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Home My WebLink AboutBuilding Permit # 6/29/2015 1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION it NO: Perm ' Date Received t Date Issued: IMPORTANT:Applicant must complete all items on this page ,r §V11" 7 rr r rr r r r.,.f n r J r / � l ✓, m l�� ,r , / /r r � ,, /� /�/ �/� 1/ � /r ri PROPERT ,OWNER/,/i,,s, ��,r,,. fir,, l_,�r,,r,,/ �. r,� � ��l �,411„u�/I/�rol//��/ �ii��i,/l�f%//,.ir� r,✓/ , r rr !ii / / ,! , r r. r � ✓r.. a it ,/r. �/ ,. ..r. / rr r ,.end / r r ,.direr ,r✓. e�/rrr roi,.o ri .,rr rr ,...,,,. r / / r� „ �. �, � �>� r✓ „r �� ,, f1i//7/ /// /�l„/r%,r r// �, r / r/i/rf�r�/r7/r,c,”r,l�A/�P/�/,ro/�N�r i�/Oi�rf�.,rl�i,i��,,i,1rr�rr.f//r/iir,/,r/�/r.„,,,,i,,,r,r�,r�/,�//,//r��r!�,P/,,A/r�///ri Rrrrr,.r�,:C,//%f/Gr E///r�„Lfr�„,r./r:,rr✓,//.�/.,r-J,,,,r,,rn,/i,r„,�/r/„i,I/,rr r/,r lG,r�i r/.///,�rOr//ir/r e,�/,/r/ir/,,,/./N///�/,r.i/Gr rir��/�r�/Dr%�t%/////L,S/lr/!( e/./,//rs s1/11111" e"ye oor/r / , rr,e .. TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building .e family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial pair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑'Septicr El-we ll E]'/Floodplam; r /, ❑,Wetlands r/r ❑ Watershed District r r //rirr te,,� wer ,,,,! /❑War/Sey, DESCRIPTION OF WORK TO BE PERFORMED' ��.� 0 s., c- . r2, Identification Please Type or Print Clearly) OWNER: Name: �, .. �W;, Phone: / `1 .,.l Address: x LS t rr , ,,,r i%/%/✓,i%/dri„,'. // r ri.'r /i r%/fir �� „ , i✓ii{ U/,/r„,G/ !/,r:riir: ,i /,,, r �/,r r� r (/G/� O / rr�. r,°,.Vii. ,.� Li, ..,//�l ,i,�� r,/�� .r ��r. ,./r r / .,1, /�/ / ” /% ,, / ! / / /prf�„ o/% /r, d ✓ it,r /�� J/�,/ // err %/ / r r 1 r ,% ��i,/�� r i,..,/,r,. /� r.,.. ,i,,,,,, /,,,rvlr� �✓�Li/��, /�,I r � ./f /�. r ff .,,r/%„,,, r/,r'//i/� ,✓/,✓,J:,�� ./. i;. / „ / f ; '�i i � /r, r / �/r p � /�i/ ��/� �/➢r;� /i��/ ,.J////�r� ./ �ii/ii/� r �( //rr�,,,,Ji> r / r r / / ,i/ / // / „i ✓„ l / /... / ��f�r.a,noir„/,,,/„�, .� G,m„/o�„////✓/ Ji ! /,,,/, f r /// // rr/ // � r./1,�///,, �%r,i, / r o;, ,/ I ,/„ iHOnle Im Cpve ent Llcensei�/i, /r,,,,rr/,, a,i, ri,�. / i r i ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ;fid FEE: $ -- N. Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund gry m Si nature of etOwner Signature of contractor; . �e Plans Submitted E Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans t4ORTH Town of Andover M OA No. "coma :26 COc MIcnlwec.c y1' BOARD OF HEALTH Food/Kitchen P E IT T LD Septic System THIS CERTIFIES THAT ....... AVAPKAl BUILDING INSPECTOR ..... ..................... ................ ................. ........................ ................. I*rhas permission to erect ................. uildings on ... Foundation ....... . ......... ...... ...................................................... ................................................................................ Rough to be occupied as ........... ..... ......... ........ ..... Chimney provided that the person accepting his 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 ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO Rough Service ................ ... ........ ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Bu Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Page No, of Pages LEN GIBELY CO., INC. 23R Winter Street 2 6 81.S P OSAL PEABODY, MASSACHUSETTS 01960 All home Improvement contractors and subcontractors �t (978)531-8234 Fax(978)531-9304 engaged In home Improvement contracting., Pages www.lengibelycontracting.com specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered Submitted: with the Commonwealth of Massachusetts. Inquiries TO about registration and status should be made to the Director, Home Improvement Contract Registration, SOY Al ZST- One Ashburton Place, Room 1301, Boston, MA 02108 �—o 1410 (617) 727-8598. Owners who secure their own //4 construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund construction of MGL c.142A. ---TDATE REGISTRATION NO. ,MQ.REG.17 1 �'� JOB NAME/NO. JOB LOCATION We hereby submit specifications and estimates for work to be performed and materials to be used, of 14 0 > eve 6�9'44-46-' 2- 13 C) CPT, IA— W.Rl J.CH Di mract �!b.3, to or r r Ill It '44 Its before the Third In In,,signing on, It led herein w ill begin the work on or u ;!Sa 1 46 d by d 11 Mp,., (data). 'a ' g ' felf ."I I I'll I'bP.Gc;completed by at about 'a �ac.S'0b'.'6'nd C.nr.gIc0,!.".ont,o'Agreement, work Va'e).The Owner hereby es'. approximate and that such delays that are not avoidable by the contractor shall not be considered as v lions of this Agreement. scheduling dates are hour acknowl gas"and agrees that the a (MAN HOUR). Hidden rot of conditions not seen at time of estimate that are required to be tepalred in order to complete this contract,will be completed at$—per WARRANTY a per a flowing completion and shall comply with The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for !�NV on . Sr!semployees or agents,Is discovered within I r ,Oc one year after completion of any job,Including clean up,the Contractor shall,at his own expense,forthwith remedy,repair,correct, the requirements of this Agreement.In the event any defect In workmanship or materials,or damage caused by the Con regia e,or cause to be remedied,repaired,or replaced, such damage or such defect In materials or workmanship.The loregoing warranties shall survive any Inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: ITIM01 dD Payment to be made as follows: ...... Remove all job trash. dollars($ I- All guarantees on all products from manufacturer. ($I C)OO )upon signing Contrac"'.7-77— Add permit cost if needed-we pull permit, —%is )upon completion of No a: N greement for hom improvement contracting work shall require a do pay t(advanc depos f more than one-third of the total contract pro if tal amou all d sits or payments which the c ontracto —% upon completion of mak,In nce,to rd and otherwise obtain delivery of sp_V�ie order shall be made forewith upon mate I a equipme t, —% completion of work under this contract. Note:This proposal may be withdrawn by us it not accepted within—days. Authorl 11111 re Acceptance of Proposal I have read both sides of this d6cument and ac eptt a is s specifications and conditions stated.I understand that upon signing,this proposal becomes a binding contract.You are authorized to d the o as, ecifled, Payment will be made as outlined above. I You,the Buyer,may cancel this transaction at any time prio to I night of the third business day after the I date of this transaction.Cancellation must be done In writin DO NOT SIGN THIS CONTRACT IF THERE R ANY BLANK SPACES. signature D.I.!��f' / -ig.aline Dat. IMPORTANT INFORMATION ON BACK NO- hI Cl\ Th CmfrhMass�rchusetw~s Department oflndustrialAccidents O•f ee of Investdgadons 1 Congras Strekt Suite100 Boston,MA 02114-2017 www.massgoy/dict. Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anpli a Information Fl-ase Print Lee><bly Na111 .(Business/Qrganization/Indivjdual): L . .r . ✓ CX, k>,j Ce., Address: City/State/Zip: �A a Phone#: ,C( : . ^� 3 Are you an employer?.,Check the appropriate box: . 1. Iam a employer with 4. [� I am a general contractor and I ?'ype of pro3ect(reqd): employees(full and/or part-time).* have'hired'the sub.contractors 6• .(�New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling "—ship.ship and'have'no employees These:sub-contractors,have. []Demolition working for me in any capacity: employees and have workers' [No workers' comp. insurance comp.insurance.l 9. 0 Building addition requtred] 5. 0.We are a corporation andAts 10[]Electrical repairs'or additions 3.❑ I ain a homeowner doing ail work officers have%exercised Choir 11.13 Plumbing repairs or additions myself. [No workers' comp. right of`exemption per MGL insurance required.)t a 151,'§1(4),and we have no 12, of repairs employees. [No workers' 13.❑Other comp insurance'required,]" *Any applicant that checks box#I must also fill out the section below shgwin their workers'compensation policy information. Homeowners who submit this affidavit indicating they.are doing all work and then hire outside confractors roust subinit'a new affidavit indicating such. tContraatoa that check this box frust attached an additional sheet showing the name of the sub-contiactors'andstate employees. If the suh-contractors have employees,they must.provide whether or not those entities h$ve their workers'comp:policy number: I am an employer that Is providing workers'compensation Insurance for my information. employees. Below is the Policy andJob site Insurance Company.Natne:� % ' M� v �'ll.�t l.. ►s+ > �1 c ` �3 Policy#'or Self-ins. Lic. #: I/(,q e..- 1 O 0- A t7 I �i`-• t�rt~iExpiraticfn Date: 1 �, Job Site Address, t' >" i C city/State/zip; Attach a copy of the workers' compensation policy declaration page(show.ing the policy number,and expiration date). Failure to secure coverage asxegtured under,Section 25.kof`iviGl,c. 152 can leatl to.the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office a Investigations of the;i)lA for insurance coverage:verification.>;.. Ido hereby certify,under.thepoins andpenaltles.ofperjury ihatthe infgrmadonproylded above,Is true .and correct .. D e: Ofcial use only. Do not write in this area,to be completed by city or ioivn official City or Town: Permit/License# Issuing Authority(circle one): —77 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ,A DATE(MMIDD/YYYY) ACORQ CERTIFICATE OF LIABILITY INSURANCE F01/30/2015 PRODUCER 978.887.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC# INSURED Len Gi bel y Contracting Co. , Inc. INSURERA: First Mercury Insurance Co 23R Winter Street INSURERB: Safety Indemnity 33618 Peabody, MA 01960 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LIS-FED 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY POLIEXPIA LTR NSR � Ty PE OF INSURANCE POLICY NUMBER DATE(MMIDDIYYYYEFFECTIVE) DATE YMMIDDRIYM LIMITS GENERAL LIABILITY MA-CGL-0000051263-01 01/29/2015 01/29/2016 EACHOCCURRENCE $ -1,000,000 COMMERCIAL GENERAL LIABILITY -MIZWiE�Jrrence) $ 100,000 CLAIMS MADE I—X I OCCUR MED EXP(Any one person) $ S,000 A PERSONAL&ADV INJURY $ 11000,000 PGENERAL AGGREGATE $ 2,000,000 GE T AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY M PROJECT' F- LOG AUTOMOBILE LIABILITY 6221693 COM 02 01/29/2015 01/29/2016 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1,000,000 ALL OWNED AUTOS BODILY INJURY B SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE F1 (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—ICLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N I TORY LIMITS JOER ANY PROPRIETOR/PARTNER/FXECUTIVEF—] E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? IMandatory in NH) E.L.DISEASE-EA EMPLOYEE $ lf�es,describe under S ECIAL PROVISIONS below E.L.DISEASE-POLICY Limir $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Proof of insurances. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE lRobert Sennott/RP ACORD 25(2009/01) 071988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC-+C7R'" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYYy 08/01/2014 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: it the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. It 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 01634-001 RMLACT Edward F Sennott Insurance A/C.N..Ext: AIC.No.: 16 South Main Street E �L, Topsfield,MA 01983 A DARESS: SURE13(S)AFFORDING COVERAGE ER : A.I.M.Mutual Insurance Company 26158 INSURED Len 0 ibely Contracting Company Inc JNAUSER B; 23 Winter Street Rear InURER Q: Peabody,MA 01900.6941 INSURER • — --INSURER E: 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 POLICYPERIOD 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 yB�Yp�PAID pCLAIMS.p /LTR TYPE OF INSURANCE 11$ `WI ,POLICY NUMBER MMIDDIYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ u CLAIMS-MADE [::]OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ --- --__ _---,-•,-----_ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S OL.ICY —UIRO- OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ..—.– ---....._......_..---- AUTOS AUTOS BODILY INJURY(Per aocidont) $ HIRED AUTOS ANON OWNED PR PERTY DAMAGE OS $ o I e UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMSMADE AGGREGATE $ V/pRKDEERDg RNEgTpENNTIIOON $ ,�7 $ AND EMPLOYBRS�LIABI�ITY _ X T�Y LIMITS OY- �t�HYIPC��t' t l&AjbER/F IUTIVI YIN E.L.EACH ACCIDENT $ 500,000.00 A E)( LUDED9 � NIA VWC-100-6010979-2014A 8/3/2014 8/3/2015 �(rrMandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000.00 DEY A'PffON u0 OrPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/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 O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD k Massachusetts - Department of Public Safety Board of Building Regulations and Standards C'unstrurtion Superlhur License: C"91763 THOMAS R DOB�V '• �` � T °✓�- - " "' Expiration Commissioner 05/14/2010 GXe*arias wupeaa 010/9awa /rwet6 ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVi;MgNT CONTRACTOR before the expiration date, If found return to: k�..•.w Office of Consumer Affairs and Business Regulation #Registratl ; _ Type: Expir ` 10 Park Plaza-Suite 5170 ��st ��a Supplement Card Boston,MA 02116 LEN GISELY CON N ' ': ,INC. THOMAS DOBBIN. Z, 23 R WINTER ST �,ti % ks"�+.1�.•yc9a. PEABODY,MA 01860 Undersecretary iyot valid without signature _