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Home My WebLink AboutBuilding Permit #53 - 239 GRANVILLE LANE 7/23/20074 T NOR'i'M BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: "4 �Ss�cNusti� IMPORTANT: Applicant must complete all items on this page LOCATION a3q Ero n V I l I e— La n e M Print PROPERTY OWNER I i )1� C�� (3Qe-AT),QY) FsrA MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Villaqe ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ F ddition ❑ Two or more family ❑ Industrial C '. ,iteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Tns6ll 3-Gni� o dcOr . Identification Please Type or Print Clearly) OWNER: Name: AddrPSS- cn,5-o-N CONTRACTOR Name:6`b0Ks5 to I rnW ►AWS DiorYPhone: 603-Klq-q 4 Rs Add Supervisor's Construction License: , Q2.b-11J Exp. Date: 3- g �� Home Improvement License: 101 Aga _ _ 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: $ a45(7 ,C3 0 FEE: $_ g Check No.: a :2tmg r Receipt No.: 7D Zf% NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ 1s�._.....at Building/Frame Permit Fee $ Foundation Permit Fee $ �— Other Permit Fee $ TOTAL $ r Check # 11'7d // 20i4� wilding Inspector Plans Submitted ❑ Y 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 DATE REJECTED PLANNING & DEVELOPMENTEl COMMENTS DATE APPROVED El DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date 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.$100-$1000 fine NOTES and DATA — (For ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 ♦ • t BROOKS 01MV0C�I� SIDING - WINDOWS - DOORS DATE INVOICE # Family owned and operated 254 N. Broadway, Salem, NH 03079 6/5/2007 7918 WWW.BROOK-SSWD.COM 603-894-4488 978-686-0260 BILI_ T0: SHIP TO: 1-'j IN da Gagnon, Michael 978-975-0774 978-975-0774 239 Granville Lane 239 Granville Lane North Andover, MA 01845 North Andover, MA 01845 D e on receipt4 6/5/2007 pU j U1�u] o e ,, o -' o •l�(c � �3/Yc7kl e Patio Door*A� Harvey vinyl 3 -unit atio door center vent 2,450.0 VWA-ki-PiV1,7uSh ti�ourl l-cl�gC,�1� I aaISO . c. Total Due $ P yments/Credits $0.00 A service charge of of the unpaid balance per month will be added to balance if not paid according to terms of contract on completion of contract. u V u I 15:27 JUL 20, 2007 ID: FRED C. CHURCH TEL N0: 976-454-1865 #245654 PAGE: 112 . 1 ACORD CERTIFICATE OF LIABILITY INSURANCE Y) °A/2007 TM n7na2a17 ls:2s 5:25 PRODUCER (800) 225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Fred C.Church 40 Kenoza Avenue Haverhill, MA 01830 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 800-225-1865 GENERAL LIABILITY INSURERS AFFORDING COVERAGE NAIC # INSURED Brooks Construction Co., Inc. 254 North Broachvay INSURERA., American International Specialty Lines Insurance Con INSURER B: Natlonal:ifange INSURER C: Salem, NH 03079 INSURER D: INSURER E: Guvrrfn4.Fi 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD11 -)F INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MIMIDDIYY1 LIMITS REPRESENTATIVES. GENERAL LIABILITY AUTHORIZED REPRESENTATIVE /1 �'Q•y1 !Y EACHOCCURRENCE $ 1,000,000.00 NcOM MERCIALGENERALLIABILITY CLAIMS MADE OCCUR DAMAGE TRENTED $0,000.00 PREMISES Ea occurenca $ MED EXP (Any one person) $ 5,000.00 B MS002750 4/28/2007 4/28/2008 PERSONAL 6 ADV INJURY $ 1,000,000.00 GENERALAGGREGATE $ 2,000,000.00 GENIL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000.00 POLICY PRO LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S EAACC $ OTHER THAN ANY AUTO AUTO ONLY: AGG $ EXCESSADMBRELLALIABILrrY EACHOCCURRENCE $ AGGREGATE $ OCCUR FICLAIMS MADE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU• OTH- EMPLOYERS' LIABILITY E.L. EACH ACCIDENT 1 $ 500,000 A ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? Ir yes, descdbe under SPECIAL PROVISIONS below WC6855423 5/16/2007 5/16/2008 E.LDISEASE- EAEMPLOYEE $ 50(},000 E.L. DISEASE -POLICY LIMIT 1 $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS M"9 .l■1.rl"-'I■�:l\1f NEI a. Y'V.1f""Mf•.\dr.l.\ Michael & Lynda Gagnon SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION 239 Grandville Lane DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN North, Andover, MA 0 1845 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE /1 �'Q•y1 !Y M%.Vrcv w kAVV I1U°1 Client P, 5295 Maty Active WC/Liab Cert Cert 11 0 ACORD CORPORATION 1988 l Vi 9 � � L O V1 9 O C o ... co 9 0 Ey :C a o'a E 25 ~ p W LU O W W J LLL U- W J J p) Q Q Q N f� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street p Boston, MA 02111 �e www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .pplicant Information Please Print LeLyibl' Name (Business/Organization/individual): kD49AIS J)e/t,✓r W Address: �� / ,�R$�►�f� City/State/Zip: / yj� �i�l Phone #: MY (f% 0<'r Are u an employer? Check theppropriate box: 1. [I am a employer with f 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. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, 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 boz # I must also fill out the section below showing their workers' compensation policy information. t 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: City/State/Zip: 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 hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: 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 #: 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 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-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. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia M h Er • 0� A M .j M-1 B Z co i O CD • L v � Z °D CL O y � C CD cm CO) 0 O CO) O O 'F m`` m G3 0 G3 CL r G3 3� O O s0.. � O d CO2 S � o�Q O CcC = .5 ,v •c z a3 ts 0 CL V CO) C O C _c �. y O 0 Y/ U) 19 W 19 w U) v u o w � '�' U3 Cf)b cn Cd p., z A 04.j o w x o w G U G x a O A. o c O w W W w a o v X O U o G a W w IA z cn v Q -Nd vi A M .j M-1 B Z co i O CD • L v � Z °D CL O y � C CD cm CO) 0 O CO) O O 'F m`` m G3 0 G3 CL r G3 3� O O s0.. � O d CO2 S � o�Q O CcC = .5 ,v •c z a3 ts 0 CL V CO) C O C _c �. y O 0 Y/ U) 19 W 19 w U) O ` C H O_ ++ C O v Gi d C ' ev 'cc y �D E Q d c r.+ V • iV N E c C r.+ O O O r 'cm c EC y cc cm m y ._ W = Z C y 15.� y O C 'm a� � m y m > cCD . � o Cz ao m C3 C3 O a0.. O o. 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