HomeMy WebLinkAboutBuilding Permit # 6/9/2015 IL IN P MIT ,,ED
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TOWN OF NORTH ANDOVER �
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APPLICATION FOR PLAN EXAMINATION
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Permit No#: Date Received ��� �, 'oRa I ,PPP �h
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Date Issuedc,
PORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNERS"/,ct'C ��ev
Print 100 Year Structure yes no
MAP PARCEL: � w,� ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resid ntial Non- Residential
❑ New Building ne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
q
/ DESCRIPTION OF WORK TO BE PERFORMED:
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Identification- Please Type or Print Clearly
OWNER: Name: s' Ae�,e Cc, rr' Phone'
Address: i-lc r` I`Gca gig
04 ContractorName: Phone 5 -1-7 74o
Email: vz,:A
Address:_rtd�� o > tiz2:2 r
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Supervisor's Construction License: Exp. Date:
Home Improvement License: `/ Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
L PERMIT. 12.00 PER
1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
FEE SCHEDULE:BU DING P $
E $
Total Project Cost: $ 1 FEE: $ f/
Check No.: �m® Receipt No.: w,
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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SORT H
Town of Andover
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COC LA0141 ICK
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BOARD OF HEALTH
Food/Kitchen
PErx1v iT T LD Septic System
THIS CERTIFIES THAT ................................ BUILDING INSPECTOR
has permission to erect buildings on Foundation
.......................... .. ......... :(G ............... Rough
V
tobe occupied as ...... ... .......... .......At.�.... .. -.................................................................... Chimney
provided that the person accep ' g 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 CONSTRUCTIONSTSRough
Service
..................................... .......................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathingr Dry Wall To Be One FIRE DEPARTMENT
Until S ec e and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Page No. of Pages
• Roofing Jerry R LeBlancPROPOSAL AND CE
• Siding Construction Supervisor Specialty License
• Gutter 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 Registration: 149881
• Snowplowing Cell (978) 835-7740 Expires:2/16/2016
PROPOSAL SUBMITTED TO PHONE DATE
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STREET RA NAME
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CITY,STATE AND ZIP CODE JOB LOCATION
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ARCHITECT EKTE OF PLANS JOB PHONE
We hereby submit specifications and estimates for•
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All.^1 T t0—e
Start within days �tt
Complete in 30 days. _ �z� S= _
/ e propoSe hereby to furnish material and labor—complete in accordance with above specifications,for
–the sum of:
C( �/ dollars ($/ 2
Payment to be niadg as follows. r
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
specifications involving extra costs will be executed only upon written orders,and Signature
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.
cpt nc 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 a made as outlined above. Signature
Date of Acceptance �f Signature
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
ODM sY�V
Workers' Compensation Insurance Affidavit:Builders/Contx'actors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Please Print Legibly
Applicant Information
Name(Business/Organization/Individual): ✓e .ter
Address:
City/State/Zip:�O)C �jcr,r �/y2 sk Phone#:
Are you n employer?Check the appropriate box: Type of project(required);
1. I am a employer with employees(fill and/or part time). 7. New'construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.] 9, ❑Demolition
3.Q 1 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
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.
,[,,,]Pl repairs or additions
S.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs
These sub-contractors have employees and have workers'comp.insurance.# 14.Q Other
6.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 also fill out the section below showing their workers'compensation policy information.
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 showhig 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 an employer that is providing worlcers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: c:/'
Expiration Date: (L; / f
Policy#or Self-ins.Lie.#: s f?U�"2 y p �
l2LGt5J
Job Site Address: � ti� ��' ����`�� 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.
X do hereby certify under the pains andpenalties of perjury that the infor'matiorz provided above
is true and correct.
. r. Date: /-9
Signature:
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#:
1 1 11 Y 1 -
_ 99/9712914
t.
--irtim carnFiCATE IS ISSUED ASA MATTER OF INFO TION Y AND coNFERs NO Rmm UPON THE cmnmm HOLUM,THIS
CERTIFICATE DOES NO`r AFFUUMTIVELY OR NEGATIVELY AMEM EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF HiSURANCE DOES NOT CONSTMTTE A CONTRACT BETWEEN THE ISSUING INSURERS).AUTHOMED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT- If the certificate folder is an ADDITIONAL INSURED,the policy(les)must be endorsed. if SUBROGATION IS WAIVED,sub endorsed. to '
the terms and conditions of the policy,certain policies may require an endorsement A stMment on this certificate does not confer rights to the
carbilcate holder in lieu of such endorsemenUs.
PRODUCER }=A
Durso&Jankowski Ins Agcy LLC PNONE FAX
198 Massachusetts Avenue rjO NON
North Andover,MA 01845 ADDRESS:
Durso&Jankowski-ins.AM, PRaDucPH
casTOIIIER D .LEBLA-4 -
- _ uts(I SIAMROINGCOvERAGE rima#
INSURED Jerry LeBlanc INSURERA:
9 Atkinson DepotRoad msu,ms;Preferred Mutual Insurance Co. 96924
Plaistow,NH 03865 INsuRERo:'The Hartford
rtlstrReRfl:
NGM-insurance Co 94788
INSURME:
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHtCH-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.UMtrS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR IYPEOFINSURAHCE POUCYNV R POUCrVYM, VAU/13annnrn
EXP LW
rtS
UR
G&MM EACH OCCURRENCE $ 300,00
OMMOETORENTEF—
B X COMMERCIALGFNEMILIABIury BOP0100797134 05!0112014 05I01l2015 PREMISES ea $ 900,00
CLAIMS-MADE a OCCUR WD,EtP(Any a,eperson) $ 5,00
PERSONAL&ADVOULIRY s 300,00
GENERALAGGREGATE - $ 600,00
GEN'LAGGREGATEUWAPPUESPE' PRODUCTS-COMPlOPAGG 5 600,00
POLICYPRO IOC $
AUTIOMOBIMU BILITY (Easoadent)COMBINED INGLEUMir y 500,00
D ANY AWO BIS2755S 01/Q41?A15 Oi104l2016 BODILyIWURY(Perpwson) 5
AU.OWNEDAUTOS BODII.YIWURY(PeracadeM) $
X SCHEDULED AUTOS PROPERTYDAMAGE-
X HIREDAUiOS (PERACCIDENT) $
X NO"WNEDAvrOS $
UMBRELtALIAS OCCUR EACH OCCURRENCE $
EXCESS L IAB HCLAFMS4=E AGGREGATE $
DEDUCTIBLE $
1RETENnON S $
WORKERS COMPENSATION WCC ATU OtH
AND EMPLOYERS UABiLnY T
C YIN ANYPROPRISTORIPARMEREX C 7Cl nVE �C�()�E34123494 OSIOWZM4 Ol3/i1GI201rJ > EACHACCtDENT $ 900,00
OFRCERIMEUBER EXCLUDED? N/A
(MandefmyinNH) ELDISEASE-EAEMPLOYEE $ 900,00
Ifyes.desalbe-dot ,�.__ - -
DESCRiFnamOF.OPERAMONSbelov� ..._.. _ _. DISEASE-POUCYLtMLT $ SOO,OO
DES6RIpT1QNOFOPERATI0N5/U>OATLONSIVEfRC6ES(AflschACORDiD7,Ad�ffifton�RanaksSott�tt0 irnwrelsreq�dratl)
sole proprietor is excluded from work comp coverage
CERTIFICATE HOLDER CANCELLATION..
SAIIMPLE9
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEULED BEFORE
THE EXPIRAMON DATE THEREOF, NOTICE WILL BE DELIVERED IN
Sample forbidding purposes ACCORDANCE VUM THE POLICY PROVISION&
AuniORaED REPRESENTATNE
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Office-of Consumer Affairs&
IMPROVEMENT
Iiusin�s�ORg j
M� ENT CONTRA Ty le:
-''egistration: 149861 Individual
Xpiration: 2116%2016.
JERRY P.LEBLANC
JERRY LEBLANC g �.
9 ATKINSON DEPOT RD
PLAISTOW,
NH 03865 Undersecretary,
1 massaci-nisetts rjepari,roent of Public Safety
f3c> id Ems" t3�_tilt.< <t r e�fu atrti�, . I'd InEdards
Construction Supers Evor SpccI�iits
--°�igenae: CSSL-099633
JERRY P LEBLANC
9 ATKINSON DEPOT ROAD '•
Plaistow NH 03865
✓.��.-� J1 >�.�,s �> expiration
Cur,frr issi�ner 10/15/2015