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HomeMy WebLinkAboutBuilding Permit #914-14 - 475 MASSACHUSETTS AVENUE 6/13/2014bU1LU1NU VLKMI i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: �A I IMPORTANT: Applicant must complete all items on this page LOCATION Y s 4 � l e rPrint PROPERTY OWNER D D "7� Print MAP NOL PARCELr ZONING DISTRICT: Historic District Machine Shop. Villaae �9SSACHUS i� yes t no yes k no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial [VAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Q.Septic 0 Well, ❑ Floodplain 11 Wetlands ❑° Watershed District ❑ Water/Se er r S%1)n-1. T f/ P,*i i e' I-111ce ,Q Identification Please Type or Print Clearly) OWNER: Name: V P4 /7 J 011C CeAt7e- _ Phone: Address CONTRACTOR Name: Phone:�,� f 7� Address: e_11 a Supervisor's. Construction License: Exp. Date: Home Improvement License: 13 5 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATErD� COST BASED ON $125.00 PER S.F. Total Project Cost: $ �� FEE: $ c10 Check No.: 7-961 Receipt No.: oZ-7 NOTE: Persons contracting with unregistered contractors do not have access to �guar"ty fund Permit No#: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received . N p-Sttec ,6�°ryO\ ,] _ 4 • / 7.0 A�AATEO "PP�'�5 I IMPORTANT: Applicant must complete all items on this pane I LOCATIQ4 PROPERTY' MAP' _ _ _-PARCEL: Z-ONING DISTRICT: Historic yes rio yes no. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition 0 Two or more family 0 Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic.. 0 Well EIFloodplain 0 Wetlands ❑ Watershed District DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: ARCHITECT/ENGINEER Phone: Address: Reg. No. a FEE SCHEDULE: BULDING PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. t Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner, S' gnature of contractor: � __ 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 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 Doc: Building Permit Revised 2014 d' . , R 0,-.-1.s Plans Submitted ❑ Plans Waived E 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS s 0 Reviewed On Signature_ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comme Conservation Decision: Comme Water & Sewer Connection/Signature & Date Driveway Permit i DPW Town Engineer: Signature: F Located 384 Osgood Street FIRE DEPARTMENT - Temp ,Dumpster on sits yes. _ 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 Nu 1 CJ ana UA I A — p -or department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Locati( Y75 - No. 6�1 Ll — ILI - Date TOWN OF NORTH ANDOVER C ertificate of Occupancy $ Building/Frame Permiffee Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 27,630 Building Inspector 06/13/2014 12:52 9787443575 �o ©� CERTIFICATE OF G T MCCARTHV PAGE 01/01 DATE IMM/DD/YYYY) LIABILITY INSURANCE 10511312014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 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, certaln policies may require an endorsement. A statement on this certificate doe's not confer rights to the ..:rr..are hnldar in Ilau 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 SALEM MA 01970 INSURED LEBLANC & SON LLC P O BOX 5389 HAVERHILL MA 01835 CONTACT Deb Toumas __ NAME:,._—...--.—.—..--__—..---- —.. _ -- _—_I —_--- ..._...__ PHONE 1!978 744.5433 1PAX (978)-.7.44. -3575 (AICA Ng E- K ( ) .1(A/C. NoL_ _.._ .. ...__7 _..—.. E-MAIL debblet@gtmccarthy.com PRODUCER 35$2 INSURER(S) AFFORDING COVERAGE NAIC 0 — INSURERA : SAFETY INSURANCE COMPANY INSURER B : LIBERTY MUTUAL INSURANCE COMPANY INSURER C _ INSURER E LINSURER F COVERAGES CERTIFICATE NUMBER: 25341 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 ALLTHE TERMS, - --------- nein nr emne INSR ADO'Ll SUER TYPE OF INSURANCE I LTR.. __ NSR _%A D._ POLICY NUMBER ._—_ .._— _.—_. ._._—_--_.._—._ __—. A GENERAL LIABILITY I BMA0003851 COMMERCIAL GENERAL LIABILITY 08103!14 `CLAIMS -MADE ) X IOCCUR GEN L AGGREGATE LIMIT APPLIES PER: ---- f POLICYPRO- ... .---1-JECT._._! .LOC------ ---- L--- "--- ------ {I�-X_I AUTOMOBILE LIABILITY i BMA0003851 ANY AUTO . •P}7EMISES ALL OWNED AUTOS LIAR OCCUR SCHEDULED AUTOS I -� X HIRED AUTOS MED. EXP (Any one person) I POLICY EFF _._—LMwJ Mr"—yy)— POLICY EXP AMMIPWOOFYI� LIMITS _—. ._._ .. -- 08103113 08103!14 EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED $ 100000 EACH OCCURRENCE . •P}7EMISES (Ea-occurencj_--- LIAR OCCUR I MED. EXP (Any one person) S 10,000 EXCESS LIAR CLAIMS -MADE I PERSONAL & ADV INJURY $ 1,000,000 AGGREGATE GENERAL AGGREGATE f I $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 RETENTION $ .__....__ --- ---' ------ .------... ...--- I .. $ -----13 09128/13 - 09!28/14 08!03113 08103!14 COMBINED SINGLE LIMIT $ 1 000 000 ' ' I (Ea accident) 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE _.. OFFICER/MEMBER EXCLUDED? NIA I I ---------"----" —"---" E.L. DISEASE -EA EMPLOYEE 1,000,000 ---- ---- - 500,000 (ManOFFICER/M oNHl .. _ atory It yes, describe under BODILY INJURY (Per person) $ ....--... _..—_... ..._—.._--.-�.__.. E . DISEASE -POLICY LIMIT ._._....... I ...—__.. ..__._... 500,000 DESCRIPTION OF OPERATIONS below BODILY INJURY (Per accident) PROPERTY DAMAGE $ i $ ----------- (Per accident) —_-_- $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is requiredl LAWRENCE LEBLANC AS LLC MEMBER IS NOT INSURED UNDER WORKERS' COMPENSATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Attention: h T ur CORD 25 (2009!09) ©1988-2009 ACORD CORPORATION. All rights reserved. rw,. Arnon ria -1 Innn nra rPnisfarPrl marks of ACORD X NON -OWNED AUTOS $ EACH OCCURRENCE JUMBRELLA LIAR OCCUR I EXCESS LIAR CLAIMS -MADE I I AGGREGATE JDEDUCTIBLE - — RETENTION $ .__....__ --- ---' ------ .------... ...--- I .. ---- -- -----. .—... ----� WC531S352552012 -----13 09128/13 - 09!28/14 I. -- --$. . __... 7 STA'tLI- OTH TORY LIMITS- ..._... ......_.. (3 I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN I I _�_ .— .--.._—_.....EFL_... ___..... E.L. EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE _.. OFFICER/MEMBER EXCLUDED? NIA I I ---------"----" —"---" E.L. DISEASE -EA EMPLOYEE ---- ---- - 500,000 (ManOFFICER/M oNHl .. _ atory It yes, describe under I ....--... _..—_... ..._—.._--.-�.__.. E . DISEASE -POLICY LIMIT ._._....... I ...—__.. ..__._... 500,000 DESCRIPTION OF OPERATIONS below ----------- DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is requiredl LAWRENCE LEBLANC AS LLC MEMBER IS NOT INSURED UNDER WORKERS' COMPENSATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Attention: h T ur CORD 25 (2009!09) ©1988-2009 ACORD CORPORATION. All rights reserved. rw,. Arnon ria -1 Innn nra rPnisfarPrl marks of ACORD v C � o 0 Z y CD O CL o Q �• y O vCD CL % C — CD CD � O � CD a o °. � v O o o � O CD m -v m cn Z a� z '_'^ V+ n=$ c U) co = :5. CD N O CD C CD 0 0 � Q- PO 0 O =r �N T fA ,�� CD O O rt O. n W � CA 0 CD CD CD EL2)N CL -1 CD cc rD rD �* z O C O N �+ m M a m � r0 O OU S CRD CD >. CD 'a O m S 0 0 c� ' 5. O co S C W H � �' _S 7 o O 3 CL p =m 0, s rt 0� a a 0 2 m D 2 O 0 �� CL � Q. < N <D ' o �2)Cn � _CDCL. W rch :v � `D :� 1 su coo O � rt rt CD CD CnC �D� ID �N vCD <D •a rt �. � O Q C gloom s s i Vf U) co T Z7 T V) PO T w T n ;7 T VI T O 'T (D CD rD rD �* z O C O N �+ m M a m j O OU S a N N m rl 0 >. (D F) O m S m m Z N m m 0 5. O co S C W H � �' _S 7 O m S O 3 CL p =m C ° G1 z m 0 (D �. n Ln 3rl O O_ \ n s rD 3 0� a a 0 2 m D 2 0 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor ¢ License: CS -090414 LARRY J LEBLA'* PO BOX 5389 _ � BRADFORD MA -70183,05W, Expiration Commissioner 01/28/2016 ��e �Poa�an�za�zcocri/�/z, o���/%jcriJruc�coreCl� Office of Consumer Affairs & Business Regulation OME IMPROVEMENT CONTRACTOR egistration: 1'3'5829 Type: I xpiration: 5/14/20,16- Individual LARRY LEBLANC LARRY LEBLANC 33 MEDITATION LANE ATKINSON, MA 03811 Undersecretary t Page No. of Pages LESUNC._AMD SOM , , P.6. BOX 5389 BRADFORD, MA 01835 (9?8) 556-9440 (970) 069-6575 CELL Elc. OCSOS0414 tic . 0135829 rAwMeblAncand=axeam PROPOSAL Stfa'MITTEq;Y '� � PHONE DATE * / �� t } STR �/? 04,04 JOB NAME CITY, ST,Qfi`C�`ancj�ZIP�O �� 114V� eO%4//j3,/ l�gf,/f ���, /t� JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE fV, / Wle.PropOSe hereby to furnish mAteriala q,d`I bor — comple in agcor;d"nce with above specifications, for the sum of: OZ dollar Payment -to be made as lows: All material is guaranteed to be as specified. All `Work to be completed in a workmanl' manner according to standard practices. Any alteration or deviation from above specifics' ns Authorized involving extra costs will be executed only upon written orders, and will become M_, Authorized Signature charge over and above the estimate. All agreements contingent upon strikes, accidents orOF delays beyond our control. Owner to carry fire, tornado and other necessary, insurance. Our /by : T is proposal may be workers are fully covered by Workman's Compensation Insurance. ;with raw, s'Pnot accepted within days. Acceptance of Proposal—The above prices, specifications and conditions are satisfactory and are hereby accepted. You re authorized to do the Signature . work as specified. Payment will be-m,ade as ou ined �r Date of Acceptance: Signature J u The Commonwealth of Massachusetts Prirlt Form Department of Industrial Accidents LV Office of Investigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name Address: (T 0 Phone #: ,.f C__1 Are you an employer? Check the appropriate box: 1. 9-1 am a employer with 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.: 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' comp. insurance rectuired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 L❑ 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. 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 -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:L� �i�� Policy # or Self -ins. Lic. #:_ (&C, "Jl J 3 Sv��6 ��-(��y Expiration Date: Job Site Address: 4175 �'/1 S /J l�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. provided above is true and correct