The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 4/7/2015 BUILDING PERMIT taaRrti �I TOWN OF NORTH ANDOVER O :. APPLICATION FOR PLAN EXAMINATION ° Date Received Permit No#° arEp P � CHUS Date Issued: IMPORTANT: Applicant must complete all items on.this page I r „ a��l l Mach�"ne�Srl op � a e gip' �r I i ,i "„. ,.,II l4ar�r Lv aykr a,Vrrvma IW um ,� a rn uy �mmm ,�so�m,as ii i TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition a, llw:�l �Y�i� n�r�rr Ix xoASS,& ❑ er ,",�"�� ,�^",°��©We ( ' ooprI TO BE PERFORME ° �� / �.. " DES IPTIO OF WOR .,� �' " Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: E�Cp� Date ARCHITECT/ENGINEER Phone- Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F_ Total Project Cost: $ FEE: $ Check No.: Receipt,No :* , NOTE: -Persons-contracting-with,unregistered contr, - ors do-n h c' ess-to-the -uaranty and i 7 r r r, ; rr�l/T„ rcc,✓r ,, .,/�/ / n r r i/ / r!r/'r //� r /, ..Iiinr�,rr „rypinir/iii, , ,//d!i / i'//'�, �/�/ l/J✓ ai // i/r yr r, % !1/, rr, /i�//, /„//r„��/i%rt;, i NORTH Town of . t T.11., ndover No. - I� � Z C h ver, Mass, COCHICHEWICK y1. Z1,9 A°R^reo S fJ BOARD OF HEALTH Food/Kitchen PER IT T D Septic System tj BUILDING INSPECTOR THIS CERTIFIES THAT ......... .460%4........Le.... ....�.... J........................................... Foundation has permission to erect .............. buildings on ....... �", ............ 31. ......... ... .'.R4........ ................ ...... .. .. �� Rough t0be occupied as ........&M.�........... ........... .......... ................................................................. - Chimney provided that the person accepting this permit shall In every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN NT ELECTRICAL INSPECTOR UNLESS CONSTRUCT4n . Rough lcam� Service ............ ................................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. t Page No. of Pages (�,. s 23 (97 s ,.,,amu• i Vo r ,fefr f t3�9 r`3 vr�r f PROPOSAL SUBMITTJED TO PHONE DATE (\� "}1")I�V STREET ! 1 4 JOB NAME } )t € r CITY STATEYand ZIP CODE I JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: < s rr t j• f.�s I �• (` 0I �._4! i 1 fi�+ .. �l yVr o0l- ��bl 41-1), IJ I f1_3_110 11 j'KA 1 d V l {k t! (�_Y— (�,- f i V 1,..,� moi.._.f4. f .,r I �� (1.11 G jlt . 5 t.! 6 U ) icy ,_ i t fir? t i) _ V k 6 E I K JLJ�_� We Propose hereby to furnish material and labor— complete in accordance with above specifications, for the sum of: ------ Ax If t( dollars( j ) JPayment to be made as follows: i { �7 All material is guaranteed to be as specified. All work to be completed in a workmanlike manner accordingto standard practices, An alteration or deviation from above specifications Authorized P Y P Signature involving extra costs will be executed only upon written orders, and will become an extra g 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 Note:This proposal may be workers are fully covered by Workman's Compensation Insurance. 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 Signature ; work as specified.Payment will be made as outlined above. % � �• °' Date of Acceptance: , _� �� Signature The Commonwealth of Massachusetts Department of IndustrialAccidents - 1 Congress Street,Suite 100 Boston,MA 021142017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lel=ibly Name(Business/Organization/fndividual): ON ll'V,�n o"\ Address: 17 �,)_ c �� City/State/Zip:'�I lNv\�n Phone#( Q1A a Are you an employer?Check the appropriate box: Type of project(required): 1,E]I am a employer with employees(full and/or part-time).* 'J. F1New construction 2.rg,1,"aim a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.F1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 Demolition ❑ 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.E]Plumbing repairs or additions 5. 1 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,E]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. tContractors 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 worlrers'compensation insurance for•my employees. Below is thepolicy and job site information. Insurance Company Name: C it O :Ck,- SNS V 1-%0(.,Q_ Policy#or Self-ins.Lie.#: fh Pas -) 0 9 � Expiration Date: S- l 3 - 1 S' Job Site Address: 3 Q -Tr, ei'k4 S:�. City/State/Zip: l�pl_ G 1' ' i_,•M A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). k 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 heretify under the pains and penalties ofperjury that the information provided above is tare and correct. Si natur8c� 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#: Massachusetts -.Department of Public Safety Board of Building Regulations and Standards Construction Supe"Visor Specially License: CSSL-100972 Douglas R Mercier 232 Patriot Drive ' � ( Pelham NH 03077 " } ✓� —��- _ " "� Expiration Commissioner 06/17/2016 Restricted To: CSSL-RF-Roofing CSSL-WS-Windows and Siding Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS i 0 3 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite S 170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 125404 Type: Individual D _ Expiration: 12/512015 Tr# 2456D4 X :< o Douglas Mercier ,.s Douglas Mercier 232 Patriot Dr. - - Pelham, NH 03076 - - `Update Address and return cared.Nlark reason for change. ❑ Address C Renewal E] Employment. f J Last Card SCA1 Ci zun.-writ ':J�� r%L'IIL•7,�tOi2U_;E(7-SCJ?-f•�✓l�flSd¢Cf;1(;iHrIJ . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only -, - ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: l e istratiom :925404 Type- Office of Consumer Affairs and Business Regulation 9� � xpiration:.:r:.12151209s. Individual lOPark Plaza-SuitzS170 Boston,AIA 02116 Douglas Mercier Douglas Mercier m 232 Patriot Dr. Pelham,NH 03076 Undersecretary- Not valid without signature (A lD -0 3 'U 4/7/2015 8:46:05 AM PST (GMT-8) FROM: 100005—TO: 19786889542 Page: 2 of 2 74/7/2015 E(MM/DD/YYYY) A�® CERTIFICATE OF LIABILITY INSURANCE 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(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). PRODUCER CHOICE INSURANCE AGENCY INC NAME:CONTACT 376 SUMMER ST PHONE FAX FITCHBURG, MA 01420-0310 MALL Exl: A/C No: ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: LM Insurance Corporation 33600 INSURED INSURER B: DOUGLAS MERCIER DBA ECONOMY CONSTRUCTION INSURER 232 PATRIOT DRIVE INSURERD: PELHAM NH 03076 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 24161696 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD MLD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO CLAIMS-MADE F-1OCCUR PREMISES EM SES Ea occur ence $ MED EXP(Any one person) $ '.. PERSONAL R ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECT PRO ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION $ A WORKERS COMPENSATION WC5-31S-386689-014 8/11/2014 8/11/2015 / STER ERH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXE -U Y/N E.L.EACH ACCIDENT $ 100000 '.. OFFICER/MEMBER EXCLUDEM Y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Dyes,describe under 100000 DESCRIPTION OF OPERATIONS below 500000 E.L.DISEASE-POLICY LIMIT $ j DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR DOUGLAS MERCIER. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers'compensation coverage CERTIFICATE HOLDER CANCELLATION ROBERT LEYLAND SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 312 TURNPIKE ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 24161696 CLIENT CODE: 1614443 Didi Dangas 4/7/2015 11:43:35 AM (EDT) Page 1 of 1 04/06/2015 10:50 9783451007 PAGE 01/01 ;�IJS?Fn® CERTIFICATE OF LIABILITY INSURANCEDArM(MMIDIYYYYY) 4/6/15 THIS CERTIFICATE IS ISSUE13 AS A MATTED OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMA vELY 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($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITION INSURED, the Po Icy(iss) must be endorsed. If SUBROGATIO 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), PaouuceR NA MT Peter C. Dipacla choice -Insurance Agency, Inc: PHONE g78 343-4 3 FA 1978) 145-100 376 summer Street .M�AAl�(, Fitchburg, MA 01¢20 A06r.1 eter@ohoiae-insurance.COm INSURE b AFFORDING CQV�RAGE NAIC# INSURED INSURERA:Main Street America Assurance 29939 • ' INSURER 0. Doug Mercier DSA INSURER C! Economy'ConatxVicytion INSURER 0- 232' Patriot 'Dr'ive INSURER E: Va1ham, NH '03076 IN6URERF.- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED.NAME:D ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHrR 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 OFSUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ' R TYPE OFIN9URANCE POLICY NUMBER µ MNIIDDM- MM(nGnYv�y UMITg A GENERAL LIABILITY Y MPT5404E 5/19/14 5/13/15 EACHOCCURRENCE X COMMERCIALGENERALLIAOILITY DAhRZffM RENTED S 500,000 CLAIMS-MADE �OCCUR MED E7(P( ry ore Person) $ 10 000 PERSONAL&AbVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 0EN'LAGGRECAT5LIMITAPPLIE8PER PRODUCTS-COMPlOPAOG $_2 000 OOO POLICY X 'PR LOC S AUTOMOBILE LIABILITY COMBINEDSINGL L aaccderk 3 ANYAUTO BODILY INJURY(Por peBon) S ALLOWN_D SCHEDULED __..........._...._._.._...._ AUTOS AUTOS eODILY INJURY(Per accident) S HIREDAUTOS _ WNEO eAUTOS cASraYl $ 1.111MRRU.ALIAB OCCUR • EACH OCCURRENCE $ EXCESS LIAB CLAIMS•MADL= AGGREGATE $ DED - ENTION B $ VJONKERS COMPENSATION WC STATU• 011'H1 EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER(EXECUTNE YIN E ,EaCHaCgoENr OFFICERMEMBER EXCLUDED? N!A '.. (Mandatory In NH) I( E:L.DISEASE.Eq 0 E 8 ee desG190 under D 9CRIPTIONOFOPERATIONSbelow E.L.DISEASE-POUCY LIMrr ffi DESCRIPTION OF OPERATIONS I LOCATLONs Ivr;HOLEO (Attach ACORD 101,Addldonal Renvrke Schedule,if mora apace la regtired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF 171E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERRD IN Robert Leyland ACCORDANCE WITH THE POLICY PROVISIONS. 312 Turnpike St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Ancrela Tarr . m 1988 2010 ACORD CORPORATION. All rights reserved, ACORD28(2010/05) The.AC ORD name and logo are registered marks of ACORD Phone: Fax; (978) 688-9542 fE-Mall: