HomeMy WebLinkAboutBuilding Permit # 3/10/2017 3/13/2017
*Building Permit#23404 Alterations: Roofing/Siding and/or Windows/Doors
40 Applicant Location
Steven Poussard 145 BERKELEY ROAD , NORTH ANDOVER, MA
k. 207-312-1755 owner
@ steve.poussard@... KEATING, EDWARD V
Application Submission
Are you submitting this application as the Homeowner?
NO
Primary Contractor
Firm(Business)Name Licensee
DIPIETRO HOME ENERGY
License#` License Expiration Date
185083 04/25/2018
License Type* License Active
Home Improvement Contractor O
License Status Mailing Address
Active 5 SOUTH SUMMER ST., HAVERHILL MA 01830
Preferred Telephone#:* Alternate Phone#
2073121755
Email
steve.poussard@reviseenergy.com
certify,underthe pains and penalties of perjury,thatthe information on this application is true and complete.
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Project Information
Type of Improvement* Proposed Use
Alteration One-Two Family
Description of Work to be Performed* Is property on Town water
Weatherization through the mass save program. Yes
Is property on Town sewer
Yes
Project Cost(if new construction base on$125 per square foot and if addition/alteration/renovation base on actual contract price)'
3,508
Does this project require a temporary construction trailer?
NO
Does this project require a temporary construction sign?
NO
Danger Zone Literature(MGL CHapter 166 Section 21A-F and G min.$100-$1,000 fine)
NO
Registered Design Professional
Architect/Engineer Name Architect/Engineer Address
Architect/Engineer Phone Number Architect/Engineer Reg.#
Insurance
I have a current liability insurance policy or its substantial equivalent.
Yes
If yes,indicate the type of coverage" If other,specify
Liability
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Worker's Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Are you an employer?Select the appropriate type.Any applicant that selects#1 must also fill out the section below showing their workers'
compensation policy information.*
1. 1 am an employer with employees (full and/or part-time)
Type of project*
8. Remodeling
I am an employer that is providing workers' compensation insurance for my employees. Below is the
policy and job site information.
Insurance Company Name(Attach a copy of workers'compensation policy declaration page showing the policy number and expiration date)
Costello Insurance Agency, Inc.
Policy#or Self-Ins.License#* Expiration Date
PACEP305047 04/25/2017
Workers' Compensation Affidavit Signature
do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
la To Be Completed By Town Staff
G Zoning District* Q Is this a 100 Year or older structure
Q Is property within an Overlay District* Is the property within the Floodplain
Is the projectwithin 100'of Wetlands?*
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