HomeMy WebLinkAboutBuilding Permit #678-2016 - 31 PHILLIPS COURT 12/1/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Parr nit No#: I
Date Received
01 �AORTH
,,,_F D
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
El Addition
0 Two or more family
El Industrial
0 Alteration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
11 Others:
El Demolition
El Other
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Septic, 180Yll
E i
Floodplain
Water/sevver�
uLb(;Klv I [L)N Lit- VVUKM I U Dr- r-r-ml-UnIVILMU.
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- Please Type or Print Clearly
OWNER: Name: Wij
Phone:
ARCHITECT/ENGINEER Phone:
Address:
Reg. No
FEE SCHEDULE. BULDING PERMIT' MOO PER $1000-00 OF THE TOTAL ESTIMATED COST BASED OM $125.00 PER S.F.
Total Project COSI: $ FEE: $
Check No.: ou Receipt No.: (P3
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
/n,�7,npran�ttjne 'ofi7,6'n'tra"r-f6":r.; A'
Plans Submitted ❑ dans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Well ❑
Private (septic tank, etc. ❑
Tanning/MassageBody Art ❑
Tobacco Sales ❑
Permanent Dumpster on Site ❑
Swimming Pools ❑
Food Packaging/Sales ❑
THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF a U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Consr•"rvation Decision: Comments
i
Water & Sewer Connection/Si nature Date Driveway Permit
r
DPW Town Engineer: Signature:—
' *" 11� A
ignature:
Located 384 Osgood Street
ter gni sife yes4':
'*"11YA
COMMENTS
�lill�'ilSlwll
Number of Stories:
Total land area, sq. ft.:.
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of deter location, mast or service droprequires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE. Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Bnilding Pemait Revised 2014
Im
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The following is a list of the required forms to he filled out for the appropriate permit to he 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
3 TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Desks
❑ 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/Cross Section/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
ATE: 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
)TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
n all cases if a variance or special permit ,was required the Town Clerics office must stamp the decision from the ]Board of Appeals
hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
oust be submitted with the building application
Doc: Building ]Permit Revised 2014
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL a
Check #
29763
Building Inspector
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. Page No.
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• Rooting Jerry LeBlancPROPOSAL AND ACCEPTANCE
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• Siding-.
Gutter Construction Supervisor Specialty License
Painting9 Atkinson Depot Road _ License: CSSL -099633 Restricted To: RF WS
• Carpentry Plaistow, NH 03865 Tr#: 5177 Expires: 10/15/2015
I• Windows . Home (603) 382-0817 Home Improvement Contractor
�• 9 Snow lowin Cell (978).835-7740 Registration: 149881
Snowplowing Expires: 2/16/2016
PROPOSAL SUBMITTED TO
'PH E
DATE /
C77(
J!STRE
JOB NAME
CITY, STATE AND ZIP CODE
JOB LOCATION
Allye-A/7-44,`
ARCHI`PECT, A
BATE OF PLANS
JJOBPHONE
We hereby submit specifications a 1 d estimates'for: / l
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Start within days
Complete in 30 days.
We Propose hereby to furnish material and labor — complete in accordance with above'specifications, for the sum ofi,
I 2"//E.'h. &"F: /r,t dollars($. ` "
Payment to be made as follows:. f i
a,4.
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 /
specifications, involving extra costs will be executed only upon written orders, dnd Sign�dture } _£' ✓
will become an extra charge over and above the estimate. All agreements contingent G ++,
upon strikes, accidents or delays beyond our control. Owner to carry fire, tomodo Note: This pro sal may be
�� and other necessary insurance. Our workers are fully covered by Workmen's Com- ,wifhdrawn by us if no4'accepted within days.
i pensation Insurance. ar
Acceptance of Proposal - The above prices, specifications '
and conditions are satisfactory and are hereby accepted. You.are authorized
to do the work ass specified Pam I twill be
p y made as outlined above, Sig
Date of Acceptance ` ' Sig
I�
7
The Commonwealth of.i6kassgchusetts
: Department of. IndustrialAceldents
N 1 Congress Street, Suite 100
Boston, MA. 02114-2017
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www -mass.
Workers:, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers-
TO BE FILED WITH THE PERMITTING AUTHORITY. -
Name (Business/organization/individual)'—) �ttrf� LP
.Address:
City/State/Zip: O
Are you aemployer? Check the appropriate box:
Phone #:
1. aam a employer with__:_employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employeesworking for me in
any capacity. [No workers' comp. insurance required.]
3. Q I am a homeowner doing all work myself, [No workers' comp. insurance required.] t
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
proprietors with no employees.
5. F1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. Q We are a corporation and its ofC ers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
*Any applicant that checks b0x#1 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 state whether or not those entities have ,
employees. If the sub-conlrac &s fiave employees, ley' rinust provide their workers' comp. policy number.
I am an employer that is pi dvidiizg workers' compensation insurance for my employees.' Below is the policy and job site
20
Type of project (required):
7. C] New construction
8. [] Remodeling
9. ❑ Demolition
10 C1 Building addition
11. E] Electrical repairs or additions
12. [] Plumbing repairs or additions
13. Roof repairs
14. [] Other
information.
Insurance Company
Policy # or Self -ins, Lic. #: - 7&115— Expiration Date:1, 1.10
Job Site Address:._.
Attach a copy of the
declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL e. 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. A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance
coverage verification.
I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct.
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): i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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 bf 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 enferpxise, 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 Ell -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-'contractox(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 cavy 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 foi• confirmation ofinsurance 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 ox if yo'u'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. Anew 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
GERALEB-01 JONEILL
ACORO" CERTIFICATE OF LIABILITY INSURANCE
DA 1211/2D/YYYY)
12/1 /2015
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
Durso & Jankowski Insurance Agency
11 Saunders Street(A/C.No
North Andover, MA 01845
CONTACT
NAME:
PHONE F4x
Ext): (978 ) 688-7000 A/c No): (978) 688-7001
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: Preferred Mutual Insurance Co. 15024
05/01/2015
INSURED
INSURER B: MSA Group 14788
INSURER C: Hartford Insurance Co.
Jerry LeBlanc
INSURER D:
9 Atkinson Depot Road
Plaistow, NH 03865
INSURER E:
INSURER F:
PRODUCTS -COMP/OP AGG $ 600,000
COVERAGES CERTIFICATE NUMBER: RFVIsrnN NHMRFR-
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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR
LTR
I TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE FRI OCCUR
BOP0100717134
05/01/2015
05/01/2016
EACH OCCURRENCE $ 300,000
DTgAGPREMISES (Ea occurrence) $ 100,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 300,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY 1-1PE� LOC
OTHER:
GENERAL AGGREGATE $ 600,000
PRODUCTS -COMP/OP AGG $ 600,000
$
B
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED X SCHEDULED
AUTOS AUTOS
HIRED AUTOS X NON -OWNED
AUTOS
B1 B2755S
01/04/2015
01/04/2016
COMBINED SINGLE LIMIT
Ea accident $ 500,000
BODILY INJURY (Per person) $
BODILY INJURY Per accident $
( )
PROPERTY DAMAGE
Per accident $
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITYSTATUTE
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N
OFFICERIMEMBER EXCLUDED? y
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
6S60UB2E34123415
08/06/2015
08/06/2016
PER OTH-
ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE $ 100,000
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
ACORD 25 (2014/01)
vru�v���r► I wn
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
�0
'01
1"O-Zu14 ACUKU CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
I
Massachusetts_ Department of Public Safety
' board of Building Regulations and Standards
P+
License: CSSL-099633
Construction Supervisor Specialty
JERRY P LEBLANC
9 ATKINSON DEPOT;ROAD
PLAISTOW NH 038651
,i
„M Expiration: '
Commissioner 10115/2017