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Home My WebLink AboutBuilding Permit #54 - 780 FOREST STREET 7/25/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received L byN\ S d 'SS H Date Issued: -01 7 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building tvOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial �Y,Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ell,.. OWN 1",N i w3" , w .s ^:.,% ". c✓a.' i z �,,:u 3,/n. Z.Y3., i "i DESCRIPTION OF WORK -JO B PREFORMED: -5/ fns. UJ;43,,rl,�'S kvo' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ �; ZZ— Check No.:y�"� Receipt No.: 02 o r'1 NOTE: Persons contracting with unregistered contractors do not have access to the,&arants,4un'd , Signature of Agent/Owner Signature of Location-7kU �euy X7— No. 5x, Date�— NORT1y TOWN OF NORTH ANDOVER F A Certificate of Occupancy $ �— CMUs � Building/Frame Permit Fee $ ✓� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 204.j2 __ Building Inspector J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS ■❑ DATE REJECTED Stamped Plans ❑ DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Prvate (septic tank, etc. ❑ Permanent Dumpster on Site ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connecti Located at 384 Osgood Street cyly/7 7 L 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 2 1 A —F and G min.$100-$1000 fine Nu i is ana UA I A — o -or ciepartment use ❑ Notified for pickup - Date 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 Com (davit ❑ Photo Copy f H.I.C. nd/Or C.S.L. Licenses ❑ Copy of Contrac ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products 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/ 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 s. (U;00 O 'G 0 s.. w O O v u o e a z A ,a C G neo as a no O w a U ►-� w m a°' cm w � a d C7 m m w w w P -WG w a cA o z +� V) v Q cn MCD s c � O O c H ' � C v C� d C R A CO C ;t O O L N CD E c 0 �= w .. : 0 a E c t� m c cooi CLO" c J C � � C � a ' a W CD 0 m NOWCD CD m CDo R ,r oa CA Ca. J2 CJ ca wS C ` .. F— � Q � y m c = m a= p H O CL F— y rr to m •O.. O w LL m y c .ca y •O �" m c W .E ��c�o, V� O' 0 Joe CD O � _ �0y'= c . a. .'.. m m US iA N c cm m oc os c CID O cp C c N CD Z w O Z O J 0 co O E c L O V Z C. O y D � ICD Ccm O•— G3 p O y O •— m m O co CL �- 3� O �G3 0 O a CL a O_•+ C t� O CO3 C Z G3 CL C.7 H � � C C C _cc 0. CO3 0 LLI U) 19 W LLI ce w C4 DATE (MWDDIYYYY) ACORDTM. CERTIFICATE OF LIABILITY INSURANCE � 0712612007 ODUCBR PROM, 19 6174444aa Fw.. (976)744-b67s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GERALD T MCCARTHY INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 92 NORTH ST ALTER THE THIS GIECATE DONS AFFORDED 807 AMEND, eEL OR P O BOX 839 SALEM MA 01970 INSURERS AFFORDING COVERAGE NAIL M 1■ _,... .._....._. INSURER k SAFETY INSURANCE COMPANY INSURED......_.— LAWRENCE LEBLANC INSURERS.. .._ _..,_�..._ .._.. P O BOX $309 INSURER C 14AVERMILL MA 01835 INSURER D unTurtTUCY1Nf11NP TME POLICIES OF INSURANC LISTED BELOW HAVE BEEN ISSUIcU IU IMt IMOVKCN NAI"QV --1 I �� ^� �- - -- -- - OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR SHOULD ANY OF THE ABOVE OESCRISED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMEO TO THE LEFT. BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILMY Or ANY KIND UPON THE INSURER. ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH ITS AGENTS OR REPRESENTATIVES. POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. . .... .... ... _. .. Attention: ---_.... ... ._.... NBR A00'L Type Of INSURANCE ppLR;Y NUMBER POLICY EFFEG7P'C �� POLICY 6X►IAATIOR LIMITS LTR N9RD GENERAL LIA m 15/100003051 06103108 08/03/07 EACH OCCL/RRENCE Q.0 To i EPOICO '100,00_0 X COMMERCIAL GENERAL LIABILITY) DAM s PgEMptESQt1000W?M!I , ,. MED. EXP (Any one Demon) I iY 10,000 CLAIMS MAGE I X OCCUR - - PERSONAL 6 ADV INJURY ~f _ 1,000,000 GENERALAGGREGATEf _ 2,000,000 GEN'L AGGREGATE LIMB APPLIES kit: PRODUCTS-COMPIOP AGG. f 2,000 000 _ ..._ ,J POLICY . I PRO- �.._...._.- LOC' AUTOMOBIL! LIABILITY COMBINED SINGLE LIMIT I $ ANY AUTO �tEaALTJdenll ALL OWNED AUTOS j BODILY INJURY I (Per person) f SCHEDVLEDAUTOS HIRED AUTOS I BODILY INJURY f I (Per eccw4 tl NON -OWNED AU706 -` ..._.. j . —�-- .... .-.... DAMAGE S 1P ACdeN1 GARAGE LIABILITY I AUTO ONLY - EA, ACCIDENT I f „ • „_� -, „ ,_ ANY AUTO OTHER THAN EA ACC _ .__�„�• _•!-.`_ AUTO ONLY: AGO f EXCESS I (ARBRELLA LIANV" EACH OCCURRENCE f OCCUR CLANS MADE � AOOREOATE t DEDVCTIBLE RETENTION 6 s WORKERS COMPENSATION AND ! ro_arTi MATS I OTHER . -.._ EMPLOYERS' LIABILITY �..... E.L. EACH ACCIDENT i f ANY PROPPUETORTA"TMWoxecUTWE OIf1eElk#M9EEA EXCLUDED? I I .. .. .._•••_ .-... .: _. .�..__........ E.L,WSEAfE•EAEMPLOYEE f ...-..-.- NECIAL PRONalON Wow E.I. OISEASE-POLICY LIMIT S OTHER: I D RIPTION OF OPERATiONS/LOCATIONS/VEHICL XCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS ANG, GUTTERS, DOWNSPOUTS INSTALLATION JOB: SCOTT BLANEY, 780 FOREST $T, NO ANDOVER, MA CERTIFICATE HOLDER [.AN[:FI.1 ATlnlJ TOYYN QF NO ANDOVER bftHALL 1800 SHOULD ANY OF THE ABOVE OESCRISED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMEO TO THE LEFT. BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILMY Or ANY KIND UPON THE INSURER. NO ANDOVER, MA ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: ��b'e6bFalh T`�/�� AWKU LD (LUVI/VB) LienII1C8LB S z3UB 0 ACORD CORPORATION 1i88 -1-1e 'glow ONS PERv1SOR oflp- i3OP�p NS�RVCT\ 4 CO 9041 senses CS 0 g0414 be' p8 }, s cte4 ARK I� Snb. .i comm�551 21 VE N��-� MP HP Board of Building Regulations and Standards i HOME IMPROVEMENT CONTRACTOR Registration; 135829 Expiration: 511412008 Type. ; individual LARRY LEBLANC LARRY LEBLANC. 21 WINGATE ST. #704 Deputy Administrator HAVERHILL, MA 01831 • • Pages Page No.' of LEBLANC AND SON P.Q. BCCA 53$9 BRADFORD, MA 01835 1254 (978) 556-9440 ;978) 869-€575 CELL Lie. #CS090414 Reg, #115829 www.isbiancandson.com PROPigALSUBMITTE e ONE DATE involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or STREET withdraw JOB NAME CITY,'STA.Tp anIP CO Acceptance of Proposal —The above prices, specifications JOB LOCATION F Jo Signature work as specified. Payment will be made as o4ined above •. L" ARCHIT CT Date of Acceptance: cTx f DATE OF PLAN JOB PHONE We by submit specifications and estimates ®r: tlg;�t a^e .r Vr- above specifications, for the sum of: doAars 6 `` All material is guaranteed to be as specified. All work to be completed in a worknlike AuthorizE manner according to standard practices. Any alteration or deviation from above specifIcations Signatur( involving extra costs will be executed only upon written orders, and 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 and other necessary insurance. Our withdraw workers are fully covered by Workman's Compensation Insurance. Acceptance of Proposal —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the Signature work as specified. Payment will be made as o4ined above •. L" Date of Acceptance: cTx f Signature Name (Business/ anization/Individual): Address: �Ie> &) City/State/Zip: d&4� eez //Yffs phone #: / 79R--�? 65 - Are S Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts 4. ❑ I am a general contractor and I Department of Industrial Accidents have hired the sub -contractors Office of Investigations listed on the attached sheet. 600 Washington Street These sub -contractors have Boston, MA 02111 c� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contrac Name (Business/ anization/Individual): Address: �Ie> &) City/State/Zip: d&4� eez //Yffs phone #: / 79R--�? 65 - Are S Are you an employer? Check the appropriate box: 1'C1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or pa -time).* have hired the sub -contractors 2. ❑ 1 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition. 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks boz #I 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date: �% Job Site Address: / �v �� 1° City/State/Zip: if �%✓� CfAze`� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). l 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. I do hereby cert ur the Ed iOAFA0 of perjury that the information provided above is and Date: Official use only. Do not write in this area, to be completed by city or town official, City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 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 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 Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, 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 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 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 "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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 07/25/2007 10:09 9787443575 GERALD MCCARTHY INS PAGE 01 Gerald T. McCarthy Insurance Agency, Inc. P.O. Box 839 - 92 North Strati Saletn, MA 01970 978-7446433 - Fax 978.144-3575 July 25, 2007 Town of "North Andover 1600 Osgood Street No Andover, MA Re. Lawrence LeBlanc -Liberty Mutual Pol# WC231 S352562015 Dear Sir: Enclosed please find a certificate of insurance as evidence of liability coverage for the above mentioned. By law, certificates for workers' compensation insurance must be issued by the assigned insurance carrier; therefore, we have faxed a request to the above mentioned company to issue a worker's compensation certificate of insurance which they will mail directly to you. In the meantime, please be advised by us that this coveragc is, in fact, presently active for the period of 9/28/06-07. 1 hope you will find everything in order; and if you have any questions, please feel free to call. Sincerely, Deborah Tournas dt