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Home My WebLink AboutBuilding Permit # 7/29/2016 pl0 ri TFq BUILDING PERMIT oF�sL�o la �q. TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION a Permit No#: ATED 96 � � Date Received R°�R`�„�`w.e¢ti�c5 �sSACFiU`�F'� Date Issued: IMPORTANT: Applicant must complete,all items on this page LOCATION � Print PROPERTY OWNER �,��;; Zr- jc 4 s g Print 100 Year Structure yesCno o MAP ! PARCEL: ZONING DISTRICT: Historic District yeso Machine Shop Village yes 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 Septic ❑Well 0 Floodplain ❑Wetlands ❑ Watershed District Water/Sewer. DESCRIPTION OF WORK TO BE PERFORMED: a L' Ile Identification- Please Type or Print Clearly OWNER: Name: L Phone: Address: Contractor Name-f Phone: Email: Address- �q Supervisor's Construction Licenser 4--a.q 111, ,7- Exp. Date: /&//5 12'P -7 �. Home Improvement License: Exp. Date.- ARCH ITECT/ENGINEER ate:ARCHITECT/ENGINEER Phone: Address: Reg. No. FEF SCHEDULE:BULDING PERMIT:. 12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project C st: $ A e FEE: $ ,16/ - Check No.: Receipt No.:_ DOTE: Persons contracting with unregistered contractors do not Have access to the guarantyfund - Flans Submifted ❑ PIans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SE'WERAGE DISPOSAL Public Sewer ❑ TanninglMassagelBody Art ❑ Swimming Pools ❑ Wall ❑ Tobacco Sales ❑ Food.Packaging/Sales ❑ Pxivate{septic Tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR. OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING � DEVUOPMENT Reviewed On � � Signatures COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water Sewer Connection/S"r nafur��Dade ©rivewa Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRK DEPAOMONT - Temp Dump5ier an,sit.e yes. . . no . . Loeated at 12.4 Main Street Fire Department signature•/date COMMENTS t%ORT� own of 0 No. w �O aA : h , ver, Mass, Q Z� ZAQJ46 COC MICM�W![.l 4' �,QSDRATED A'P�``�,��? U BOARD OF HEALTH Food/Kitchen PERMIT T LD�t Septic System THIS CERTIFIES THAT ......... .... �..G.'.. . ��.. X—.!� ,...... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings ......., Rough t0be occupied as ,... ...��.`.�. ..... ...........:......................................................... 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 Fina[ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR ON S Rough ervice ... .... ......... ....... .......... .......... ..... Fina BUILDING INSP OR GAS INSPECTOR Occripancly Permit Required Occupy By 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 Approved by the Building Inspector. Burner Street No. Smoke Det. Page No. of Pages • PROPOSAL AND ACCEPTANCE •Siding Rooting Jerry P. LeBlanc •Gutter Construction Supervisor Specialty License • Painting 9 Atkinson Depot Road License:CSSL-099633 Restricted To:RF WS •Carpentry Plaistow, NH 03865 Tr#:5177 Expires:10/15/2015 •Windows Houle (603) 382-0817 Home improvement Contractor •Snowplowing Cell (978) 835-7740 Registration:149881 Expires:2/16/2014 PROPOSAL SUBMITTED TO PHONE / DATE /� cL � vis,^ STREET JOB NAME ` CITY,STATE AND ZIPCOD = JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: j .M G • ?h 42 ff7 le i_4�14 !f .s h f Z-7 er,�P r e ' e r- ; r n � We Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: dollars Poymaht,fa be made as follows. / ' he � v ft ''t C / c y :✓L•Z'dt f . All material is guaranteed to be as specified.All work to be completed in a workman- Authorized like manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed anly upon.writtan orders,and Signature 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 Note:This p posal may be and other necessary insurance. Our workers are fully covered by workman's tom- withdrawn by us If not accepted within days. pensation Insurance. Acceptance of Proposal -The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Pay ant will be made as outlined above. Signature r Date of Acceptance Signature j T"he Commonwealth of Massaehusetts Department ofindustrralAeeidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.govldia Workers,Compensation Insurance Affidavit:Builders/Contractors/.Electricians/Plumbers. TO Ills MED WITH THE PERMITTING AUTROXdTY. APPY cant Inform-00 n PleasePriut Le `bl Namr, (Business/Oxgauizatiorffndividual): Address` d city/state/zip:�l' f� fd 4 (� Phont; Areyou rr employer?Clreclttiie aplixopriafe box: Type of project(�'gquired): 14a a employerwith s employees(full and/or part time).* 7.. New coristraction 2.Ej I am a sole proprietor or partnership and have no employees working for me in S. Remodeling any capacity.[No workers'comp.insurance required.] 9 ❑Demolition 1❑I am a homeownerdoingall work myself[No workers'camp.Jasurance required.]i 10 ❑Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will -ensure that all contactors either have,workers'compensation insurance or are sole 11:❑Electrical repairs ox.additions proprietors withna oinplcyees. ' 12:[�Plumbing repairs or additions 5.❑I am,a general contractor and I hayo hired the sub-rantractors listed on the attached sheet. 13.'Q Robf repairs These sub contractorsTizace employees and have workers'comp.insruance.t 6f]We are a corporation andits nf�cers have exercised their right of'oxemption per MGL c. 14.❑Other 152,§1(4),andwe have-.qoJ aployogis.�,No workers'comp.insurance required.] Any applicant that checks box 41 must alsofdl out the section below showiugtheirworkers'compensation policy information. T Ilomeowners kho submif il3is affidavit indicating they are doing all work and then hire outside contractors must s4bmit anew affidavit indicating such. tContractois that checkthis box must•Attached an additional sheet showing the name,of the sub-contractors and state whether ornot those entities have employees. workers'comp,policy number. I ain an employer that is providing-workers'compensation insurance for my employees'Below is the policy alid job site information. Insuramco Company Name: Policy#or Self-ins.lie. Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers' compensation p olicy declaration page(showing the policy number a-ad expiration elate). Failure to secure coverage as roquired under MOL m 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$250.00 a clay against the violator.A copy of this statement may be forwarded to the Ofco of Investigations of tho DIA for insurance coverage verification.. I do hereby certify under the pains and penalties ofpeijury that the information provided above is true and col-:ecf Si afore: Date: ,71- 61 Phone#: Official use only. Do not-►vrite in this area,to be completed by city or town off cial City or sown• Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.CIWTown Clerk 4.)i lectrical inspector 5.Plumbing Inspector 6.Other Contact;Person: Phone#: �-, GERALEB-01 JONEILL AC0I20" �. CERTIFICATE OF LIABILITY INSURANCE HATE(MMIDDIYYYY)7129!2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME:__ Durso&Jankowski insurance Agency PHONe978 688-7000 FAY Nol: 97$ 688-7001 11 Saunders Street AIC No Ext: ) 8-7_ ( j..____ North Andover,MA 09845 E-MAIL INSURER(S)AFFORDING COVERAGE NAIC it INSURERA:Preferred Mutual Insurance Co. 15024 INSURED INSURER B:MSA Group _ 14788 Gerald LeBlanc INSURER C:Liberty Mutual Ins.Co. 9 Atkinson Depot Road INSURERD: Plaistow,NH 03865 INSURERE: 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. �._,......,.,.. ADDL SUBR - POLICY EFF POLICY EXP �...._, . !NSR TYPE OF INSURANCE LIMITS LTR !NSD WVD POLICY NUMBER MMlDD MMfDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGE TO RENTED CLAIMS-MADE 0 OCCUR BOP0100717134 05101/2016 05/0112017 PREMISES(Ea occursnce) $� 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[—IPJECTRO F] LOC PRODUCTS-COMPIOPAGG $ _ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 500,000 Ea accident � B ANY AUTO B1 B2755S 01104/2016 01/04/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS X NON OWNED PROPERTY DAMAGE X $ HIRED AUTOS AUTOS Per accidenjJ_._,_ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEQ RETENTION$ $ WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY _ STATUTE ER _ C ANY PROPRIETORIPARTNERIEXECUTNE YIN WC531 S369385025 10/1212015 10/12/2016 E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory In NH) E.L.DISEASE-FA EMPLOYEE $ _ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACORD 161,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 4. r' ('r/�r7Na�rintrr///n rrFrrr�rcr�ellr Office of Consumer Affairs&Busyness Regulation, OME IMPROVEMENT CONTRACTOR .' i,115, a istration: ` ' 0 9 149881 Type: i � Expiration. 2/162018, Individual' JERRY P LEBLANC `i JERRI' LE BLANC 9 ATKINSON DEPOT RD PLAISTOW,NH 03865 ` R " Undersecretary Massachusetts,Department of Public Safety Board of-Building Regulations and Standards License: CSSL-099633 Construction Supervisor Specialty JERRY P LEBLANC 9 ATKINSON DEPOT.ROAD:: PLAISTOW NH 03866 L Expiration Commissioner 10116120.17