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Home My WebLink AboutBuilding Permit #625 - 101 GRANVILLE LANE 3/26/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ��S Date Received Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION _ Print: PROPERTY OWNER - Print' 100 Year"OId,Structure yes (no- TYPE o: MAP NOA� CPARC.EL: ZONING DISTRICT: Historic.District yes no Machine.Shop Village yes.OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition El Other Septic. ❑Well El Flo odplain 0 Wetlands: 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: -re-�4, eA/ Phone 7�— ZZV Address: Cl/f��f✓� Sin ��o� � ��r`S /�i�. . 5 l Supervisor's:Construction License: Exp. Date:-4(2 � Home Improvement License:/` ,�,yo Exp. Date: 2//& 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: $ 9�5 O,l?d FEE: $ �l Check No.: I` _Receipt No.: o NOTE: Persons contracting with unregistered contractors do not have ccess to the guaranty fund gnature of Agent/Owner -- �Signafure of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ S am )ed lans ❑ Location No. 1 Date- "Et o� t i TOWN OF NORTH ANDOVER Certificate of Occupancy $ yBuilding/Frame Permit Fee $-- wk Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 4� _ 26230 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ .. Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc, ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature t COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sower Connection/Signature& Date Driveway Permit DPW Tows ]Engineer: Signature: Located 384 Osgood Street FIRE'DEPARTMENT - Temp Dumpster on site yes no Located at'124 Mainhstreet Fire Departir>Ier�t signatureldate ` COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— For department use ® Notified for pickup - Date I Doc.Building Permit Revised 2010 Building Department artment The folowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from. Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the app;al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui!ding Permit Revised 2012 „rte Di t +_ttlat'or1 'L� ne _ ki °nStTu�ti� SL estc�cted to. R JE Y Q .+ 0 4 FtR 1NS�N,H; 3865 ,;.PLPdST��'• X svatto r. 51?.;s ► .- ,;,` ;.t •� � Tom: . S!S Re m' ffznrs G� c6u MENT CANT ' • - N Ofr'ce of Regls1�9� p1� 2 _ NM. . s'ereID tat5 �y ” JERRy,SEB pEP "' Unaer r... Pte' ;•_s--` y� . Page No. of Pages •Roofing Jerry P. LeBlanc PROPOSAL AND ACCEPTANCE •Siding Construction Supervisor Specialty License •Gutter 9 Atkinson Depot Road License:CS-SL 99633 Restricted To: RF WS •Painting Plaistow, NH 03865 Tr#:5177 Expires: 10/15/2013 •Carpentry Home (603) 382-0817 Home Improvement Contractor •Windows •Snowplowing Cell (978) 835-7740 RE Spires 1 2/1 6 208 41 PROPOSAL SUBMITTED TO PHONE DATE l STREET j JOB NAME CITY,STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: 1<26,9 I // s S L2 LA 5 ( r Gf yQ C.-- —� !✓ �iGd o� 71rr ��e�----- J c 4,41 e GG!} i� � STF A iil T Ue-44 P- P i� n r /< ts oll We Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: v1" / vh .^ A S dollars($��S Payment to be made as follows: A& 7e r---t 4-0 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 (` /� /L7 �Y=3--t.. 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 7� upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Note: This proposal may be and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within days. pensation Insurance. Acceptance of Proposal -The above prices,specifications rtE nd conditions are satisfactory and are hereby accepted.You are authorized o dothe work as specified. Payment will be made as outlined above. Signatureate of Acceptance ^� / / ` Signature ��✓w ��.. Wuse I IS ICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CON ERS NO RIGHTS UPON 7 R ALTER THE COVERAGE AFFORDED BY THE�POLtC1�ES THIS CERTIF CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER II must be endorsed. ff SUBROGATION iS WAIVED,subject to IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED,the po'cy(i the terns 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 endorse III s 978-688-7000 NA NEACT PRODUCER FAX Durso&Jankowski ins Agcy LLC 978-688 T001 PHO Alc No 198 Massachusetts Avenue ,. North Andover,MA 01845 PRODuR LEBLA-L Dorso S"Jankowski ins.Agcy. oMERro AFFORDING COVERAGE — ... - INSURED Jerry LeBlanca 13024: . 9 Atkinson Depot Road IMSURiR B:preferred M a - Plaistow,NH 03865 INsuRmc-Hartford Insurance Co. 14788 1 INSURER D:MSA Group INSURER E ' INSURER F REVISION NUMBER: OD COVERAGES CERTIFICATE NUMBER: _ WITH RESPECT TO WHICH THIS THIS IS TO CERTIFY THAT THE POS EREQOUI IRUMEN1 CTFRM aER CANON OF�CONTRACT O OTHER DOCUMENT WITH FOR THE POLICY PERI INDICATED. NOTWITHSTANDING CERTIFICATE MAY BE ISSUED OF SUCH POLICES.LIMITS SHOWN C MAY HAVE BEEN REDUCED BY PAID CLAIMS. HEREIN IS SUBJECT TO ALL THE TERMS' EXCLUSIONS AND CONDITIONSPOLICY EFF EXP LIMITS ILTR TYPE OF INSURANCE NUMBER EACH OCCURRENCE $ 300,00 GENERAL LIABILITY $ 100,00 j CPP0130597590 05/01H2 O5101N3 PREM SSS Eaoaxmence 5,00 B X COMMERCIAL GENERAL LIABILITY MED EXP(AM one person) $ CLAIMS-MADE Fx_1 OCCUR - PERSONAL&ADV INJURY S 300,00 ff GENERAL AGGREGATE S 600,00 1 _ PRODUCTS-COMPIOP AGG $ 600,00 GENT AGGREGATE LIMIT APPLIES PER`- - POLICY - PRO- Loc come,NE 3 SINGLE LIMIT $ 500,00 AUTOMOBILELIABILITY 01/04112 01104118 (Ea amdem B1 B2755S BODILY INJURY(Per Person) s D ANY AUTO BODILY INJURY(Per acadefd) $ ALL OWNED AUTOS PROPERTY DAMAGE $ X SCHEDULED AUTOS. (PeraWdent) X HIRED AUTOS S X NON-OWNED AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR AGGREGATE S EXCESS LIAB CLAIMS-MADE $ DEDUCTIBLE $ WC STATU OTH- RETENTION $ WORKERS COMPENSATION100,00 AND EMPLOYERS'LIABILITY Y(N OU89861 M79412 '08,06112 08/06113 E.L EACH ACCIDENT Si_-- C ANY PROPRIETORIPARTNEREMCUME ---INIA EL DISEASE-EA EMPLOYE $ 100,00 OFFICEWMEMSER EXCLUDED? 500,00 (Mandatory in NH) EL DISEASE;POLICY L1MTr S ifes.desaibevrMer _ _ -•- DESCRIPTION OF OPERATIONS below . 10t AddWonat Repu%e Schell H motece ) DESCRIPTION OF OPERATIONS t LOCATIONS I VEFtlCLES(ACach ACORD u 1CANCELLATION CERTIFICATE HOLDER BIDDIN1. BE CANCELLED BEFORE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VATH THE POLICY PROVISIONS. AUTHORREDREPRESENTATNE 4641L ... D 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 av www.mass.gov/Zia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual):--J L-__ Address: City/State/Zip:�`Gir` Phone#: kre you an employer?Check the appropriate box: Type of project(required): ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition - [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions E] I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 1311 Other comp.insurance required.] iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. W irn employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmation. urance Company Name: ot .icy#or Self-ins.Lid.#: ��sl+ 0 U� (1,44 '--! Expiration Date: Site Address: Jo z e!�;f�� jrr` C City/State/Zip: li`��/l mch a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. 1 hereby certify under the pains and penalties of perjury that the information provided above iis�true and correct. nature: Date: l2 d ly official use only. Do not write in this area,to be completed by city or town official. �ity or Town: Permit/License# ssuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector �.Other 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 employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed 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 Iicense 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 permit/license 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. 'he Department's address,telephone and fax number: The Cow onwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 021.11 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE r..._. a ZA17 nIn P77nn � gaORT1.� Town of Andover No. L�K. h ver, Mass, (� C0C"1C 1W#CK y1. �,9 p�RwTeo �Pa��S S U BOARD OF HEALTH Food/Kitchen PE.. RM.. 1T ._T LD Septic System ILTHIS CERTIFIES THAT 64W. .......�j. .. .. .........�.... .....................:MIR ..... ...... :......................... BUILDING INSPECTOR has permission to erect.......................... buildings on .j.p!......�. Anah?:(... .............................. Foundation Rough to be occupied as ...........L.ct f;�..... :...... ......................... Chimney provided that the person accepting this ermit shall in every respect conform to the terns 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 IN6 MONTHS ELECTRICAL INSPECTOR l UNLESS CONSTRU N RTS 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 Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE