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HomeMy WebLinkAboutBuilding Permit #858-14 - 52 LACONIA CIRCLE 5/25/2014TOWN OF NORTH ANDOVER / (,� APPLICATION FOR PLAN EXAMINATION / / Permit NO: Date Received Date Issued: �� 2A 1 IMPORTANT• Applicant must complete all items on this nage LOCATION L --A c -®,S, , ;A C, Print I ' Print MAP NO: I LPARCEL: !q ZONING DISTRICT: TYPE OF IMPROVEMENT ❑ New Building ❑ Addition ❑ Alteration Repair, replacement ❑ Demolition �'Sepfic 0 Well; 4 - PROPOSED USE Residential e family ❑ Two or more family No. of units: ❑ Assessory Bldg ❑ Other N Historic District yes no Machine Shop Village yes ro 100 year-old structure yes o ; DESCRIPTION OF WORK TO BE PERFORMED: Z-{ 0YC C S % �Lv � (Identification Please Type or Print Clearly) OWNER: Name:��, . d?'- -0 / 'T�r. Address:_ a L ,,A,,,, t Non- Residential ❑ Industrial ❑ Commercial ❑ Others: D' WatersfiediDstnct+. , ak "tzf CONTRACTOR Name: �..P,t� 6,.v Z4� �,� Phone: L? -7 9 S Address: �. 3 1R, L.LJ ��� �� �Q (0 v O Y Supervisor's Construction License: Exp. Date: Home Improvement License: - / (.) 1) 3 1 Exp. Date: 6 - --)- 3--- 9 1-( ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT.• $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $_1 & L Q 0 0" FEE: $_ 1cfe 60 Check No.: -IF17 Receipt No.: V;;1619 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �ignature`of Agent70wner _Signature�of3contractor, �.. 34.31 r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swnnmmg 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 DATE REJECTED 11 DATE APPROVED 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 Conservation Decision: Comme Water & Sewer Connection/Signature & Date Driveway Permit Y ti DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street yes no 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 department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 NOTE: 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/Crossection/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 NOTE: 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 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: Doc.Building Permit Revised 2008mi Location �� c 0 V /,(-" r" /,Ile No. -/ Check # �,5-7 Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $— TOTAL Building Inspector J = LL O m yi \ -6 O LL Em N ?O N U ',�,. O. N O N z Q z C 'D C 3 LL t bybq =1= W N C U LL O z z m J d t = C LL O N z a u � u W J W t by 7 i= vz U > ch ll.. cr O a Z N L to =. = — C LL N W w a W LL N O L ca �. N `) (% v Y O (n r o VWa o amz Z O m coZ W w a w H W a a 0 �i w N Z v v E Z L 0 V a U 0 _ _ O R � O •� L Q �a . O O \`•4t �: +�' yam.+ E �?-0@ COD� � J c1 N — C 0 .foo z d CL _ ,- N O o 3 IA tm O = _ NCL2m �y- W_ _ +r O O N EL O :E �+ r W C.1 Q N O > w= C 2 F- � t = O O. 0 U Z O m coZ W w a w H W a a 0 �i w N Z v v E Z L 0 V a U 0 a tr9`rt ipp �,� yY LqYa, ' i %k'3T t t �f.•�"F`�d%+["�`�.v 7�.{ r��'`r��w Sxi.Y F{ychtli@tiffPArtmqnt Of Public lr ! a. 0 qr i J,� Y1 s5�t� / r' r IttKYJ >�A�►� Qt @ulldfnp.,RQpulAtion:Rnd Stan��►d� � ,wt„r � ��) ,.�, ,� '4011-trUou//n►►QQ.(un*146r n d � E 11 i rl}1 r'tl ^j �igonse: MlTM� Y."� rr - �'ytf f y.• Xd EXpirstion Canmit+t;ionor. : //. .• •• .. ;,�f� �a�r'��t<t Fit.`_„•:_ ='•=• f)Iticc of G,unsumrr rlffulrg & lfusiness Reeululiun 1,I1'e11SN UI' registration valid for�indrividu i . '�^1�jOME IMPROVEMENT CONTRACTOR beforN t11N Nxpiratlon date, if T I use unty f eglstratign: 100t}11 found return to: Expiration; 6/23/2014 Typo' OtTicN of Consumer Affairs ane! Business Regulatiun •r:i” Pfival9 Corpgratior, 10 Park Plaza • Suite 3170 LEN GIBELY CONTRACTING CO., INC• Ruston, MA Q2 110 - Brian Dobbins 23 R WINTER ST. PEASODY, MA 01900�— Un4lersocrclary 744'l Not yallttur0, . ........+nr,,,,y.a.ayut,.u,MMw.f4�I..'^.��Y3=lWIV•1Mw4ry w.... ... ... •, y • ...+w. f t ' Ij r � LEN GIBELY CONTRACTING CO., INC. 23R Winter Street PEABODY, MASSACHUSETTS 01960 (978) 531-8234 Fax (978) 531-9304 www.lengibelycontracting.com submittedTO 2 L,OA co -A, c. G_ru� -- Page No. _/—Of / Pages qr;FRa PROPOSAL All home Improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-8598. Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c. 142A. PHONE REGISTRATION NO. (rl ��� ��2� cAT� �/ MA. REG. 100811 JO. 7 JOB LOCATION OB NAM We hereby s bmit specifications and estimates for work to be performed and materiaIto be used: _..��;.Jt _c _ G 4q �'._6uer- � -�c� -�aa� �_l.,P-�o��� �� ,_a�'o��► --- �C_�'_ re�ezP�a�_ _.. _ Ulf X 3 ` _--lo_A - �5-�—p�- j�G ��C�I--.- P,�t� o-�-✓Pr��-Pd O u�J ..� �0_ _P_ CU Quc �P� - - _ Construction latep rmds:, LRrd17iM'fA M,L Pro UI.A_ lopl 0V 14, WORK SC E QL JN Contractor i t b work or order the materials be re the third day following the signing of this Agreemeh nt, unless specified herein y 1 ractord ;ill babe Ownerrhe eb about (date). Barring delay caused ximcir stances beate and that such (iolay thatond larelor's control. Inot avoidable by the contractorlha I nloted cynsidered as v' I(' sof this Agreement. acknowle ge n agree that the scheduling dates aro app WARRANTY tollowin completion and shall comply wit The Contractor warrants that the work furnished hereunder shall be tree from defects in material and workmanship for tr period o 9 P t sryearrafterncompletongot any fob! including ncleab up,el�he Conin tractor shall, aOf rt his ownaterials expe sego thwi h emtedy, epair, Contractcorrtect, r p ace, otrr cause employees bee remedied. epavlad, or r paces such damage or such detect in materials or workmanship. The foregoing warranties shall survive any Inspection performed in connection with the agreed-upon work. We Propose hereby to f}lrnis� I -ial d I or - l mpiete in ccordanc with bov specifications, for the sum of: l�/ TG (� r 1 r i �i "A dollars ($ Payment to be made as follows: ($ ] upon signing Contra ?P G0 ($• I ) upon completion ' % ($ ) upon completion f------ - - ' ( shall be made fore -with upon $ ) completion of work under this contract. Notice: No agreement for home improvement contracting work shall require •+ down payment (advance deposit) of more than one-third of the total contract prp e nr the total amount of all deposits or payments which the contractor must make, ,n advance, to order and/or otherwise obtain delivery of special order materials and equipment, "'^hev�r amount is greater. Name of Contr; Street Address City/State Phone / d Registrant Pho ederal to No. proposal may be withd/(wn try us it not accepted within di Acceptance of Proposal I have read both s des of this �,cument and accept the prices, specifications and conaltlons staleu. 1 wwo - that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined abovE You, the Buyer, may cancel this trans.nction at env time prior to midnight of the third business day after th date of this transaction. Cancellation must bt. c'v ne in writing. DO NOT SIGN THIS CONTRACT IF THERE AR Y BL NK SPACES. r Signature Data Signature - " - -- IMPORTANT INFORMATION ON BACK Aco O CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD(YYYY) �� 07/26/2013 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(les) 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 016U.001 Edward F Sennott Insurancej 16 Fi��C. South Main Street - - --tL No•: Topsfield, MA 01983 �G COVERAGE ^— - ---INSURFR A, A.I.M. Mutual insurance Company 33758 iNSURED Len Gibely Contracting Company Inc -- INSURER—• _ _._.__ 23 Winter Street Rear INSURER C ---- --- Peabody, MA 01980.6941 INSUR envFoer_ac .....,�....,..�.... 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. ILS TYPE OF INSURANCE - 1 Il POLICY NUMBER LW11TS GENERAL LIABILITY - __-.__.__�_._ EACH OCCURRENCE $ COMMERgAL GENERAL LIABILITY AM FJTED - $' ' CLAIMS -MADE ❑OCCUR PREMISES (Ea occuirfatcal MED EXP (Any una poison) PERSONAL S ADV INJURY i --- _..... 0,11 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE b _ __1_� PRODUCTS - COMP/OP AGG $ - etE UMI j ---" AUTOMOBILE LIABILITY ANY AUTO - BODILY INJURY (Pel person) _ ALL OVMIED SCHEDULED BODILY INJURY (Per acadant) f - AUTOS AUTOS MIRED AUTOS^ SWIJED Pk0--PDAMAGE(Per acc*dantl S -UMBRELLA LIAR OCCUR �— EACH OCCURRENCE _.._.._ EXCESSLIAB CLNMSMADE - — -- - - -- AGGREGATE f RREgTpENTION $ s ---- pDED 0 ���LOYERS LIABi X TORY UAN7S A ECUTIVE N �Id��d NIA VWC-1005010879-2013A 8/312013 8!3/2014 E.L. EACH ACCIDENT { 500,000.00 E.L. DISEASE - EA EMPLOYEE i $00,000.00 (Muntlddutory In NM��){{�,,,�� •- �t-JLRI N �F OPERATIONS babes -__ E.L. DISEASE - POLICY LIMIT 5 500,ODU.0 J DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is vequimd) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION. All rights reserved. 1&v ,vrvv1 I ne AWKU name ana logo are registereO marK$ of ACORD AC.ORQM CERTIFICATE OF LIABILITY INSURANCE PRODUCER 978.887.4900 FAX 978.887.2404 Edward F. Sennott Insurance Agency, Inc. 16 South Main Street N. 0. Box 457 Fop sfield, MA 01983 t;SURED Len Gibely Contracting Co., Inc. 23R Winter Street Peabody, MA 01960 DATE (MMIDU/YYYY) 02/06/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE _ NAIC # INSURER a Catlin Specialty_ Ins_u_r_a_nce Co INSURERS: Safety Indemnity _ 33618 INSURER C: INSURER D: INSURER E: :;OVERAGES 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 RFnLICFn RY Paln rl nIUQ I 512 IR r pD' IANSR[] TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDD/YYYY POUCY EXPIRATION DATE (MWDDNYYYI LIMITS I GENERAL LIABILITY X l COMMERCIAL 3700302145 01/29/2014 01/29/2015 EACH OCCURRENCE 0 RENTED $ 1,000,000 -- -$ 100,000 - - - -5' ---- i --- GENERAL LIABILITY CLAIMS MADE AOCCUR PREMISES Ea occurrence -- MED EXP (Any one person) $ U00 q PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE ...__ $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: j. . - $ 2,000,000 PRODUCTS - COMP/OP AGG n ------- POLICY E LOC AUTOMOBILE UABIUTY 6221693 COM 01 01/29/2014 01/29/2015 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) _ 1,000,UUu' ALL OWNED AUTOS - 1 I X SCHEDULED BODILY INJURY $ AUTOS j i (Per person) X HIRED AUTOS X j BODILY INJURY i NON -OWNED AUTOS (Per accident)— - - PROPERTY DAMAGE $ (Pe(accident) r GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ t ANY AUTO -'- OTHER THAN EA ACC $ AUTO ONLY: AGG EXCESS 1 UMBRELLA UABILITY EACH OCCURRENCE $ — _J OCCUR (� CLAIMS MADE AGGREGAI E $ r� DEDUCTIBLE $ - RETENTION $ $ WORKERS COMPENSATIONA - T - - AND EMPLOYERS' LIABILITY YIN - _TORY LIMITS I I ER $ — - ANY I'ROPRIETOR/PARTNER/EXECUTIVE� OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT (Mandatory in NH) ityeS, de6<XiLe Under SPECIAL PROVISIONS below E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER ----- i _:� -roof of insurances CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRAl1ONI DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS W RI r I er, NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE Robert Sennott/RP ACORD 25 (2009/01) © 1988-2009 ACORD The ACORD name and logo are registered marks of ACORD PORATION. All rights reservea. •INThe Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Ndnic(Busiuess/Organizatioa/Individual): Lam, e42 C7 i i2a L. y Cci.tenzA C' e�✓ 6 C' Address: Q 3 ., W k,.� L .e >'z. city/State/Zip:_ pPhone #: 9 9 8 -- S71 \ S a. 3 Are yuu an employer? Check the appropriate box: . ( 1 aan a employer with �-� 4. [] I am a general contractor and I employees (hall and/or part-time)." have hired the sub -contractors ❑ 1 tull a sole proprietor or partner- listed oa the attached sheet ship and have no employees working for me in any capacity. [No workers' comp, insurance reyuircd.J 5• 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance., We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' coma. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs oi- 1 1. D r11.❑ Plumbing repairs ur ud i:t:6: 12.❑ Roof repairs 13.❑ Other__ appliccntt duct checks box #1 must also fill out the section below showing their workers' compensation policy utfonuation. iumcownrn who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new ailidavit indicating sari: untractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have c,npioyees. 1f the sub -contractors have employees, they must provide their workers' comp. policy number. I um an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site rn f ur�ruitiurr. li_surancc Company Name: �, � (�1 v % L AL --I: C p ---------- 1'o:icy 4 or Self -ins. Lic. #: t2 D j 09 q O I Expiration Dater ,:,t; S;tu Address -__5 L n r >— LA City/State/Zip: 4 � vrtncli a copy of the workers' compeusatiou policy declaration page (showing the policy number and expiratiuu tl:A F i:; lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pcnaltics u, 1mc up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and -,i C ii-: oi. up to $250.00 a day against the violator. Be advised that la copy of this statement may be forwarded to the Office of' Investigations of the DIA. for insurance coverage verification. 1 du hereby certify ander the pains and penalties of perjury that the information provided above is true and correct. S.wnature: r � --�9--'— Date: Phone it Ojjirial ase only. Du not write in this area, to be completed by city or town of Ual. lf i 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. nspector6. Other _ Contact Persuu: Phone #: _.