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Home My WebLink AboutBuilding Permit #850-13 - 186 INGALLS STREET 6/6/2013I TYPE OF IMPROVEMENT PROPOSED USE TOWN OF NORTH ANDOVER Residential APPLICATION FOR PLAN EXAMINATION Kone family Permit NO: El Addition Date Received _6_1,9d IZ-3 11 Industrial Date Issued: No. of units: El Commercial KRepair, replacement El Assessory Bldg IMPORTANT: Applicant must complete all items on this page 11 Demolition El Other ,7 , V vlji: El wovigffds� -7 r --ti -1c Q -17T7 - ,R -in! _J $�o 0 . .. ...... . 1,00,iYopriplo Sqqq 5 yes; 7, MA E Z0 ,lNG-,1,Q-I-5JTR-lG-_T Historicyes i cf� hift�jh -0:911a' no, y 'rw TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building Kone family El Addition El Two or more family 11 Industrial El Alteration No. of units: El Commercial KRepair, replacement El Assessory Bldg El Others: 11 Demolition El Other ,7 , V vlji: El wovigffds� -7 r --ti -1c Q DESCRIPTION OF WORK TO BE PERFORMED: 7-f-TI/011 " Zvi 'n cle) ki 5 '6'� Ye R -g -� Poo f-4, A Identifi:c7tion P ease Type or Print Clearly) OWNER: Name Q Phone:- I / )�-Y 7 D 77Y/V Address:,��'! /S �'7 'T me, n 1A a- A 17FS: N h T 57 Ad d' -4 _x Z h 'I . S-' L -J'( .0m; H -bi�l--'M"bfbve'meht�Lli6�enge-1. b rh ffateiL '5: r2' 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.: 731-6 Receipt No.: 9 NOTE: Persons contracting with unregistered contractors do not have access tot g arpn nd ,(7 @tqre'OT.contract Plans SubmittedEl Plans WaivedEl Certified Plot Plan El tamped Plans ❑ L___ Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE. DISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ .. 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 COMMENTS HEALTH COMMENTS Reviewed on 1 I-3 S fjC5 00\ Reviewed on r1,c Zoning Board of Ap'oals. Planning Board Decision: Variance, Petition No: Zoning Decision/receipt submitted yes Comm Conservation Decision: Comments f Water & Sewer Connection/Signature & Date Driveway Permit DPW To` o ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Departmerit`signatu"re/date' COMMENTS Dimension Number of Stories:_ Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 - Date i Doc.Building Permit Revised 2010 Building Department The folawing 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 ❑ 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 ❑ 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 o 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 2P!).al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:ated with the building application Doc: Doc.Bui!-Jing permit Revised 2012 Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee At Permit Fee Other TOTAL Check #7--T.& 26490 Id' g Inspector s J LL OCL O O m u o O LL v Ln o u a N (n O V Z O Z -' m c O •++ a � o LL t :) o K ? c t U = LL O W Z Z d t D O LL O W Z J u .WJ LU}' r ao p d' u v y C LL O Lu N Z t p K C LL Z UA c Q W LLI a LL c j m O Z v v �% N 0 v le 0 N n VrA e �• � O o r s, m r Y ,0 Q O 8 Cn tOCL i � Cc d c t L. H opo 0 tm L1 Cc o � > .� X00 Z E C C • o ~ r CL- L c L co V O Ctm p C .O F=- CL 4) N N 4) Vco m = UJ m �. W C' d O O 40"P: •N to O P: N .= t O o Z • V LU m 0 -0 0. mN Q y 0 c = OJ H s .M C.0U > 2 Z m CDZ W w CL w H W CL 141 w E o z O C a U) . ca O �+ v D LO cc O a � a� Q OM r 0-0 U) Z 0 CL 0 w Cc N 5/20/2013 12:24 PM FROM: Fax Gerald T. McCarthy Insurance Agency Inc. ,,,TO: 1-978-688-9542 PAGE: 002 OF 002 AC"I?oe CERTIFICATE OF LIABILITY INSURANCE DATE 0120 /YYVY) 05/20/2013 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 Ileu of such endorsement(s). PRODUCER Phone: (978) 744-6433 Fax: (978) 744-3575 GERALD T MCCARTHY INSURANCE AGENCY, INC 92 NORTH ST P O BOX 839 CAME Deb Tournas AM PHONE (978) 744-6433 a No . (978) 744-3575 E -MAL debbiet@gtmccarthy.com ADDR PRODUCER36H2 CUSTOMER ID' SALEM MA 01970 INSURER(S) AFFORDING COVERAGE NAIC 08/03/12 INSURED LAWRENCE LEBLANC P O BOX 5389 INSURER : SAFETY INSURANCE COMPANY INSURER B LIBERTY MUTUAL INSURANCE COMPANY INSURER C HAVERHILL MA 01835 INSURER D: INSURER E INSURER F MED. EXP (Any one person) $ 10,000 COVERAGES CERTIFICATE NUMBER: 23510 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 POL Lli AITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTRINSR TYPE OFINSURANCE ADD'L SUBR WVD POLICY NUMBER POLICY EFF MM DnYYYI POLICY EXP (MM/DO/YYYY1 LIMITS A GENERAL LIABILITY BMA0003851 08/03/12 08/03/13' EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I -XI OCCUR ETORENTEoPR�nce $ 100'000 DAMAGE ES (Ea � 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 —ill POLICY PRO LOC AUTOMOBILE LIABILITY BMA0003851 08/03/12 08/03/13 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 HIREDAUTOS (Per accident) $ X NON -OWNED AUTOS $ $ UMBRELLA LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS DA9 DEDUCTIBLE $ $ RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? F1 (Mandatory In NH) It Yes, describe Under DESCRIPTION OF OPERATIONS below N/A WC531 S352562012 ! 09/28/12 09/28/13 WOC YTAM� S OTH $ E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 _LLDESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) - SIDING, GUTTERS, DOWNSPOUTS INSTALLATION LAWRENCE LEBLANC AS A SOLE PROPRIETOR IS NOT INSURED UNDER WORKERS' COMPENSATION TOWN OF NORTH ANDOVER TOWN HALL NORTH ANDOVER, MA Attention: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of G��G�56fah UrG6 i1a��✓ ORD CORPORATION. All rights reserved. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Larry LeBlanc Address:po box 5389 City/State/Zip: Bradford Mass Phone #:978-869-6575 Are you an employer? Check the appropriate box: 1. ❑✓ I am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.T required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comm insurance required.] Type of project (required): 6. ❑ New construction 7. ❑✓ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f 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. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: liberty mutual Policy # or Self -ins. Lic. # wc5-31 s-352562-012 Job Site Address:186 Ingalls Street Expiration Date:09/28/2013 City/State/Zip:north Andover Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure.coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebycerti uder the p�ip�enalties of perjury thatthe information provided above is true and correct 7 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Page No. of ; Pages , r TY � P.O. BOX 5389 LEBLANC AND SDRC BRADFORD, MA 01835 1873 (975) 555-'%% '(975) 559-5575 CELL Lic. #CS090484 Rte. #135529 mwi.161ancendsm.com PROP L SUB ` ITTED TO � /" PHONE DATE � STREEJ_� JOB NAME ' t � CITY, S ATVand ZI Cd6 JOB LOCATION � ARCHITECT { DATE OF PLANS JOB PHONE herebyWe •specifications 249�' 4/4 r i� �t � I ;v l >f►s 0 77 T herebv to_fupffsh material and labor — follows:, i r, All material is guaranteed to be as specified'. All work to be completed ,! a workmanlike manner according to standard practices. Any alteration or. deviation from above specifications Authorize Signature involving extra costs will be executed only upon written orders, and will become an extra — charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Ourc n by workers are fully covered by Workman's Compensation Insurance. withdrI T � Acceptance of Proposal—The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do. the Signatu .work as specified. Payment will be made as outlined above. Date of Acceptance: Signatu ce with above specifications, for the sum of: dollars ($ j 0` � s 1 may be. d within days. f Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-isur" License: CS -090414 1 LARRY J LEBLANC a, - PO BOX 5389e -"c ' =_ BRADFORD, 41A 01835 - r ` s e r Commissioner Expiration 01/28/2014 l Office -0 »r A/yF /MPR Sa erAffa�'z`�'c/j P�Stration.�'EMENTCO Busis'k LARK ation: 135829 NT �CTCR b'ulaha� �e � CEB�ANC a%2p14 33 CRY �FB�N lndiviype: dual ATKINSQ� TIpN�NE MA 03g1j Underseeretar3 JUN -5-2013 04:00 FROM:BATESON ENTERPRISES 9784755451 TO:9786888476 P.1/1 Commonwealth of Massachusetts """ a Title 5 Official Inspection Form L-Dca__�' Subsurface Sewago DISPOSal Systom Fort» - Not for Voluntary Assessments 188 Ingalls Streot Property Address Owner oland Muise lnfnrmation is owner's Name — required for North Andover _— every gags. cit r own ^"— — — 01545 8/4/2013 V1 �.._A- ._- . State ZIP Code p®te afinae�o�r��' We %�YULIUM Information (cont,) - - -- - Sketch Of Sewage Disposal System; Provide a view of the sewage disposal system, Including ties to at least two permanent reference landmarks or benchmarks. Locate all wells, within 100 feet. Locate where public water supply enters the building. Check one of the boxes below, ® hand -sketch in the area below Cl drawing attached separately �A_07a"16_ �pe&rz -�v ��-� F��. (Sim • 3113 Title 6 0Mcfal Irop=,*n Tann; 311D6u 40189wap9 D19pe6911 SYMOM • P99915 of 17