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HomeMy WebLinkAboutBuilding Permit # 4/21/2015 Of OORTfi BUILDING PERMIT T F THANDOVER � � APPLICATION FOR PLAN EXAMINATION Permit NO: 0 �_ Date Received �w � Date Issue IMPORTANT: Applicant must complete all items on this page / ,.,, r r IIAP N ► PARCEL r //r r„l ' ( N11IC%CPI't T MIt 'I -� to t itr� I c me 'h p r,age TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ©'One family E]Addition ❑ Two or more family [J Industrial ❑Alteration No. of units: a Commercial R'Repair, replacement F1 Assessory Bldg ❑ Others: I I Demolition EI Other E] "pt 1.1/11 11 n Floodpilaim '� Wetlands 'El, Watershed; ) tri t C_1;�l1/aite'r/ �rV�r /f� 9 Ind Identification Please,Type or Print Clearly) OWNER: Name: � � t, Phone ��� `.., Address: r ,r r �^'� rrrrrrrrrrrrrrr r ,,,. %,,,, ��' ,r rri rr ,r rr rr rr r /. / %,/// �/ � ,� / % / ,, r/�, �/ /r � r r . , i rrrrrrrrrrrrrrrrrrrrrrrrrrrr ,,., ' r r�• r � i�;/,�o�/� �/���%l/; „r;--/%� Ali/// �,//%%G / /i,,,,:/ /iriiiii 2`1 %. �,�� ICIi"If1 ICl"I � UYtftf `� II1e EXE„ fat / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 01 Total Project Cost: $ 13, 540 FEE: $ Check No.: '7 Receipt No.: -) 6; &. `"�_ NOTE: Persons contracting with u egistered contractors do not have access to the guaranty fu d Ile 14 ignatur of Agent/OwnerSignature of contractors ,, F t4®RTH Town of2 s �, Andover ® ® ' _ �` QQ LAKE n ver? a 477 �p cocmkc"tw.C. F� ®RATE® !'���,Z�S , U BOARD OF HEALTH Food/Kitchen P �ERMIT T LD Septic System if� aBUILDING INSPECTOR THIS CERTIFIES THAT ................... .... . .. ........... ....... .1/.r,�......j1.. 01es"900 Foundation has permission to erect ........ buildings o ......... .......... .................. Rough to be occupied as .... ., ...................... ......... .. .. .. ........................................................ Chimney provided that the person acc pting this permit shall in every respe nform 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMITaft EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS s TI Rough Service .. .......................... ........................ Final BUILDING INSPECTOR GAS INSPECTOR ccupancV Permit Required t® Occuy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' No Lathing all oBe Done FIRE DEPARTMENT Until i s ecte and Approvedthe Building Inspector. Burner Street No. Smoke Det. .1 . ,1 AdLL. D l'IY.'tl ER.AJ'b...I C T. :`d.A C„,1W RS, INC. 27 PRISOLLAWAY PFLI A , Nil 03076 TEL. 603.635.7008 FAX. 603.3 86.6009 6.60 4/21/15 Louis and Kathleen Capobianco 280 Middlesex Street North Andover, Ma 01845 Re: Roof and Front Porch Following price covers all labor and material to: Remove existing roof and replace with timberline architectural shingles. Replace existing porch, frame will be pressure treated with composite deck. Estimated time of completion is May 8, 2015. i Job Complete: $ 13,500 Contractor Homeowner The Commonwealth of Massachusetts Department of lndustrialAccidents „1 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 PERAUTTING AUTHORITY- Applicant Information Please Print Lep-ibl Name (Business/Organization/Individual): Address: t I City/State/Zip: lm /Y H OW9Phone,#• 03 S_ Are you an employer?Check t&appropriate box: Type of project(required): 1.N I am a employer with 1 t employees(full and/or part-time).* 7. []New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in $. [1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 [J Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1Electrical repairs or additions proprietors with no employees, 12•b Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.®Roof repairs These sub-contractors have employees and have workers'comp.insurance) )?00(" n 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.F51 Other t G t P 152,§1(4),and we have no employees.[No workers'comp.insurance required.] tl / *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-cori•tracfors have employees,i$ey,must provide their workers'comp.policy number. Xttin an employes•thai is providingworkr rs'compensation insurancefor my employees'Below is the policy andjob site information. Insurance Company Name: ! ,a e° Z Policy#or Self-ins,Lic.#: C l Expiration Date: o'� Job Site Address: lda,les ie City/State/Zip: ! to 4 _ 63kv-61 . f 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 WORD.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 DTA for insurance coverage verification. . p � � J yinformationp' � nd correct, Ido hereby certify under the gins ani elraltles o r'ur that the provided abov is true a Sr nature: . Date:je " Phone#: Official use only. Do not lvrite 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#: IMG 1374.jpg(JPEG Image,2048 x 2048 pixels)-Scaled(40%) https://web.maii.comcast.net/service/home/—/?auth=co&loc=en US&... o„ Jr ! rr 10t v owl i,) / / qr u ' !W" 4/18/201.5 5:22 PM 1 of 1 a.. ."�"`� ^��/�c-�`cYc�rvrrr�rs�rt�e�rr�l�c�/����rlurc�rar�!✓.z .. ........ Office of Consumer Affairs&Business Regulation rOME IMPROVEMENT CONTRACTOR egistration: 137349 Type: xpiration: 10/30/2016 Private Corporatir BRUSSARD GENERAL CONT.INC. STEPHEN BRUSSARD 27 PRISCILLA WAY PELHAM,NH 03076 Undersecretary AC"RV CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DD/YYYY) 314/2015 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 CT 376 SUMMER ST PHONE Fax FITCHBURG, MA 01420-0310 No Ext: A/c No);_._ E-MAIL _ ._._._—... ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# iNSURERA: LM Insurance Corporation....... 33600 INSURED INSURERS: DOUGLAS MERCIER -- DBA ECONOMY CONSTRUCTION INSURERC: 232 PATRIOT DRIVE INSURERD: PELHAM NH 03076 _.---.__-----...._..----...------- ---- — INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 23695041 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 SUER POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1:1 OCCUR DAMAGES( RENTED CLAIMS-MADE -PREMISES occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT D LOC PRODUCTS-COMP/OP AGG $ OTHER: $ - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-386689-014 8/11/2014 8/11/2015 STATUTE EOR AND EMPLOYERS'LIABILITY - - Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? � N/A ---- (Mandatory in NH) EJ__DISEASE-EA EMPLOYE $ 100000 if DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 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 BRUSSARD GENERAL CONTRACTING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 27 PRISCILLA WAY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PELHAM NH 03076 ACCORDANCE WITH THE POLICY PROVISIONS. 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 .al,C"RV� CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 3/2/15 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 CONTACT NAME: C. DiPaoli Choice Insurance Agency, Inc. PHONE ---- FAz--- ------- 376 Summer Street (AJQN (978 343-4853 r No: (978) 345-1007 ADDRESS: peter@choice-insurance.com Fitchburg, MA 01420 INSURER(S)AFFORDINGCOVERAGE NAIC# _ ........_._. INSURERA:Main Street America Assurance 29939__ INSURED INSURER 8 Doug Mercier DBA INSURER C: Economy Construction INSURER D: 232 Patriot Drive INSURER E: I NSU ---- Pelham, NH 03076 INSU 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. INSR ADDL SUBR POLICY EFF POLICY EXP ---- — LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER M/DD/Y MM/DD/YYYY LIMITS A GENERALLIABILITY y MPT5404E 5/13/14 5/13/15 EACH OCCURRENCE $ 100 000 G X COMMERCIAL GENERAL LIABILITY E DAM" ISE (Ea E TO RENTED ace $ 500,000 _- CLAIMS-MADE I-XI OCCUR MED EXP(Ary one person) $ 101 000 PERSO NA L&ADV I NJU RY $ 11000,000 GENERAL AGGREGATE ..$--2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY x JE LOC $ AUTOMOBILE LIABILITY GO �NEINEEDSINGLELIMIT(fHaacride $ ANYAUTO BODILY INJURY(Per person) $ ALLOWIED SCHEDULED BODILY accident) (Per AUTOS AUTOS 80D _ $_ NON-OWNED PROPERTY DAMAGE HIRED AUTOS _AUTOS eraocident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY ITS FP ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCI DENT OFFICERMtEMBER EXCLUDED? � N/A If (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ I yes describe under — .-._- — DESG�RIPTIONOFOPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,ifmore space Isregdred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Brussard General Contracting ACCORDANCE WITH THE POLICY PROVISIONS. 27 Priscilla Way Pelham, NH 03076 AUTHORIZED REPRESENTATIVE Linda Baker ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: brussardoc@Comcast.net "TRUSS-1 OP ID:WC TI ILIABILITYI DATE(MMIGD/YYYY) 12/04114 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 978-975-1300 CONTACT Se reve&Hall Insur.Assoc.Inc 305 North Main St. 978-975-7596 PHONE E-- Andover,MA 01810 MAIC Ext): - --- (AJC,_No): - ADDRESS; INSURER(S)AFFORDING COVERAGE NAIC it INSURERA:Arbella Protection Ins.Co. _ 141360 INSURED BPUSSard General INSURERB:GUard Insurance ------- Contractors Inc t __.._ 27 Priscilla Way INSURERcc_ - �— Pelham,NH 03076 INSURER D: — 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. INSR TYPE OF INSURANCE r f --_ -- POLICY EFF POLICY EXP - - LTR GENERAL LIABILITY POLICY NUMBER I NIM/DDNYYY MM1DDMfYY LIMITS IiI ! I ( EACH OCCURRENCE S 1,000,000 _DAMAA L X COMMERCIAL GENERAL LIABILITY ITBI 11/04114 ( 11104/15 O RENTED 300 000 t—� PREMISES(Ea occurrence) S , ((! _f . CLAIMS-MADE OCCUR I MED EXP(Any one person) 5,000 —,- ----- I ` PERSONAL&ADV INJURY ,$ 1,000,00 -- (GENERAL AGGREGATE $ 2,000,00 AGGREGATELIMITAPPLIESPER: IPRODUCTS-COMP/OPAGG $ 2,000,00�GEN'L POLICY J I JE CT LOC I I S AUTOMOBILE LIABILITY ! ! i COMBINED SINGLE LIMIT -- IP Ea accident Is ANY AUTO i I i i BODILY INJURY(Perperson) 1$ ALLOWNED ��SCHEDULED # i - — � AUTOS AUTOS ( t ( !BODILY INJURY(Peraccitlent) S I HIREDAUTOS I NON-OWNEDAUTOS I PROPERTY DAMAGE S '—j (Per accident) is I f UMBRELLA LIAR OCCUR J EACH OCCURRENCE 5 ij EXCESS LIAB I ---- _. I CLAIMS-MADE AGGREGATE S DED I I RETENTIONS w 1 F i S WORKERS COMPENSATION @ AND EMPLOYERS'LIABILITY 1 1! I ITQRY LIM TS ER_! B ANY PROPRIETOR/EXCLU R/EXECUTIVE Y�1 , �8RWC563080 12/01/14 � 12!01!15 I E L EACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? N/A+ � ( - , (Mandatory in NH) if I IL DISEASE-EA EMPLOYEES 500 000 If yes,describe under _ DESCRIPTION OF OPERATIONS below I I I EL DISEASE-POLICY LIMIT S 500,000 DESCRIP71ON OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ' CERTIFICATE HOLDER CANCELLATION 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 1 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD