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HomeMy WebLinkAboutBuilding Permit # 6/4/2015 BUILDING PERMITt%oRT" TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 4( Permit No#:(p it Date Received ED SSq C Date Issued: 1 TANT: Applicant must complete all items on this page LOCATION -- 6" 5-S 6L, Print PROPERTY OWNER �,LVXE Print 100 Year Structure yes no M p PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building D One family 11 Addition [I Two or more family 11 Industrial El Alteration No. of units: -,JJ,,,dommercial 9-kepair, replacement El Assessory Bldg El Others: El Demolition El Other P"(11URT, 1, 0 1 01 0"'I'll"111ANI DESCRIPTION OF WORK TO BE PERFORMED: �� 0 AL� Q�, C'I R C- /09(" Identification- Please Type or Print Clearly OWNER: Name: '710k, i,1 I)d,,IC Phone: Address: '�.�Lj AJ, Z Contractor Name: Phone: &61 -- ues Email: Address: '5 W Afe 54 (kI L 41 11,k 6c� Supervisor's Construction License:- —Exp. Date: Home improvement License: t za),K,., Exp. Date: I ARCHITECT/ENGINEER Aj0je'7Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project COSt: $ & FEE: $ 57 Check No.:_ Receipt No.: r_� NOTE: Persons contracting with unregistered contractors do not have access to th5,gran' tyfund o iii iil IP5, am IrM M U-6-M—M—M—W tjORTtown of � 2 4 �. ..71, Andover A"h ® ..�.. �+ No. O ver, ass, � Y LAKE COC MICMEWICK 1• A°RATE® 111111117- BOARD OF HEALTH Food/Kitchen PtR ..MIT T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ........... ... .. . . . ........ ................�°:�....................... ................... Cothas permission to erect . . ...................... buildings on ..,5. ,�...... �111 (:t?,�4.1....... ......... ...,....... Foundation ® Rough to be occupied as .......... .�4 .......... ........ ....................................................................................... 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 6 MONTHS ELECTRICAL INSPECTOR - UNLESS CONSTRUCTI S TS Rough Service ................. ..... ... ............................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. PRODUCT 211 WHHRDONEE MU LOUIND p D Q' 432-6925 mmm JOB WORK ORDER 6'k s r E t 491.f ? I CUSTOMERS ORDER NO. DATE ORDERED ✓' i ORDER TA1(Eltl BY DATE PROMISED ❑A M BILL TO ❑ P.M. ' PHONE ADDRESS MECHANIC CITY �t 4 HELPER JOB NAME AND LOCA I1O w - - "5 ❑ DAY WOR"4 DESCRIPTION OF WORK " `""' ❑CONTRA.cT �'�' Y'S", d ❑EXTRA QUANT. DESCRIPTION OF MATERIP.L USEDPRICE AMOUNT o r � f e i � e e P e, r � n � m„ e r � _ r ..HOURS LABOR .� AMOUNT f MECHANICS @ TOTAL �IaTERQaLs HELrLk§ m, TOTAL J, _ LABOR I hereby acknowledge thesalisfactory" TOTAL LABOR completion of the above described work. TAX SIGNATURE DATE COMPLETED �.� TOTAL r '9 The Commonwealth of Massachusetts Department of Industrial Accidents 1 d I Congress Sty eet,Suite 100 Boston,MA 021142017 .�� www.mass.gov/dia Sys~ Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Legib Applicant Informationly Name(Business/Organization/Individual): � ► Address: 30 AblSbuA City/State/Zip: w Phone#: ` Are you an employer?Check the appropriate box: Type of project(required): 1.n I am a employer with _ ._employees(full and/or part-time).* 7. , construction 2. 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.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.F1 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.0 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.1 14.❑Other 6.0 We are a corporation and its officers have exercised their right of'exemption per MGL c. 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. X am arr employer that is providing war Iter^s'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t": //1 o'7- Policy#or Self-ins.Lie.#: 1 5� - & Expiration Date: r r Job Site Address: 5,5 l a t " -r City/State/Zip: Va M O -L- ""t 4 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. fp j y f p bove is true and correct. Z da hereby certify pains and penaltre a er ur that the rrz orrnatzon provided a ' under the Date: /. Si nature: 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#: From Elliot Insurance 1.603.296.4547 Thu May 14 11:53:36 2015 MDT Page 2 of 2 DATE(MM/DD/YYYY) ACCW"® CERTIFICATE OF LIABILITY INSURANCE 5/19/2015 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(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 CONTACT e Deborah Stanhope p Elliot Insurance Agency A Division Of PAHONE Ext: (603)497-4143 aC No; (603)497-2521 Stanhope Associates, Inc E-MAILss:dstanhope@elliot-ins.com ADDRE 11 North Mast Street INSURER(S)AFFORDING COVERAGE NAIC# Goffstown NH 03045 INSURER A MSA Group 29939 INSURED INSURER B Rive ort Insurance Com an Steven & Sylvain Lebel INSURER C: Dba Lebel Construction INSURER D: 36 Nashua Road INSURER E: Pelham NH 03076-2355 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1551402153 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 ADDLISUTYPE OF INSURANCE IVSD W D POLICYNUMBER MM/DD/YYYY POLICY EXP LIMITS LTR $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 A CLAIMS-MADE [A]OCCUR DAMAGE TO RENTED 500,000 PREMISES Ea occurrence) MPK86836 6/29/2014 6/29/2015 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 500,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X POLICY❑ PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 1,000,000 '.. JECT OTHER: ADL Insd Less of Leased $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BO DI LY I NJU RY(Per person) $ ALLOWNED SCHEDULED BO DI LYINJURY(Per acddenl) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peracddent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION SPER OTH- AND EMPLOYERS'LIABILITY TATUTE ER ANY PROP RI ETOR/PARTN E R/EX ECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ❑ N/A B (Mandatory in NH) WC2883005862-02 11/15/2014 11/15/2015 E.L.DISEASE-EA EMPLOYE $ 100,000 It yes,describe under DESCRIPTION OFOPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached i1 more space is required) All Jobs/All Locations CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Att: Brian ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Deborah Stanhope/FAUC - _ _ •Y„ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(9n1401) Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165208 Type: DBA ;'a Expiration: 1/19/2016 Tr# 248488 LEBEL CONSTRUCTION ' ' SYLVAN LEBEL }` 36 NASHUA RD PELHAM, NH 03076 Update Address and return card.Mark reason for change. SCA 1 ca 20M-05/11 Address [-] Renewal F] Employment 0 Lost Card ,/}�� �fe�paaw»zorzcuecc�tl a�C�av�ac�icateCta —\ Office of Consumer Affairs&Business Regulation License or registration valid for lndividul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gxepgistration: 1'65208 Type: Office of Consumer Affairs and Business Regulation iration: 111912016 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 LEBEL CONSTRUCTION SYLVAN LEBEL 36 NASHUA RD PELHAM, NH 03076 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards —041stI I.ictiOn SUpe1 Ylso 1 & 2 PAlllll�' License: CSFA-055892 � SYLVAINR LEBFt. 36 NASHUA RD ---- PELHAM NH 03876 Expiration Commissioner 07/16/2016 0