HomeMy WebLinkAboutBuilding Permit #986-2016 - 521 PLEASANT STREET 3/22/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
TYPE OF IMPROVEMENT
PROPOSED USE
Residejitial
Non- Residential
0 New Building
1p6ne family
El Addition
[I Two or more family
11 Industrial
El Alteration
No. of units:
0 Commercial
El Repair, replacement
0 Assessory Bldg
[I Others:
0 Demolition
[I Other
--ell
70 Wat6-rsh ed Qistrict
E]_Mter/�wer_
DESCRIPTION OF WORK TO 13t PtKtUKMtU:
- ION I —' hot/ f e /,."p �'A
Identification - Please Type or Print Clearly
OWNER: Name: J fonaf,,;1i Phone:
1
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ i A 00 60 FEE: $ l.,2c7,-
Check No.: 11 6V Receipt No.: '3_� /Vo
NOTE: Persons contracting with unregistered contractors do not have a�W to the guarantyfund
Building Department
The following is a list of the required formls to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehaibilitation Permits
Building Permit Applicatio,
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 I Engineered products
OTE: All dumpster permits require sig i off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Applicatioln
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract I
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
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
,& Building Permit Application
4, Certified Proposed Plot Plan
4. 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
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
lin 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
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans F1
TYPE OF SEWERAGE DISPOSAL
Public Sewer
well
Private (septic tank, etc.
Tanning/Massage[Body Art F1
Tobacco Sales 11
Permanent Dumpster on Site F1
Swimming Pools
Food Packaging/Sales 0
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
Planning Board Decision: Comments
Conservation Decision: Comments
�1�
Water & Sewer Con nectio WSLcLnature & Date Driveway Permit
or
DPW Town Engineer: Signature:
Located 384_9sgood Street
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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.$100-$l 000 fine
Doc.Building Permit Revised 2014
Location '5.171
�"& .2&1,
No. d
Check # //0 ?-
D ate
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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10 14,
#4
• Boofing
• Siding
Jerry P. LeBlanc
• Gutter
• Painting
9 Atkinson Depot Road
• Ca.rpentry
Plaistow, NH 03865
• Windows
Home (603) 382-0817
• Snowplowing
Cell (978) 835-7740
Page No. - of Pages
PROPOSAL AND ACCEPTANCE
Construction Supervisor Specialty License
Ucense: CSSL -099633 Restricted To: RF WS
Tr#: 51777 Expires: 10115/2015
Home Improvement Contractor
Re-aistration: 149881
Expires: 2116/2016
rr.%jr%jaAf. zutsivil 11 tU jU
PHONE 71
7 7
Z 014
STREET
JOBNAME
CITY, STATE AND &CCibE
JOB LOCATION
�4 14 IV 41C
`ARCHITECT
DATE OF PLANS
JOBPHONE
We hereby submit specifications and estimates for:
94 C�a a, K-A,,M-4
oqj i4m L 4Aa_x�d�_-611014 E
940. ez. gal
41) jatorll�/_r_ ;I
e"
Start within days
Complete in 30 days.
We Propose hereby to furnish material and labor — complete in accordance with above s ifications, for the suff I:
1%e
Payment -to be macro s`f6flows dollars (Sr
le r LA._X e4l fat, J --
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 Signature C4- 4 41, - 9A
will become an extra charge over and above the estimate. All agreements contingent
upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado N4. This p4posol"may be
and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within days.
pensation 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. Payment will be made as outlined above. Signature
Date of Acceptance Signature
The Commonwealth ofMassa.chusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, AM 02114-2017
. . . . . . . . . . . . . . . .
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu.mbers.
TO BE F11LED WITH THE PERNUTTING AUTHORITY.
Name
Address: ?4Ja1^r,?A
City/State/Zip: P&,�f 5" Phone #: 7-7Z2�&
Are you a ployer? Che�k tbe appiriopriate box:
Type of project (Tequired):
1, [1 amaemployerwith employees (Ul and/or part-time).*
7. F1 New construction
2.FJ I am a sole proprietor or partnership and have no employees working for me in
8. Remodeling
any capacity. [No workers' comp. insurance required.]
9. F1 Demolition
3.0 lam a homeowner doing all work myself [No workers' comp. insurance required.] t
10 F1 Building addition
4.FJ 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
I L. Electrical repairs or additions
proprietors with no employees.
12. E] PI bing repairs or additions
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
. .
1�. roof repairs
These sub-contractor*s h6 e er�ployees and have wo rkers'comp. insuranceJ
t I 1 1
6. n We are a corporation and its. officers , have exercised their right of 'exemption per MGL c.
14. Other
152, §1(4), and we have no�e loye�s. [No workers' comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submif Us affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
fContractors 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-co'ntractors have employees, ihe� inust provide their workers' comp. policy number.
I am an employer that ispiovidiiig workers' compensation insurancefor my employees.' Below is thepolicy and)ob site
information.
Insurance Company Name: tz
Policy # or S elf -ins. Lic. L) Expiration Date:
Job Site Address: 4.ce,,�
S.� IV -014J Citv/State/Zil):
Attach a copy of the workers' 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 verification.
I do h ereby certify under Ili e pains an dpenalties ofpeiju ry th at th e information provided apove is true an d correct
Phone #:
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. 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 employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contrdU 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 enterprise, 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
Plea'se fill- out the workers' compensation affidavit completely, by checking - the'boxes that apply to your situation and, if
necessary, supply sub-contractoi(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 carry 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 Depaitment of Jhdustrial
Accidents fb� confinnation 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 o*r if you'are re'q*ed to obtain a Workers'
compensatiod'policy, please call the Department at the number listed below. Self-iiisur6d companies sh,ould'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
poll' information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or
CY
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
I 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
rv1FRALFR4K JONEILL
CERTIFICATE OF LIABILITY INSURANCE
12f112015
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, W(TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SL AUTHORIZED
REPRESENTATIVE 0 R 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 torms and conditions of the policy, certain policies may require an endorsemeft A states. ent on this certificate does not confer rights to the
certificate holder in lieu of such endorseme!�[S;).
PRODUCER
Durso & Jankowsld Insurance Agency
11 Sounders Struet
CONTACT
NAME:
PHONE
M ,, (978) 688-7000 N.). (97S) 688-7001
E,M
A DD%6_
North Andover, MA OIS46
INSURMS) AFFORDING COVERAGE IWC#
0510112016
INSU A: Proferred Mutual Insurance Co. 16024
DAMAGE
- TO RIEN IED $ 100,00
PREMSES(Eaocagrence)
INSURED
tNSURM 0: MSA Group 14788
Jerry LeBlanc
RERc: Hartford Insumnce Co.
INSURERO:
9 AtItinson Depot Road
SURERE:
Plaistow, NH 03865
Fit SURERF:
COVERAGES - CERTIFICATE NUMBER: -REVISION NUMBM
THIS, IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT M ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. umrrs SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
- TYPEOFINSURANCE
ADUL
INSO
POLICY NUMBER
POLICY EFF
POLICY EXP
WoMmar"M
LIM"s
A
X commetriAL GENERAL LIABILITY
E Fx
CLAIMS401AD OCCUR
BOP0100717134
0610.112016
0510112016
EACH OCCURRENCE $ 300,000)
DAMAGE
- TO RIEN IED $ 100,00
PREMSES(Eaocagrence)
EXP (Any one permn) $ spa)
-MEO
PERSONAL& ADV INJURY S 300,000
Geri. AGGREGATE L - IMIT APPLIES PER
PRO -
POLICY F� jEcT D LOC
OTHER:
GEN84AL AGMGATE S 600,000
PRODUCTS - COMPIOP AGG $ 000,000
AUTOMOBILE LIABI - LITY
ANY.A�UTD
ALL OWNED SCHEDULED
AUTOS AUTOS '
NON -OWNED
x- HIRED AUTOS AUTOS
B182756S
0110412015
01104r2016
COMBINED SINGLE LIMIT S -500,000
BOOLYUCIURY(P-P—) S
BODILY DWRY (PermicleM 3
PROPERTYOArM—GE S
(Peraccident)
UMBRELLA LIAB
MCCESS LIAB
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE - S
AGGREGATE S
OED RETENTION$
$ —
.0
WORKERS COMPENSATION
AND EMPLOYERSLIAStLITY YIN
ANY PROPRIETORIPARTNI"-�U'
OFFICERIMEMSM EXCLUDED?
IMandatofy in NH)
If ye% descrbe under -nONS below
DESCRIPTION OF OPERA
NIA
LUOUB204123415
0810612016
0810612016
ELEACHACCIDENT S 100,000
IEL DISEASE - EA EMPLOYEE S 100,000
E I DISEASE - POLICY LIMIT, $ 500,000
DESCROMONOFOPERATIONSIIOCATIONSIVEHICLES (ACORD101.AddI0onaIRWrdftSdWM N'tuch-domorespwalgrequired)
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�-ACORD 26 (2014101)
tw -1 woo-Aw M ~%or"r --- ----
. The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE VWLL BE DELIVERED IN
ACCORDANCE VM THE POLICY PROVISIONS.
AUTHOR22D REPRESENTAIM
�-ACORD 26 (2014101)
tw -1 woo-Aw M ~%or"r --- ----
. The ACORD name and logo are registered marks of ACORD
Massachusetts'Department of Public Safety
Ef6a . rd of Building Regulations and Standards
License: CSSL-099633
Construbtion Supervisor Specialty
JERRY P LEBLANC
9 ATKINSON DEPOT,ROA6'-1;,, J1,
PLAISTOW NH 0386
--A CA_
A Expiration:
Commissioner 10/15/20.17
allleluelz
Office of consumer Affairs& Bu
siness Regulation
OME IMPROVEMENT CONTRACTOR
P L E B LA g-
egistration: 1.49881
Type:
4 Expiration:����.2/J6/"201:,8,,
Individual
JERR Y N t 011�
BL
1,1JERRY LEBLANC §Vl�
9 9 T -
AT'
... KINSON DEPOT RD --7—
PLISTOW
A
�EAISTOW, NH 03865
Undersecretary
19