HomeMy WebLinkAboutBuilding Permit # 3/2/2015 Carbonless a a
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BUILDING PERMIT of �t�eo ,g'I+
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION A _
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Permit No#:�,'10J"-6 Date Received
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Date Issued:
IMPORTANT.Applicant must complete all'items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 00ne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
>f Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: S ' ,�"c arc d s°��o. � Phone:
Address:
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ARCH ITECTIENGINEER "' Phone:
Address: Reg.rNo,.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S,F.
Total Project Cost: $ ` f 61V6, 'FEE: $/ k c ✓
- Receipt.No.: _ _
Check No.:
NOTE: Persons contracting with unregistered contractors do not,have access to the g aranty fund
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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-$1000 fine
NOTES and DATA— (For department use)
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❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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Carbonless NC 318-50 3 PART
PROPOSAL
R. A. Le LANC PROPOSAL N0. ._� z CARPENTRY & REMODELING
10 HID AWAY LANE ,�
SHEET N0.
METHUEN MA. 01840
975 655 5922 DATE
PROPOSAL SUBMITTED T O: WORK TO BE PERFORMED AT
NAME
ADDPkSS
°"o Cam Ad C,'t /i01 4.
DATE OF PLANS
PHONE N0. M _w �e 7A_r_"Tr.�,—
� ARCHITECT
We hereby propose to furnish t' . and perform the labor eces.sanj for the completion of �T
ve e ih f`7"-1�0_ tl 9749rL
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All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi-
cations submitted for above work and completed in a substantial workmanlike manner for the sum of
— - Dollars ($ ✓_ �- _ )
with payments to be made as follows.
Respectfully submitted J/Pj?y
Any alteration or deviation from above specifications involving extra costs
will be executed only upon written order, and will become an extra charge Per
over and above the estimate. All agreements contingent upon strikes, ac-
cidents,or delays beyond our control.
Note---This proposal may be withdrawn
by us if not accepted within days.
ACCEPTANCE OF PROPOSAL �- -
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work
as specified. Payments will be made as outlined above.
/ / Signature
Date c% ��° ! Signature -
- —
N artment of Public Safety
{ Massachusetts -Dep
Board of Building Regulations and Standards
Construction Supergisor
License: CS-074027
v RMW A LEA,
10 IH 111DRAWAY LANE ;s
METIWFrq MA X184
s •,t,�` Expiration
06/2512016 .
commissioner
'a = �G�A9ti1,77f1?ltllCfZ��/7 �
O �i (LJ5C1n�t;�/K.
Office of Consu�c)rita�rs �3us�n�c fi uTtar%x.
W T'C NT kACT(i
e9isfraU 175303 tyi}�e
� Zj ration 513/209
a��iARD A LEBLANC_ , •,
t
� Cl LARD. LEBLANC
AWAY DANE
RiH EN,MA 01844
Un&rsecrefxry_
® ® 02^27-15; 10: 15AM;TL_Southmayd 19786889542 ;9786570201 # 1/ 1
1 ® DATE(MM/DaYYYY)
4coRO CERTIFICATEDF LIABILITY INSURANCE
`�• � 2/27/15
THIS CERTIFICATE IS ISSUED AS A MATTER OFINFORMATION 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 INURED,the policy(ies) 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).
CONTACT
PRODUCER NAME:ME:
T L Southmayd Insurance Agency PHONE 978 657-0263 FAX No): (978) 657-0201 JAIrl Na 668 Main St, Suite 9 E-MAIL
ADDRESS: louise @tlsins.com
Wilmington, MA 01887 INSURERS)AFFORDING COVERAGE NAIC#
INSURER A:Preferred Mutual
INSURED INSURER B
R A Leblanc Carpentry & Remode INSURERC:
10 Hideaway Lane INSURER D.
Methuen, MA 01844 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I SR ADOL SUBR POLICY EXP
M/DD/Y
LTR TYPEOFINSURANCE 1 POLICY NUMBER RRdlDDIYYW LIMTS
A GENERALLIABILITY BOP0100717536 5/25/14 5/25/15 EACH OCCURRENCE $ 11000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE 70 RENTED $ 100,000
CLAIMS-MADE FI OCCUR ME EXP(Anyone person) $ 10,000
PERSONAL&ADV INJURY $ 11000,000
GENERAL AGGREGATE S 2,000,000
GEN'LAGGREGATELMITAPPLIESPER PRODUCTS-COMP/OPAGG $ 2,000,000 B,1
POLICY PRO- LOC $
DSINGLEL
AUTOMOBILELIABWTY aaccideri $
ANYAU70 BODILY INJURY(Per person) $
ALLOWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS NON-OWNED PROPERTY DAMAGE $
HIREDAUTOS _AUTOS eraaiderd
$
UMBRELLAUA6 OOCUR EACH OCCURRENCE $
MESS LIAO CLAIMS-MADE AGGREGATE S
DED RETENTION$ $WC WORKERS COMPENSATION OR STATUS 0TH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $
(OMandabry In NHS)EXCLUDED?
E.L.DISEASE-EA EMPLOYE
If as,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMR $
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 01,AddiUdonal Renarks Schedule,if more space isregui red)
Fax : 978 688 9542
Job Site: 407 Wood Lane , North Andover
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE ;WILL BE DELIVERED' IN
Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS.
AUTH D REPRESENTATIVE
L ui' e� Ma � m
01988-2 10 RD CORPORATION. A11,0gliEsireserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail:
The Commonwealth of Massachusetts
Department oflndustrialAccidents
0 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LeLyiblV
Name (Business/Organization/Individual): f J �' i. e � ��>� c-_
Address: i ' ���� ���f � 4,4,,,e
City/State/Zip: /11.C_1 Phone#: l -_7d'
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.1Q 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. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑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 11.❑Electrical repairs or additions
proprietors with no employees.
12.F]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.❑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 employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i 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 wor/fens'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 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 hereby cer ' under the pains anopenalties ofpeijuty that the information provided above is true and correct.
Sijznature: � �/ Date:
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#: