HomeMy WebLinkAboutBuilding Permit #955-15 - 43 PHILLIPS COURT 6/2/2015V
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
0 Addition
erT"wo or more family
0 Industrial
0 Alteration
No. of units:
11 Commercial
El Repair, replacement
El Assessory Bldg
0 Others:
El Demolition
El Other
or Se t i6
-
ri. is r; ef
'Wa Is Tc.
h 110— 4
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DESCRIPTION OF WORK TU LSE FEK1-UKMtL):
)c
Identification - Please Type or Print Clearly
OWNER: Name: &,� t
go wca Phone:
Aririnn-,_q-
ARCHITECTIENGI NEER
Address:
Phone:
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: $ 0y, FEE:
Check No.:— Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Plans Submitted D Plans Waived Certified Plot Plan Stamped Plans F1
TYPE— —0E—S E�WERAGEDI S P 0 SAL
Public Sewer El Tanuing/Massage/Body Art El Sw��g Pools El
well 0 Tobacco Sales Q
Private (septic tank, etc. El Food Packaging/Sales 41.
El Pennanent Dwupster on Site F1
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Pla,nning Board Decision:
omments-
Conservation Decision: Comments
Water & Sewer Connection Driveway Permit
DPW Town Engineer: Signature:
I Q., \
�� T
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
MGL Chapter 166 Section 21A —F and G min.$100-$l 000 fine
-me
Doc.Building Pennit Revised 2014
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
4. Copy of Contract
Floor Plan Or Proposed Interior Work
E I ngineering Affidavits for Engineered products
OTE: 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/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
OTE: 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
4� Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Copy of Contract
2012 IECC Energy code
4, Engineering Affidavits for Engineered products
E: 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 Regi . stry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Building Permit Revised 2014
Location
No.wr— Date
Check
28861
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
'It
Building/Frame Permit Fee $
Foundation Permit Fee $-
Other Permit Fee
TOTAL $
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Page No. of Pages
• Roofing
PROPOSAL AND ACCEPTANCE
Jerry R LeBlanc
• Siding
• Gutter
Construction Supervisor Specialty License
9 Atkinson Depot Road
License: CSSL -099633 Restricted To: RF WS
• Painting Plaistow, NH 03865
Tr#:5177. Expires:10/1�12015
• Carpentry Home (603) 382-0817
Home Improverrient Contractor
• Windows Cell (978) 835-7740
• Snowplowing
Registraticin: 149881
Expires: 2/16/2014
PROPOSAL SUBMITTED TO
PHONE
DATE
.&A41
STREET
JOBNAME
cay, STATE AND ZIP CGOE
'JOB LOCATION
AlOri A 4ALizfr- 44 4
ARCHRECr
DATE OF PLANS
JOSPHONE
We hereby.. submit specifications and estimates for: Ll
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We Propose hereby to furnish material and labor complete in accordance with above specifications, for th a sum of:
f 619kc ym�/. Znz
dollars ($
r6jineM to be riiade as foflBws:
141A czrlm 'Ih
/I t,17 z", 'c' Y
All material is guaranteed to be as specified. All work to be completed in a workman-
like manner according to standard practices. Any alteration or deviation from above
Authorized
specifications involvin extra costs will be executed only upon written orders, and
will become an extra c9arge over and above the estimate. All agreements contingent
Signature Oe44dji,"
Z - - - /
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.
peri.sation Insurance.
Acceptance of Proposal - The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified Payme t ill be made as outlined above. Signature
wi
Date of AcceptanceS//C)// �r Signatil
The 'Commonwealth ofMassach usetts
(3 Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
wwwmass-gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectricians/plumbers.
TO BE FELED WITH TigE pERNUTT . ING AUTHOPJ�Y*. .
Ajjhlicant Info I rm. Please Print Ledb
Name (Business/Oiganization/individual�: 'I Z...
Address: qdj�A114Cm Ae4,W&
City/State/Zip:
nione 4: 17 1 D
Are ryou employer? Check the appropriate box:
lama
1 1 am a employer with _,.�-PIOYees (full and/or part
IF] I am a sole proprietot or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.Fj I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
<1 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, �;iiploye6s.
5.F] I am a general, contract I or and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors - iiave employees and have workers' comp, insuranceJ
6.Fj We are a corporation and its. offic6rs have exercised their right of 'exemption per MGL c.
152, § 1 (4), and we have no ernploydes. (No workers' comp. insurance required.]
Type of project (required);
7. NeiV-60'nstr6ction
8. E] Remodell�g
9. R Demolitioj�
10 Building addition
ll.Fj Electri al repairs or additions
jZ,F,ej,Phfmbing repairs or additions
131. of repair�
14.El. Other
*Any pplicant that checks bok # 1� �u§tls6 fill �out the �secfion below showing their workers' compensation policy information. affidavit indicating such.
t Homeowners who submit- this affda�it indicatingthey are doing all work and then hire outside contractors must submit a new
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether cIr not those. entities, have
employees. If the sub-contrac . tors have employees, they must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insuranceformy employees. helow, is theporicy and)ob site
information.
Insurance Company Name:
Policy 4 or Self -ins. Lie. #: & _�/, 0 IZP 2 L?V 12 3�114P Expiration Date:
Job Site Address: 4' h IA11�2 r 14 _A.,ih Aw4Lzcc . City/State/Zip:
Attach a copy of' the�forkers' , 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verl
I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct
Dnte- 1"1:2. /1 C,
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermitALicense #
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emplbyees.
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 isdefified 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'
receivbi'dr truit6e 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 hasnot produced acceptable evidence of compliance with the insurance coverage iequired."
Additionally, MGL chapter 152, §25C(1) 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
Pleas6 fill out the Workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
nece9sary, 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 d6es 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 pr town that the application for the permit or license is being requested, not the Department of
IndustrialAccidents. Should you have an y* questions regarding the law or if you are required to obtain a workers'
compensatiori-policy, please call the Department at the number listed below. Self-insured companies shoilld 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
thai 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 bum 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-NIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
-tom i imitoR i c ur LIAMILI I T IMUKANUI:
kk.� 1111712014
-TM CERTIFICK7E IS IMM AS A MATTER OF INFORMKTION ONLY AND. CONFERS NO MGM UPON THE CERTIFICATE HOLDER. THIS
CERTIFICA71E DOES NOT AFFIRMAMMY OR NEGATIMMY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDW 13Y THE POLICIES
,BELOW. THIS cERnFICAlrE OF DWJRUiCE DOES NOT CONSTITUTE A COKFRACT' BETWB31 TM ISSUING IN9IJIRERpL AtMfORIZED
ORPRODUCIEKANDYMCERTIFICA7EHOLOSt
IMPORTANII.- NtImaceiti hokler Is an ADDITIONAL INSURED, the polICYPOS) must be enddrsed. ff SUBROGATION IS WAIVED, subject to
the.terms and conditions of the policy, certain policies may require an endomernent. A statment on this certificate does not conftr ftbta to the
cwtificate holder in II9U1'of such on
PRODUCER
Durso & Jankowsld Iris Agcy LLC
198 Massachusetts Avenue
Noft Andover, MA MUS
Durso & JankowvWins. AM.
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INSURED Jerry LeBlanc
9 AtIdmon Depatitoad
Plaistow, NH 03865
RISURERA.
mmmms.- Pmbrmd Mutual Insurance Co. 15024
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nmumD:NGU-In9umnceCo, 14M
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COVERAGES CERTIFICATE NUNBER: REVISION NUMBEW
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A30VE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING MY REQUIRE11AENT, TERM OR CONDITION OF ANY CONTRACr OR OTHER DOCUMENT WITH RESPECT To WHICH- THIS
CERTIFICATE MNY BE ISSUED OR I MAY PERTAIN, THE INSURANCE AFFORDED 13Y THE PMJCIES DESCRMED HEREIN 18 SUWECT TO ALL THE TOM.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW.
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PERSONAL&AMMURY S 300,00(
GBORALAGGRErATE - S 600100(
GEIVLAGGREGAFELffiffrAPPLIESPER:
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PRODUCTS-COMPIOPAW S S09100(
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NON-OVMEDAMS
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COMSIM SOME UWr S 500,000
S0DILYN=Y(AVpmmn) S
BODILYKIUM(Pareeddft) 6
PROPERNI)mpm
MACCMENQ $
UNISRELLAUAB
EXCESS UAS
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AGGREGNE
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RETENTION 6
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ELEACHACCII)IM $ 1001m
ELOGEME-EAEMPLOYEE 5 100,000
ELOWEAM-POLICYLRW S 500,000
DEBMWIMMOFOPEPATMMILCCA'"ONBIVBBMAS VA=ftACORD1KAddff0ndR
sole oprietor is excluded from mork coveruge
SAMPIXI
Sarnple for bidding purposm
SHOULD ANY OF 7W ASM DESIMISED POLICIES BE CANCELLED BEFORE
DIE EVMTION DATE 7HBtEOF, NOTICE V41LL BE DELIMED IN
ACCORMANCIE VffrH THE POLICY PROVISIONS.
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Office- of C q Affairs & Bu
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JERRY 0,
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pLAIST
Massaichusetts - Department of Public Safety
Board 61 Building Regulations and Standards
Construction Supqvisor SpecmlO
-ticense: CSSL�099633
-�JERRYPLEBLANIC '72
1 "9 ATK[NSON D60T4R
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Plaistow NH 0386-5
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1011512615
comniissioner