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HomeMy WebLinkAboutBuilding Permit #668 - 140 MARIAN DRIVE 11/30/2015 SGij�/U►VED /61-3-/S bUiLUiNU MKiYII I lo-TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ATED Date Issued: 115 �9SSACHUS`tom IMPORTANT:Applicant must complete all items on this page 'LOCATION, 1 r� P, t PROPERTY OWNER--,1 yes Print MAP NO: 4�PARCELIFONING DISTRICT: Historic District no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building pkr_One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0.Septic - ❑ Well ❑Floodplain a Wetlands ❑ Watershed District p Water/Sewer I /) k f 4�j �` Identification Please Type or Print Clearly) OWNER: Name: Phone: 1-7����L//�� Address: CONTRACTOR Name: /° Phone: 7 Address: ,'Supervisor's Construction License: c Exp. Date: C � Home Improvement-License: Exp. Date: 1" I 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: $_ �� 60 FEE: $ r Check No.: ` �,4 Receipt No.: Q� 3: NOTE: Persons contracting unre is ered contractors do not have access to gua a ty nd ignature of Agent/Own Signature of contract t%ORTH BUILDING PERMIT °��tLEU TOWN OF NORTH ANDOVER a' "' APPLICATION FOR PLAN EXAMINATION * ,� Permit No#: Date Received gSSACHUt" Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER P'rinf 100 Year structure yes no, MAP' s_ PARCEL: -_ � . ZONING DISTRICT: -- - HistorieDistrict yes no Machine Shop Village yes no 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 [I Well Floodplain Wetlands ❑ Watershed District n.Water/Sewer, - ! I , DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name _ .____ _ _ __v-_z _ _-- -Phone: Email: Address: Supervisor's Construction License:_.- Exp. Date: I 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to, the guaranty fund f 4..9 nature of Agent/Owner_ _. Signature oficontractor_. I Building Department The following 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 o Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses Li 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 J Plans SuIJ,,..<<,;d Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body 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 PLANNING & DEVELOPMENT Reviewed On Signature_ I COMMENTS CONSERVATION Reviewed on Signature COMMENTS 9 HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: i 0.41:11. TO plrl p:� 84 Osgood Street Located +FIRE'�DEPA'R�TME.NT T m fDum ster onmsite: ryes;:_ _ n� tLocated at 124'1M _� F:re�Department.signature/date _. _}» _ =_ �- I �:OMMENTSH_- 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.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Location/IVO �v- No. Date • TOWN OF NORTH ANDOVER rLED Certificate of Occupancy. $ Building/Frame Permit Fee $cry a� Foundation Permit Fee $ r. Other Permit Fee $ ' 160 TOTAL $ Check# i 29752 _ uilding Inspector i 'T NORT1i own oAndover No. • ��' _ so h �j� ver, Mass, d 3 cocLAKR nicNewrc« 1' �••9S R�17E O All? U BOARD OF HEALTH Food/Kitchen PERMIT T LD ii,�� 1 ' /b Septic System THIS CERTIFIES THAT Y'.d.�?. '`:w .....� ( 1'"�` ........................................... BUILDING INSPECTOR ................... ... ...f. ...... ..... ... Foundation has permission to erect .......................... buildings on ... �Q./ ...... '�l Rough v�� V to be occupied as .......... ... ..........(....�. �.....c ... . ...... ...n.................................................. Chimney provided that the person accepting this perrttit 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO RTS Rough Service ................. .. .......................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 r t P.U. BOX 5389 `BRADFORD, MA 01835 2112 (979) 5561-9 (973) M-6575 CELL "t. #CSOS0414 Rc& +19.35823 PROPqSA UB I DITT-D 0 PHONE �w,i � DATE .w 9— ,...r STREET jf - JOB NAMES CITY,STT and ZIP OD�EI JOB LOCATION �W ARCHITECT DATE OF PLANS JOB PHONE We herebyubmit specifications and'estimates for: 071 ��-V�le Propos her o furnish erial and 1A',complete irI' c t die with above specifications, for the sum of: 01 'Payment to be mage ZasAo ,,./' t f f /�aa vb All material is,guaranteed to be as sp Cifed. All work to be complete !f a wlrkmanlike manner according to standard'practice Any alteration or deviation fromf ab specifications Authorized involving extta costs will be execute only upon written orders, and twill become an extra Signature _ 'charge over and above the estimate. All agreements contingent upon strike/accidents or // �// delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our -tNt�This'proposal may be workers are fully covered by Workman's Compensation Insurance. with.rawFroy us if not accepted within days. - Acceptance of Proposal —The above prices,specifications f and conditions are satisfactory and are hereby accepted.You are authorized to do the SignatureA _ Work aS:specified.Payment will be made as outlined above. v t Date of Acceptance: . Signature NOU-30-2015 11: 15 From:G T MCCARTHY INS 978 744 3575 To:19786889542 Pase:2/2 AC RO o' CERTIFICATE OF LIABILITY INSURANCE 711130/2015 IMM/DD/YYYY) 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 Phone: (978)744-6433 Fax: (978)744-3575 CONTACT NAM Deb Tournas GERALD T MCCARTHY INSURANCE AGENCY,INC PHONE (978)744-6433 aD N (978)744-3575 92 NORTH ST weo E P O BOX 839 E-MAILSS: debbiet@gtmccarthy.com DDRE PRODUCER3682 SALEM MA 01970 CUS ME ID: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER : SAFETY INSURANCE COMPANY LEBLANC&SON LLC P O BOX 5389 INSURER : LIBERTY MUTUAL INSURANCE COMPANY HAVERHILL MA 01835 INSURER INSURER D: —INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 30687 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 PO .LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADD'L SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IN D POLICY NUMBER flMM/DD/YYYY MM/ D/Y YY LIMITS A GENERAL LIABILITY BMA0003851 08/03/15 08/03/16 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100 000 P EMIS cc oence CLAIMS-MADE I7 OCCUR MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X PRO- POLICYE]JFCT LOC $ AUTOMOBILE LIABILITY BMA0003851 08/03/15 08/03/16 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION WC531 S352562012 09/28/15 09/28/16WC STATLT OTH AND EMPLOYERS' LIABILITY TORYLIMITS $, Y/N EACH ACCIDENT E.L.ANY PROPRIETOR/PARTNER/EXECUTIVE $ 500,000 OFFICER/MEMBER EXCLUDED? I� N/A (Mandatory in NN) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 71 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) SIDING,GUTTERS,DOWNSPOUTS INSTALLATION LAWRENCE LEBLANC AS LLC MEMBER IS NOT INSURED UNDER WORKERS'COMPENSATION CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: � �4��61`a hu rTb ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAceidents F 1 Congress Street,Suite 100 d Boston,MA.02114-•2017 C www mass.gov/dia ,y. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Legibly Name(Busines Organization/Individual): e � Address: ; 6 0 Y S -S < - City/State/Zip d 5 Phone#: 7 � - � � /f Are you an employer?Check tth.eeaappropriate box: Type of project(required): 14&1 am a employer with d .. \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 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.Q I 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. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 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. i 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-cor&actors have employees,ley must provide their workers'comp.policy number. I am an employer that is pioviding workers'compensation insurance for my employees.'Below is the policy and job site information. �� ( CI A Insurance Company Name: / IN Policy#or Self-ins,Lie.#: �' 7 S 3 S�5 � Expiration Date' J/ Job Site Address: �`� ` /'t�" 6_l City/State/Zip: ��t p /7 � 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. copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatio . I do hereby certi nde t Z ai enatties ofperjury that the information provided above is true and correct Si nature: Date: Phone#: a 6 5 7-5 Official use o rly. 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#: Informati®n 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 license 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-contractof(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 fok confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affiidavit 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia . r l License or regLsuat i vand for mdividul use only Office of Consumer Affairs&Business Regulation f before the expiration date. If found return to: U'W,�ME IMPROVEMENT CONTRACTOR type: Office of Consumer Affairs and Business Regulation gistration: ,135829 Yp 10 Park Plaza-Suite 5170 Individual xpiration:, 5/14/2016 Boston,MA 02116 LARRY LEBLANC ��i LARRY LEBLANC 33 MEDITATION LANE �— LL 5 X. No hd without signature ATKINSON,MA 03811 Undersecretary Massachusetts -Department of Public Safety j Board of Building Regulations.and Standards Construction Supervisor License: CS-090414 LARRY J LEBLA$C PO BOX 5389 . ` 9 BRADFORD MA7018ofj P i ✓,,�,.��11 '� ti'`� Expiration Commisssiionneer' 01/28/2016