Pay men s wi o mat e as of dnec ovo/� � ! ' Date of Acceptance— ___-----.--- .�__._.__._ Signature — A-Nc381e/T-3£150 09-11 i t The Commonwealth of Massachusetts F Department oflndustrial.Accidents d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �} / Please Print Le 'b ") l Name(Business/Organization/fndividual): f d /�_ Z�c !�" Address: /0 City/State/Zip: Lle e, ,nA, o/ %' Phone#: Are you an employer?Check the appropriate box: Type of project()required): 1.❑I am a employer with employees(full and/or part-time).` 7, []New construction 2.M I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] • 9. ❑Demolition 3.F1 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.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.F1We are a corporation and its,officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no.employees.[No workers'comp.insurance requited.] '`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I.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. Ifthe sub-contractors have employees,'tliey must provide their workers'comp.policy number. X am an employer that is providing ivorkers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lia#: Expiration Date: Job Site Address: 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 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. --- I do hereby certi y un der thheepaiains and penalties ofperjury that the information provided above is true and correct. Signature• `` i'`dam Date: Phone#• t 7 ` ��Z— 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#: ®® 04-13-16;02: 01PM;TL_Southmayd 19786889542 ;9786570201 # 1/ 1 DATE(MMMIDVI YYI IFILIABILITY INSURANCE 4/13/16 ■ 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(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). PRODUCER CONTACT NAME' T L Southmayd Insurance Agency PHONE FAX (97e) 657-0201 668 Main St, Suite 9 E-MAIL Egim 978 657-0263 Ar N Wilmington, MA 01887 ADDRESS: louise@tlsins.com INSURE S AFFORDING COVERAGE NAIC# INSURER A:Preferred Mutual INSURED -- ---- INSURER B: R A Leblanc Carpentry & Remode INSURERC: 10 Hideaway Lane INSURER 0: Methuen, MA 01844 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 ANDCONDITIONS OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOFINSURPNCE ADDLSUBR POLICY EFF POLICY EXP N POLICY NUMBER (MMfDD1YYYY1 INMIDIYYYYY)lUMTS A GENERALLIABILITY BOP0100717536 5/25/15 5/25/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIALGENERAL LIABILITY PREMISES(Ea QxuDAMAGE TO RENTED e $ 100,000 CLAIM -MADE I—]OCCURLED EXP(Ary ore person) $ 10,000 PERSONAL&ADVIMURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO- F1 RO JECT LOC $ AUTOMOBILE LIABILITY Ea accident)NED IM $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accidenl) $ AUTOS AUTOS NON-OWNED PROPPEonRdTeYMDAMAGE $ HIREDAU70S _AUTOS UMBtZELLALIAB F OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ IAORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTNE -A NIA E.L.EACH ACCIDENT $ OFFICE R/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Nyye,describeunder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OFOPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Re marks Schedule,if more space Is required) Fax : 978 688 9542 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Louise Southmayd , Manager ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: _.� .. Massachusetts -Department of Public Safety i;casd�of�Building'Regulations and Standards - onstvuction Supet-visor License: CS-07*27 IIC�3ARb A LEBJIAN� 10 HIDEAWAY I:ANE - METHUEN MA 61844 Expiration 06/25/2016 commissioner n '�fi�Fc oI Co u� r '�fny, " u .1E11� siN�N� Nf1 eg�statit#M, y5363KA irA A LEBLANC R ,!CHARD LEBLANC � trii AWAi�LANE g �i` �A EN,MA 01844 [undersecretary.`