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HomeMy WebLinkAboutBuilding Permit # 12/1/2015 BUILDING PERMIT ®1R�LEo ,�`6 TOWN OF NORTH ANDOVER Yb ®� APPLICATION FOR PLAN EXAMINATION 0 Permit N0#-. �- Date Received -A US Date Issued: �� IMPORTANT Applicant must complete all items on flu page �� + �.. �� ��/,t//� / r`� �/�rl, „1�����1r1�����✓..r/����./rOr i.,-v.,,, e/ c //rr�r�, r%/��/ ,J l �/ J�opo,. ✓„ � l i � w r 1 J' / r �J J /r r /�,,r,�l ffl/i lY� %'%'' ,��,�11 � � ����r / rr r �,�r ,ry i� .arm r f'ly +r u ,r/ ,,�?m�hrc-r,� ,.,r- 'arp�wvrramrd'J y//��/'✓,�v�,ttw�rmar�i,��r ���/ / , e � l � �,f •v� � ,,I �ZONING DISTRICT /�.., �,,,r� ,.Hi � �1i� ,,/ //�Yn / � /� PARCEL�!� /,,r, ��✓ � � s �/ ,///�� r/,// / n0,/i, ` , a TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other � ❑yFloodpIaim, /,,❑,Wefla`n"ds ❑1/rWatersh"ed Distr, cfi ❑ Se tlGs „i,❑(wVVeII, //, rY/ p `/ /r ✓r,l r/ „ /o///,/ %0//1 .// i, ".,ri 4,i�ri.rr1Y r,H ica %//�r✓i/G/i�r%yi/'//r//i r lfk ri,/// / ,.`.lr�ri / //f i///J r r r� /l?"11✓//����/�///i //J/ ,� r / / ////// //�r� / r/// ❑F�/�1`dter/:P W_ /d r DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: 11Z Phone: Address q r �/r r r r / � r / ,Contractor,Name > � ' � Phone: , ,r//r, /i:..,a, r/ �,•;/%/0�„n.„ / /. r//„ r,,,,,,, ,/,,, ,,;,,,,r, ,s„'i',;'<': >;��, ;s �' / ,i r rr rJi/i�/r%'/�j�/I%/�!l/i�iio, ''' ; r r 9 a r, //,./ / //W �01/ ✓1����// /il��//r/�J�i �u����, �1������� (r ,.,: J Ji ., o,,,, �r/, t ,,, r ,,, ,//r✓.,i,io i iii; r. ,� r.. r/,1, ,,., „ -rr ✓��s.�.ill ri��c�/%�%/� �//1f/� /L„1../i /f //� r ,.,;,, ,i„ _: ,.,/ ,. .'���.� ilFr',.�/� � Y ,..Mfr//,i, Su .ervisor�s C �� ” /�r�/i//rr //(r /�/ /„,r /i�f/ / i„ /L,r ✓/ /l�/,, � c,,,, ,,,, /r�i��/i,,,i, io,���+��,�,�r /, / ri., r .� r ,.r �i . ,,,, ,,,,,,, ,, i,,r;.0 r rr r ,,, % ✓„ i ///...,/. /l, //�/ � llC l >%// he.�%/,/.r/r ✓ r//,r / /// r/ rof/r,.,,;,,,,,, � ,, ..., D,/,,,:,ri r oil',. r � ra i, rt ,,,,,!✓ r,� %i/��,�. rr. ,;�� �.'�>l. ��.��;r hHomerlm rovement� %ice�se � ��". ” �v r .!,.. � E•Xp,. �Date�,,, �, ��� �'%� %/ �, f ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE":BULDINO PERMIT;$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ � 0 .. R N Check No.. Receipt _ NOTE: Persons contracting with unregistered contractors coo not have access to the guarantyfund �griture_ofAgenf/Owrier Signa%ure af•contractory 'Town ofNORTH 2 *. . _ L Andover ® ® -t I L �,° :�.�. h ver, ass, coc Nlc"t-WICK S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System I (a BUILDING INSPECTOR THIS CERTIFIES THAT ........................: . .�4.I!!►.......................................:........... . ............................... Foundation has permission to erect buildings .... ,L ...... Rough tobe occupied as ......... ... .. ... ....... ................................ .. .......................................................... Chimney provided that the person accepti this permit shall in every respe 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 PERMITIE IN 6 MONTH ELECTRICAL INSPECTOR rUNLESS CONSTRUCTIO R Rough Service .. .......... ................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' 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 • Roofing a LeBlanc• Siding Jerry • Gutter Construction Supervisor Specialty License • Painting9 Atkinson Depot Road License:CSSL-099633 Restricted To:RF WS Plaistow, NH 03865 Tr#:5177 Expires:1011512015 • Carpentry Windows Home (603) 382-0817 Home Improvement Contractor • • Snow lowin Cell (978) 835-7740 Registration: 149881 P 9 Expires:2/16/2016 PROPOSAL SUBMITTED TO PHONE DATE � ISTREE JOB NAME limit/ CITY,STATE AND ZIP CODE JOB LOCATION ARCHIYECT' DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: / zwl z Z ZZ Ga � zA / t SA ,.��s� A,�� � 6� /✓tai F�r �s 1 a •r . .. 7/ Start within days Complete in 30 days. r We propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of, dollars ($ )• f,,� r"r:,�.L-' d"r^c Payment to be made as follows: l I t All material is guaranteed to be as specified.All work to be completed in a workman- like manner according to standard practices.Any alteration or deviation from above Authorized 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 prop6sal 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. itit ®f Proposal -The above prices,specifications and con ons are satisfactory and are hereby accepted.You.are authorized to do the work as specified Payme' twill be made as outlined above. Signature Date of Acceptance � ' Signatur 1 r i; L i; The commonwealth of Massachusetts Departmez2t oflrzdustrial�Aceldents Q. u 1 Congress Sheet,Suite 100 =: Boston,MA.02114-2017 www mass.gov/dia Workers'Compensation insurance Affidavit: HEWITH TPEgN1ITrTINGAUTHORZTX.tricians/Plumbers. TO BE'FILFjD Applicant Information Please Print Le ibl Name(Business/Organization/Individual): rkftj �P L Address: k City/State/Zip: 0 Phone#: Are you a employer? ec'kthe appropriate box: Type Of project(]'equired): Ch 1. am a employer with employees(full and/or part-time).* 7. 0 New construction 2. I am a sole proprietor or partnership and have no employees working forme in 8. []Remo delhig any capacity.[No workers'comp.insurance required.] 9, U 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. l will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-cointractors listed on the attached sheet. 13.E]Roof repairs These siib-contractors have employees and have workers'comp.insurance., 19 ❑Other 6.Q We are a corporation and ifs offieers have exercised their right of exemption per MGL,c. 152,§1(4),and we have no,errnployees.[No workers'comp,insurance required.] *Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information. I Ilomeowners who stbaf this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 those entities have , employees. If the sub-contrac&s have employees,they limit provide their workers'comp.policy number. X am an eniployei•that is pi•ovidiiag workers'compensation insurance for my employees.'Below is the policy and,/oh site information. Insurance Company Name: Policy#or Self-ins,Lic.#: ' / 1 �l ExpirationDate: L v d' fob Site Address: f' —City/State/Zip: Attach a copy'of the WO Akers com �nsationt pobley declaration page(showving the policy number and expiration date). Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 I as civil penalties in the form of a STOP WORD.ORDER and a fine of up to$250.00 a and/or one-year imprisonment,as wel be Office forwarded to the Oce of Investigations of the DIA for insurance day against the violator.A copy of this statement may coverage veriftoation. -- �"do hereby certify under thepains andpenalties of per jury that the information providedabove is true and correct. • � Date: Si nature: Phone#: Official use only. Do not write in this area,to he completed by city or town official. City or Town: PermitlLicense# Issuing Authority(circle one): i 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6,other Contact Person: Phone#: GERALEB-01 JONEILL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/1/2015 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 CONTACT NAME: Durso&Jankowski Insurance Agency PHONE 978 688-7000 FAX No: 978 688-7001 11 Saunders Street (AIM, Ext):( ) ( ) North Andover,MA 01845 A DRIESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Preferred Mutual Insurance Co. 15024 INSURED INSURER B:MSA Group 14788 Jerry LeBlanc INSURER C:Hartford Insurance Co. 9 Atkinson Depot Road INSURER D: Plaistow,NH 03865 INSURER E: 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBRI POLICY EFF POLICY EXP TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDNYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 300,000 DA AGE TO RENT CLAIMS-MADE OCCUR BOP0100717134 05/01/2015 05/01/2016 pREMiSEs Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 300,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 600,000 X POLICY❑PE� LOC PRODUCTS-COMP/OP AGG $ 600,000 OTHER: BIND AUTOMOBILE LIABILITY EO a.id.ntSINGLE LIMIT $ 500,000 B ANY AUTO B1 B2755S 01/04/2015 01/04/2016 BODILY INJURY(Per person) $ OWNED ALL OWX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ H $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N/A 6S60UB2E34123415 08/06/2015 08/06/2016 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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 Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover,MA 01845 ,/ AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD irlrrrf r{rifl . �C� % crc1�€r.F! r ;flftace f 0usumerAffairs&Business Regulation lE lA1P€OEP�rT CONTRACTOR gitcatCgn: `,1881 . Type:, xpiration. , 2/1f016 . Individual ERR P! LANt� JERRY LEBLANC ATKINSZ7N DEPOT RD p1 t:,l_AIST W,NH 03865 Undersecretary i Massachusetts Department of Public Safety Board of Building_ . Regulations and Standards .r License: CSSL-099633 Construction Supervisor Specialty JERRY P LEBL'ANC 9 ATKINSON DEPOT ROAD PLAISTOW NH 03865 J i MA„, CA- Expiration: ,f Commissioner 10/16120.17