The URL can be used to link to this page

Home My WebLink AboutBuilding Permit # 6/9/2015 r%ORT#1 B .UILDING PERMIT o��T,ED ,bgNo TOWN OF NORTH ANDOVER F � APPLICATION FOR PLAN EXAMINATION Permit No#: , Date Received/ r '$J�pD"ArED PPp` 6`9 gSsgca+U5 Date Issued: �L* PORTANT: Applicant must complete all items on this page Z /t II LOCATION 42 /,( C " -<" Print PROPERTY OWNER eq �w Print 100 Year Structure e MAP PARCEL: ZONING DISTRICT:_ Historic District ye Dn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 01�'wo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: Demolition '�� ) IN= ❑ � � DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: 6c�jZ Phone: Address: Contractor Name: � 14Phone: , '":2 Email: a a,, Address; Supervisor's Construction Licenser ( ! (e j!2 Exp. Date: 0// Home Improvement License: / Exp. Dater ll 111zelle,- ARCHITECT/ENGINEER Phone: 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: $ Check No.: Receipt No.: e," NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �i91Gb �Ili'7r"%�i'llrnl/ Iry F„�'nlr!)ia,"' ,,. (j, �'. l�' 10 l r ANN,at nri r ;i.� V%O R TH Town of Andover 0 h ver, Mass, c� S cocHicnew,C. U BOARD OF HEALTH PERMI �T T LD Food/Kitchen Septic System THIS CERTIFIES THAT �,,.. BUILDING INSPECTOR ' Foundation has permission to erect .......................... buildings on Z ........ .......... .t. ............................................ Rough tobe occupied as .... . ...... . ....... ...... ...........:... .. .. .......................:.............................................. Chimney provided that the person accepting this permit shall In eve respect conform to the terms of the application Final e 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT E E IN 6 MONTHS ELECTRICAL INSPECTOR 10 UNLESS CONSTRUCTIO ST ITS Rough Service ..................... .....................................I.................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy BulldinRough Display in a Conspicuous Place on the Premises — Do Not Remove Final ® Lathingor all To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Page No. of Pages • Roofing Jerry P LeBlanc PROPOSAL AND ACCEPTANCE • Siding • Gutter Construction Supervisor Specialty License 9 Atkinson Depot Road License:CSSL-099633 Restricted To:RF WS • Painting Plaistow, NH 03865 Tr#:5177 Expires:10/15!2015 • Carpentry Home (603) 382-0817 Home Improvement Contractor •Windows Cell (978) 835-7740 Registration:149881 • Snowplowing Expires:2/16/2014 PROPOSAL SUBMITTED TOPHONE DATE// �( 7 nU ' STREET f JOB NAME CITY,STATE AND ZIP C( DE JOB LOCATION Al Or T4A17A ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: L / f j l� We Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: ! c/C dollars ($ �G ls�n 0 U ). Payme t to be made as fo ows: t f..f14aA All material is guaranteed to be as specified.All work to be completed in a workman- Authorized like manner according to standard practices.Any alteration or deviation from above Signature specifications involving extra costs will be executed only upon written orders,and 9 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 Note:This proposal may be and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within days. pensation Insurance. Acceptance f Proposal -The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified Payment will be made as outlined above. Signature Date of Acceptances / / Signatur �' The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia ensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. Workers'Comp TO BE FILED WITH THE pEg .Z TI1VG AUTHORITY. Please Print Le ibl A licant luformation Name(Business/organization/Individual): 6r4-al Address: y City/State/Zip: Phone 4: 41 7 7 e-(� F9. of project(required): Areyou employer?Checicthe appropriate box: NeW'construCtion 1. I am a employer with employees(fiill and/or part-time).* Remodeling 2.❑I am a sole proprietor or partnership and have no employees working for me in Demolition any capacity.[No workers'comp.insurance required.] 10❑Building addition I❑lam a homeowner doing all work myself- [No workers'comp.insurance required.] I will 11.❑Electrical repairs or additions 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. ensure that all contractors either have workers'compensation insurance or are sole 12.❑Plumbing repairs or additions proprietors with no employees. 5.F1 I am a general contractor and 1 have hired the sub contractors listed ur the attached sheet. 13. oofrepairs These sub-contractors have employees and have workers'comp.insurance# 14.❑Other 5 Q 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 alsM they are doing all work and then hire outside contractors must submection below showing their-workers'co-P nsation policy oit aanew affidavit indicating such. i homeowners who submitthis affidavit .-- indicating Tcontractors that check this box must attache Banes whey must provide their tw workers oompspoh policy number.and state whether or not those entities have employees. If the sub-contractors have r Y I ant an employer that is pt'oviding wot Iters'compensation insurance for MY employees. Below is the policy and job site information. Insurance Company Name: y✓` v rl Policy#or Self-ins.Lic.#: h Expiration Date: //� City/State/Zip: Job Site Address: Attach a copy of thd expiration date). e orkers compensation policy declaration page(showing at onpunishableby a fber nne up to$1,500 00 Failure to secure coverage as required under MGL c. 152,§25A is a criminal v Pd a fine of up to$250 ,as well as civil penaltiein hw WORKORDER and/or one-year imprisonmentided to the office of Investigations of the DIA for insura 00 a ce day against the violator.A copy of this statement may be fo coverage verification. I do hereby certify under the pains and penalties of pe�ju�y that the information provided above is to ue and cot rect. Date: ,2- �2 0� foneafore: #: official use only. Do not write in this area,to be completed by city or town official. Permit/License# City or Town: issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.other Phone#: Contact Person: LOCK I It14A 1 C ur L1AtSILI I Y MbUKANUL 1111712014 Y, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFiRUATMMY 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 tNSUREIRM AUTHORIZED REPRESENTATIVE OR PRODUCER,AMD THE CERTIFICATE HOLDER. IMPORTANT.- N the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endoraed. IT SUBROGAMON 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 . cet¢ificate holder in lieu of such endorsements. - PRODUCER NNE Durso&Jankowski Ins Agcy LLC PRONE FAX 198 Massachusetts Avenue fm Nft eft 'North Andover,MA 01845 IL Durso&Jankowski-Ins.Agcy._ Sm D0LEBLA-4 RMOSMAMROINGCOVERAGE NAZCA INSURED Jerry LeBlanc INSUFMA: 9 Atidneon Depot-Road Ureal ms;Preferred Mutual insurance Co. 16024 Plaistow,NH 03865 mauftmc:The Hartford IwwRERD:MGM Insurance Co 14788 WOURERE: 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.LIM0TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INR iMOPRRISURANCE PM=fflmm U11018 GENERALLIABILnY EACHOCCURRENCE $ 300,0001 B X co c►ALGMERaLUABft= 13OP0100717134 05!0112014 05/01/2045 P IBomarerce $ 100,00 CLAIMS-0AADE I-Z�I OCCUR MED EEXP one poson $ 6100 PERSONALSADVINJURY s 300,00 GENERALAGGREGATE S 600100 GENIAGGREGATELIMITAPPLIES PEFL PRODUCTS-COMPIOP AGG S 600,00 POLICY PRO- LOC $ AUTOMOmw uAmLn Y COMBINED SINGLE UMR' y 500,00 D ANYAUTO B1B2755S 01/04/2015 01/0412046 (EM goddeM BODILYROJURY(PWPar$W) $ — ALLOWNEDAUYOS - BODILY MJURY(PerasaddW) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIREDAUTOS (PER ACCIDENT) $ X NON-OWNEDAUTOS S - - S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ Exch UAB CLANS-MADE AGGREGATE S DE1UCrIBLE $ — R ON S S WORI(MCOMPENSAMON WCSTATLJ OTH- AND EMPLOYERS•LU BILrFY T,Sff,.�£ ER C ANYPROPRIETORIPARMERIEXECUINE 6S60UO2F.34123414 MOW2014 00/0612015 E.LFa,CHACCIDENT $ 100,00 OFMCEWBIBER EXCLUDEP9 Y NIA E L DISEME-FA EMPLOY $ 100,00 (Mandatory in NN) Ifdestx3na tender _.,...,M...__.__.�--- ..,--.----._.--.-- — yyeass DESCRIPTION OF OPERA EL DISPASE-PODGY lRYfrT $ SOO,OO DEWRiFnomOFOPERAMONS/WC/TOMSIVEHMM(A0=hACORDlot,Addrdo"RMwInSdidwe,irmpre6P=*Isr***6* sole proprietor is excluded from work coop coverage CERTIFICATE HOLDER CANCELLATION _. ... SAMPLES sHDULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sample for bidding purposes ACCORDANCE VWTH THE POLICY PROVISIONS. AUn WIZED REPRESENTATIVE sj %�.rN iNriN[I•r r7 f1�G L,/C��i[:fit[c�lr,<<:.;. 7 "a.M1office of C onsumGr Affairs&BVON usiness Regulahbn b 3 ME IMPROVEMENT CONTRALTO Type: --' o ; ration: 149881 Individual (piration: 211612016 JERRY P LEBLANC . JERRY LEBLANC g ATKINSON DEPOT RD [, Undersecretary PLAISTOW, NH 03865 , Vias a<1t ,F,rits UeI ar r Er i t of Punl r, Safety Bc"arJ o Pwh �'6 Cunstructinn Supcf�i,or rspccisslt CSSL-099633 Al JERRY P LEBLANC 9 ATKINSON DEPOTROAD Plaistow NH 03865 Conv�iissioner 10/15/2015