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Home My WebLink AboutBuilding Permit # 10/15/2015 ............- --—--------------------------------------------------------- TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO--� Date Received Date Issued: C IM1110 )Iican:t must co e 7777 7" s '40, ............... fC7 l-M--PROVE-M'--EWT---" PROPOSED USE Residential U New Building U One family ["]Addition L!tlfwo or,snore family I] Industrial 0 Alteration No. of units: 11 Commercial &0epair, replacement 11 Assesspry Bldg F.1 Others: 0 Demolition Cl Other An Ac vlzi rief Id le Identificatimi I'lease'17ype or Print Clearly) joh 3 OWNER: Name: Phone: Address: //)J a'lazovel- 0)''S v's 77-77 dy ARCH ITECT/ENGINEER-- Phone:----.— Address:----.— Reg. No. FEE SCHEDULE:SULDING PERMIT,'$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total,P-f-o'je'-c"t Cost: $—I ---FEE: Check No.: Receipt No.---�'- Persirions con i;��-uollalplt nd NOTE: ractin r',tered contractors da not have acces,'1;i o the g' t%ORTH Townt_E .� R Andover ® No. �O /LAKE h y ♦ er, Mass, / � e 2 COC NICNl WICK 1' AERATED S U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT ...................................Q .!.................................................................... BUILDING INSPECTOR ........ has permission to erect .:........................ buildings ons'. .................} �. ..a1-5 6 ,,, ,, ............ Foundation � � ��. . Rough to be occupied as .............................Lr . .. ...... .. ........ .............................................................. 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 CONSTRUCTION STARTS Rough Service .............. .... ..... ..... Final UILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 Approved by the Building Inspector. Burner Street No. Smoke Det. BRUSSARD GENERAL CON'I'RAc,rORS, INC'. 27 PRISCILLAWAY PPL .M, NH 03076 'TEL. 603°635.700 FAX. 603.386.6009 10/8/15 John Ca,mozzi 285 Middlesex Street North Andover, Ma 01845 Following price covers labor and material to replace 2nd floor 6x8 existing rail system with 3 composite railing sections. Job Complete: $ 1,950 Stephen Brussard John Camozzi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con necti o n/Si_q nature&Date Driveway Permit Located at 384 Osgood Street FI#2E DEPARTMENT Temp Dumps#er on=sl#e yes nQ' Looted at'124 Mart Street F��e Department sagna#urelc��t� r COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2012 The Commonwealth of Massachusetts Department oflndustrialAccidents X Congress Street,Suite 100 Boston,MA 02114-2017 4�t ww1v.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY'. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: / Phone#: �--'S' Are you an employer?Check the appropriate box: Type of project(required): L®T /am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. aRemodeling any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12,(]Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14, Other 6.❑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. t 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-contractors have employees,they must provide their workers'comp.policy number. Iain an enrployef•that is pt•ovidi»g workers'compensation il:surmrce for•my employees. Below is the policy and jab site infot'rnatiort. Insurance Company Name: ( �° �°°�, Ex �' "��/ �/� Policy#or Self-ins.Lie,#:, 3 Expiration Date: "p Job Site Address: / lej" Sr 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. I do hereby certify ill the ains a nalties o rjatry that the iiifon ration provided above is true and carred Si nature• � Date: 1. Phone#: official use only. Do not 1twite 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: BRUSS-1 OP 1D:WC CERTIFICATE OF LIABILITY I DATE(MMIDDIYYYY) 12/04/14 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 pollcy(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). CONTACT PRODUCER 978-975-1300 NAME: Segreve&Hall InSUr.ASsoc.InC NE _TFAX 305 North Main St 978-975-7596 PHOPHO E !(AJC,No): Andover,MA 01810 EMAIL ADDRESS- _� INSURERS)AFFORDING COVERAGE _ _ NAIC q - _ INSURERA:Arbella Protection Ins.Co. 141360 INSURED Brussard General Contractors Inc INsuRERB- :Guard Insurance- - ! I - --- — -- 27 Priscilla Way INSURERC: _ I Pelham,NH 03076 INSURERD: INSURER E:_ - INSURER F: i 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 P D S — POLICY EFF POLICY EXP LTR , I ( POLICY NUMBER i MMIDDNYYY ,MMJDDIYYYY ; LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A X]COMMERCIAL GENERAL UABILITY I ITBI ! 11/04/14 11104/15 I A A R�N7ED PREMISES[Ea occunence) S 300 0_00 I CLAIMS-MADE 17 OCCUR I I MED EXP(Any one person) j$ 5,000 - --- I 1 PERSONAL&ADV INJURY j S _ 1,000,00 '.. +J I GENERAL AGGREGATE 2,000,000 EEN'LAGGREGATE LIMIT APPLIES PER; f I PRODUCTS-COMPIOPAGG I$ 2,000,000 POLICY I j P CT LOC I i I-- S IAUTOMOBILE LIABILITY "COMBINED SINGLE LIMIT i I I I(Ea accident) I$_ NANY AUTO i BODILY INJURY(Per person) I S ALLOWNED SCHEDULED L_I AUTOS r--!NON-OWNEDi ± BODILY INJURY(Peracc(dent) S HIREDAUTOS I AUTOS i PROPERTY DAMAGE I (Per acadent) $ I �S ! UMBRELLA LIAB ( OCCUR I I i — I i EACH OCCURRENCE I S EXCESS LU16 I CLAIMS-MADE ;l AGGREGATE is I DED i I RETENTIONS I j I I I is WORKERS COMPENSATION I ' 'WC STATU- I 0TH AND EMPLOYERS'LIABIUTY - '' STORY LIMITS ER -' B (ANY PROPRIETOR/PARTNERIEXECUTIVE YIN i I IBRWC563080 12101/14 I 12/01/15 j EL $ 500,000 OFFICERIMEMBER EXCLUDED? ,N lA F�CH ACCIDENT_ (Mandatory in NH) If yes,describe under iEL DISEASE-EA EMPLOYED S 500,000 DESCRIPTION OF OPERATIONS below i 1 ELDISEASE-POLICYLIMIT I S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS J 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ffi TrnM"wolrcuealIir 11ci'C«JJcle/1[Je Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Type. eg i strati o n: 137349 7 Private Corporatic Expiration: 10/30/2016 BRUSSARD GENERAL CONT.INC. STEPHEN BRUSSARD 27 PRISCILLA WAY g4 }— PELHAM,NH 03076 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ;n 10 Park Plaza-Suite 5170 Boston,MA 02116 L --- N o ot va without signature Massachusetts Department of Public Safety Hoard of Building Regulations and Standards License: CS-058086 ROBERT N DUMONT 60 PELHAM RD f /'r"frr HUDSON NH 03051 'Expiration: Commissioner 08/18/2017