HomeMy WebLinkAboutBuilding Permit #994-15 - 440 WINTER STREET 6/2/2015%AORTti
BUILDING PERMIT
APPLICATION FOR PLAN EXAMIN
TOWN OF NORTH ANDOVER 0
ATION
Permit No ived 0
Date Rece
Date Issued( 11:2- -11 :Z
I I - ANT: Applicant must complete all items on this page
�OCATION
Print
PROPERTY OWNER -Cleve-.'
Print 1 bb �(ea.r. Structure- ye's no
MAP PARCEL' ZONING, DISTRICTO Historic. District yes- no
Machine. Shop -Villagqr'- yes no
TYPE OF IMPROVEMEi4-T-
PROPOSED USE
Resid ntial
Non- Residential
New Building
family
El Addition
El Two or more family
El Industrial
El Alteration
No. of units: -
El Commercial
El Repair, replacement
El Assessory Bldg
El Others:
El Demolition
El Other
0 S, - plit- 0 We
�10"' ElfttiOn' -dh
d
'�he [1Di$tnq;
n;:QrPIPT1()hJ
nF WORK TO RE PERFORMED:
L5, I/ RC_&Pa,3 J� -a 4 Z 4 e- &eez 41e
Identification - Please Type or Print Clearly
OWNER: Name: .('Aet-,r 6c,,- -t tl Phone: .2.Z V tv.7_17
Address: "/1 -01x'-
Contractor Name: 4 Phon6."" e 7eW
Email:
Address:
License. Exp; Date:. 1,9A
Su'ervisor's Construction 1!� 14- 1
p
Home Improvement Libense., Ej(p. Date. -,2
ARCH ITECT/ENGI N EER_ Phone:
Address:
Reg. No
FEESCHEDULE: BULDINGPERMIT. $12.00PER$1000-00 OFTHE TOTALESTIMATED COSTBASED ON$125.00PERSA
Total Project Cost: $ 11; 9 7 T 00 FEE: $
Check No.: t Receipt No.:
L
NOTE: Persons contracting with unregistered contractors do not have acces-31dro th-e guarantyfund
Plans Submitted Plans Waived Certified Plot Plan 0 Stamped Plans 0
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art 0 Swinnning Pools 11
well Tobacco Sales 11 Food Packaging/Sales El
Private (septic tank, etc. El Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature'.
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
,I$
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_
PlOnning Board Decision: Comments
*&-'onservation Decision: Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
-1 IDE ME 7.
F1 sit
9 �Y'u rn 0- �46-5 , � es
07- iE I ti ",V�
"in
o- e, a !Ra.... FeB
ID ; a ix -ure/gMate
E
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
M
Doc.Building Permit Revised 2014
r--
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
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4 Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
4 Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
4 Mass check Energy Compliance Report (If Applicable)
,4. 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
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
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 Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Building Permit Revised 2014
Location
No.
Check# /0,5-1
28862
DateA"5—
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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Page No. Of Pages
Roofing Jerry P. LeBlanc
PROPOSAL AND ACCEPTANCE
Siding
Gutter
Construction Supervisor Specialty License
9 Atkinson Depot Road
License: CSSL -099633 Restricted To: RF WS
Painting Plaistow, NH 03865
Tr#: 5177 Expires: 10/1512015
Carpentry Home (603) 382-0817
Home Improvement Contractor
Windows Cell (978) 835-7740
Snowplowing
Registration: 149881
Expires: 2116/2016
PROPOSAL SUBMITTED TO
PHONE
DATE�
ye 1, Z
9�7Z
5�& 7
7 �,7 12
STREET
JCrB NAME
q q b e_r_- I �_
CITY, STATE AND ZIP CODE
JOB LOCATION
/V,2 api aLL" Z_, ryi- ir- Q r
ARCHITECT DATE OF PLANS
8 PHONE
We hereby submit specifications and estimates for:
-rL4,..s t4 e Lo_ 4
'55 A,4_
-.e Or
rZ A, f L-
7'
M ZZI _- '14
h�,V,-e rv-, Olez;,. L,--.fz 1-:�IA
A 4 4 1
4oh,z A
�144 ie_-4n:�� A_iAZ1_A1,6Z
qj
ce: dq"j-Z 41j.
A4 a
1-7
Zlk e- 411-0'_1_ e, XIM/
Start within days
complete in 30 days.
We Propose hereby to furnips I h material and labor — complete in accordance with above specifications, for the sum of:
C11-1-23 k1l 4--J1-16Z �-?jtt-44LO
JrU�� dollars ($ 2 57_1 6,20'
Payment to be n(ad6 -as -follows
13
/7 rfl
_4
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 involving extra costs will be executed only upon written orders, and
will become an extra charge over and above the estimate- All agreements contingent
Signature—
upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado
and other necessary insurance. Our workers are fully covered by Workmen's Com-
Note: This proposal may be
withdrawn by us if not accepted within days.
pensation Insurance.
::f�
Acceptance of Proposal - The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Payment will be made as outlined above. Signature
Date of A cceptance Signature
The Commonwealth ofMassachusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www-mass-govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers.
TO BE FILED WITH THE pEpMTTiNG AUTj1ORriY'.
Please PrIAt LeMbIl
ADDlicant Informa
Name (Business/OrganizatioDAndividual): J!14 a
Address:
,41y 02g( Phone#: R
City/State/Zip:,0)a,.'e/-nw__
Areyou employer? Check the appropriate box:
I am
a employer with ___��ml)10`Yees (full and/or part-time).*
2. rl i am a sole proprietor or partnership and have no employees workirfg for me in
any capacity. [No workers' comp. insurance required.]
3.n I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.rJ 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 6mployees.
5. 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
' h'
These sub -contractors ave employees and have workers' comp. insurance.t
6.FJ We are a corporation and its. officershave exercised their right of exemption per MGL c.
152, § 1(4), and we have em
no , pi6yees. [No workers' comp. insurance required.]
Type of project (required):
7. E] NeW'c6nstr&tion
1
8. 0 Remodeling
9. El Demolition
10 E] Building addition
11. Electrical repairs or additions
12. PI bing repairs or additions
11t�Zreoairs
14.F] Other---
st als fill out the section below showing their workers' compensation policy information.
*Any applicant that checks box # I Mu 0 ibating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I Homeowners who submit this affidavit ind eet showing the name of the sub -contractors and state whether or not those entities. have
tContractors that check this box must attached an additional sh ir workers' comp. policy number.
employees. If the sub-cont�actors have employees, they must provide the
ensation insurancefor my empl6yees. Below is thepolicy and)ob site
I am an employer that isproviding workers'comp
in rmation.
02
Insurance Company Name:
ExpirationDate: �-k
Policy# or Self -ins. Lic. #: 144Z�J -
fobSiteAddress: qYd2 144 Alr City/State/Zip: iration date).
Attach a copy of the workers' compensation policy declaration page (showing the policy number and exp
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 verification.
ove is true and correct.
fy under thepains andpenalties ofperjury that the information provided ab
do hereby certi I /
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 5. plumbing Inspector
1. Board of Health 2- Building Department 3. City/Town Clerk 4. Electrical Inspector
6. Other
Contact Person: — Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emp�loyees.
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
receivo,r'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 c i hapter 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 commonwealih f�r any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(l) 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 th is 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
nec6sary, supply sub-'contractor(s) name(s), address(es) and phone number(s) along with their certificate('s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carTy 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 I 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 �'afl 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-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
tom i irmoR i c ur LIADILI I T INOUKAMA: 1111712014
'no cEFmRcA-rE 6 IMMIED AS A VATM OF RFMIIATION OWY AND COMM NO IRMIM UPON THE CERTFMTE HOLWR THIS
CERTIFICATE DOES f= AFFIRIFATN&Y OR NEGATIV&Y ARM, Mam OR ALTER THE cmmm AFFORDED By imE Poticies
-BELOW. THIS CERTWMTE OF M1911RANCE DOES NOT CONSITIME A CONTRACT SEMEN THE LSSUM INSIMERIA). AUT14ORIZED
ORPRODUCER.AND '1111ECEFITIFICATEHOLMR
IMPORTANT: U the ceMcateholder is an ADDITIONAL INSURED, the pollWies) ;jWt be enddrsea if suBRor.AmON IS WAIVED, subject to
the.tenns and conditions of the poflcy� ceftin policbs may require an end6rsemeft Astawnent on this. certificate does not confer rights ti6 the,
cerblicate holder in lieu of such endomenient(s).
PRODUCER
Dumo & Jankowski Ins Agcy LLC
198 Massachuseft Avenue
North Andover, MA 01846
Dum6 & Jimkowsid-Im Agcy.
ADIX
PHONE
1k
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PRDDUCM
CUSTOMERIDy.,LEBLA-4
INSURERMNFORDINSCOVERME NAIC#
INSURED Jerry LeBlanc
9 Atkinson Depot'Road
Plaistow, NH 03865
A
muRER9;Pm%ffed Mutual Insurance Co. 15024
msumme.The Hardlord
NGM -insurance Co 114783
Imsumm):
MSURERE:
INSURERF:
1%F1MFf('-AT9 NI IMPR- REVISION NUMSER!
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 WM RESPECT TO WHICWTHIS
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 MALY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
!YPE OF 89PJPAUM
ADIX
SUIW
POLICYNU111BER.
POUCVEFF
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Lem
B
CENERM LLABILJTY
X cowmRcm GENERAL Lumm
CLVMS4K4DE r -V-1 OCCUR
BOP0100717134
015(01120114
0901=5
EACHOCCURRENCE $ 300,001
W"Yr-ETORENTW S 100,01
PRMISESCEaomummm-)
MEDEXP(Anyampenm) $ 5,00(
PERSONAL&ADVOMURY S 300,00(
GENERALAGGREGATE S 600100(
GEN'LAGGREGATE LWAPPLIES PER:
PRO.
r] POLICY F]JECT F I toc
3 600,00(
-PRDOUCTS-COW]OPAGG
D
AI)TOMOMMUMLITY
ANYAUTO
ALLOWNEDAUTOS
SCHEDULEDAUTOS
X HIREDAtrios'
X NoN-amEDAuTos
BIB27M
01104=5
01110401116
COMBINEDSKGLELWr 600,000
- waaaw"
8mILymmy(PWPmm) $
PROPEMDAMAGE-
(PERACCIDEIM
S
$
UKkUUAUA13
EXCESS UA13
HCLARASMADE
OCCUR
EACH OCCURRENCE
AGGREGATE
DEDUCTIBLE
RETENTION S
C
--I
WORI(ERSOOMPENSAMON
AND EMPLOYEW UABRM YJ N
ANYPROPRIETORMARTNEREXECUTIVE [y)
OFR
(Mandmory m mm
if desaft
DNS'd=ON
NIA
SSSOU82E34123414
M06)2014
W861201S
qTH-
ER
ELEACHACCIDEUr 5 100,000
EL DISEAM-EAREWPff-4 $ 100,000
F-LDISEASE-POUCYLMr $ W01000
DESompnoN OFOPERATIONSILOCATION81VEHIC1.0 VUt=hACORD10IAddff0" Rom sdm*dqVnm65P=&I5m4dnW)
sole proprietor :Ls excluded :Ercm 1work coverage
Sainple for bidding purposes
SAMPLEI SHOULDA . W OF THE ASM MMCREM POLICIES BE CMCELLED BEFORE
THE ExPiRknom DATE mimmm, mornm wiLL BE DELIVERED IN
ACCORDANCEVVITH THE POLICYPROVIIRION&
I rk
........ .
alatift
-of Consunier Affairs &.Business Reg'
MCC - \ . TRACTOR I
lMp.-ROVFMtNT CON Type*
cjistration:
individual
XPI ion: -
C
jERky,
3ERRY
ATK� SON DE 0 R
W, NH .. 03865 Undersecretary i
PLAISTO
Massachusetts - Department of Public Safety
. Board of Buildt rig Regutat . ions and St andards,
Construction Sup�tVisff Specialt 04
,---tiqense: CSSLwO99633
-jERRY'P LEBLANt
9 ATIONSON DEPOT,ROAD,
Plaistow NH 0386-5
E xpiratio n
10/1512015
Comn�issjoner