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HomeMy WebLinkAboutBuilding Permit # 11/30/2015 bUILUINU MKIN111 I 0 ........-.........TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION X_ Permit NO Date Received AT Date Issued: 2/-Lo IMPORTANT t must cam lett all items an this a e f/i/%/ '' ori,;' / i /r //�% //i .......... TYPE OF IMPROVEMENT PROPOSED USE Residential Nan® Residential ❑ New Building tQ,,,Qne family 11 Addition 11 Two or more family 11 Industrial gAlteration No. of units: 11 Commercial El Repair, replacement El Assessory Bldg 11 Others: 11 Demolition El Other ,/.,,..,, ,///,0 ,, �..,r ��,,.,,, /,,, ,,.,� )%,//ri��i,l�/,,,,,.ter,,.ilii,. ,,;,ii///i���%�/,,�,//i/,f,�i�/�/%ir%�///,�,��l�,,/%,//��/r/�i/�//,i//.,i/�i/�.:,,o�, ,i/I„--„ <; Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: en1,1 rl II it l / rI 1 / 7r r , � ,/ /// // r! /�i r� � /�� 1, /, ,//��//�/i//�r�� f, // / ,,/%// /l „ ���// r�/i,/ ARCH ITECT/ENGI NEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: Check No.:,--- Receipt No.: Qri '-4- '�o_nt_raalng unre istered contractors do not have access ty NOTE: Persons gua ,fiund 'Town of � NORTPy Andover ® .. ^ . : to �O LAKE h very ass, COCNICHEWICK V� ATEo rP¢��5 U BOARD OF HEALTH PERMIT T� LU Food/Kitchen Septic System THIS CERTIFIES THAT ................................................... BUILDING INSPECTOR �..� ................... .......I�. ... .. ........... .. . ........................ has permission to erect buildings on - Foundation .......................... ... .Q. . ................. ....................... Rough tobe occupied as ..........Fkll..........� ... ..... s�? .�.. ,. ..........r.................................................. Chimney provided that the person accepting this per t 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT ®NTS ELECTRICAL INSPECTOR LESS CONSTRUCTIO RTS Rough Service ................. .. .......................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired t® Occupy Building Rough Displayin 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. Page No. of Pages L!,,,RLANC AND SON �I I ru"A [ fXl, 59 ["IRADFURV, MA 01835 rmrrt r i 2 1A 2 ( 9°d / 6 '!� d�e ) r evg 101 �aA5,2 r PROPO$ U ITT O � t qua PFG3NE "o DATE " � "'�,✓✓°' d'`�"„,��°�tµre,�d",r7 STREEf JOB NAME t f�w ,i CITY,ST a d ZIPO ' JOB LOCATION °r , ARCHITECT DATE OF PLANS JOB PHONE We e erw�yu mit specifications a9a tp stimarte"s, or., /A, � „ 10 ,,....011 mr rww 11, 'r %a„,. uyv'�,”^ ',• r " a f *fitr t19 �µ " a,r v �, "kt,�. p p a at ,t kyr^ ,� „ w �� d r, t t eat er " tart wsv w' re' m' Mme. dr' J " � rr ' 41011i , P f w0 , .,�°�d um. � '" dt�t W`,;. air " M""" "✓ d� ^mf' , r� t / m x r Y i Ve I PYA /hereb`�,,`�to fuWrnls„h f erial andlaOr-,,,complete jo" c dp,6ce with above specifications, for the sum of: nwu dollars f a met to be m e as f ' t° d0 ot t m. d �' b d � w y �a y �' s. p /„ rw .........6, el L .W''"p ,A�'.�!�,� d"P �10 � G" `2�""^` ks +rc' .......rem�" �r fw tt , r r w manner according to stantlardpractice Any a lterationrortdevatonmploetd+bc Rpe fcatio�ns Authorized involving extra costs w�II be execute onl upon All material is guaranteed tc be as sp died. All ar ke y -- v with raw Nyte:This ro osal may be r' d g y p written orders, and ill Yne an extra charge over and above the estimate. All agreements contingent upon strikos�accidents or x delays beyond our control. Owner to car fire, tornado and other necessaryinsurance. Our °P P y workers are fully covered by Workman's Compensation Insurance. us if not accepted within days. Acceptance1 Proposal —The above prices,specifications y "r t' and conditions are satisfactoryand are hereby accepted.You are authorized to do the Y P Signature work as:'specified.Payment will be made as outlined above. Date of Acceptance: �' Signature FIOU-30-2015 11: 15 From:G T MCCARTHY INS 978 744 3575 T0:1978G889542 Pa9e:2�2 ,acoRD° CERTIFICATE OF LIABILITY INSURANCE DATE 0/20/VYYY) ��- 11/30/2015 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(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). PRODUCER Phone: (978)744-6433 Fax: (978)744-3575 CONE:TACT Deb Tournas NAM GERALD T MCCARTHY INSURANCE AGENCY,INC PHOIJE FA (978)744-3575 92 NORTH ST "; ;"No E� (978)744-6433 AC n. P O BOX 839 ADDRESS: debbiet@gtmccarthy.com PRODUCER 3682 SALEM MA 01970 CUSTOMER ID* INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER SAFETY INSURANCE COMPANY LEBLANC&SON LLC LIBERTY MUTUAL INSURANCE COMPANY P O BOX 5389 INSURER e . HAVERHILL MA 01835 INSURER C INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 30687 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 CONDITIQM OF SUCH POLICIES.I-I AITS SHOWN MAY HAVE BEEN REDUCED BY PAI CLAIMS. INSR TYPE OF INSURANCE ADUL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YYYY MM/DD/YYYY A GENERAL LIABILITY BMA0003851 08/03/15 08/03/16 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 '.. PREMISES Ea cccurence CLAIMS-MADE IXIOCCUR MED.EXP(Any one person) $ 10,000 '.. PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY BMA0003851 08/03/15 08/03/16 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY(Per accident) SCHEDULED AUTOS PROPERTY DAMAGE X HIREDALITOS (Per accident) $ X NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION WC5313352562012 09/28/15 09/28/16 WC STATU- OTH $ AND EMPLOYERS' LIABILITY TORY LIMITS Y/N E.L.EACH ACCIDENT 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 500,000 V yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) '...... SIDING,GUTTERS, DOWNSPOUTS INSTALLATION LAWRENCE LEBLANC AS LLC MEMBER IS NOT INSURED UNDER WORKERS'COMPENSATION CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE � Attention: �.���� ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts : Department oflndustrialAceldents } ,,y 1 Congress Street, Suite 100 Boston,MA.02114-2017 www mass.gov/dia 5�• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH THE PERM[TTING AUTHORITY. Applicant Information Please Print Ledb Name (Bnsines Organization/Im vidual): Address: fa floy City/State/Zip� �)/9 Jkx-,Q Phone#: A.reyon an employer?Check the appi opriate box: Type of project(required): 1I am a employer with mployees(full and/or part-time) 7. Q New construction 2.Q I am a sole proprietor or partnership and have no employees working forme in 8. [1 Remodelhig 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. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors withno employees. 12.[)Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have eiriployees and have workers'comp.insurance., 14.[)Other 6.[I 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 snbaf this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 a those entities have employees. If the sub-contractors have employees,they must provide their workeis'comp.policy number.' X am an employer that is providing-workers'compensation insurancefor my employees.'Below is the policy and job site information. 1 a �( "" )- Insurance Company Name: i� Ex iration D ate: / s Policy#or Self-ins,Lie.9: � p Job Site Address: 1 City/State/Zip: `i' 'f 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. copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veriftcatio l I do hereby cer•ti nde t ae a' s enalties ofperjury that the information provided above is true and correct • d Si nature: Date: Phone# ' 4 Official use ly. 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#: V7LB lgaol1/IlzaaztaeCG��77a ���CcddCcc�rCJe�J l - License or registration valid for individul use only Office of consumer Affairs&Business Regulation before the expiration date. If found return to: kqj"'xe MEIMPROVEMENT CONTRACTOR Type: Office of Consumer Affairs and Business Regulation gistration: 135829 10 Park Plaza-Suite 5170 p1ration: 5/14/2018 Individual Boston,MA 02116 LARRY LEBLANC LARRY LEBLANC 33 MEDITATION LANE ATKINSON,MA 03811 Undersecretary X. 1 signature M i Massachusetts -Department of Public Safety I Board of Building Regulations and Standards Construction Supervisor License: CS-090414 LARRY J LEBLAIlkIle, PO BOX 5389r I 011 411F BRADFORD MA=01835 Expiration Commissioner 01/28/2016