HomeMy WebLinkAboutBuilding Permit #950-16 - 1520 Forest Street 3/8/2016A -d
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date
ANT: Applicant must complete all items on this
LOCATION sjrrt&.�-
Print
PROPERTYOWNER -�Oe_"�)rCky\CA5�
I oc� Print
MAP NO J PAR ELPD6 ZONING DISTRICT: -Historic District yes no
0
Machine ShoD Villane ves rn
TYPE OF IMPROVEMENT
PROPOSED USE
Resid tial
Non- Residential
Ll New Building
Ybne family
Ll Addition
0 Two or more family
0 Industrial
El O!teration
No. of units:
U Commercial
V'Repair, replacement
tj Assessory Bldg
[I Others:
[I Demolition
El Other
0 Septic D Well
.0 Floodplain El Wetlands
El Watershed District
[I Water/Sewer
tAcOr,l( np� _�6,-e, c,_)ood&Jyve- s,--jd,4
�rlln
i,o -e,.-, / -,n
Identification Please Type or Print Clearly)
OWNER: Name: S Phone:
Address:
CONTRACTOR Name:, 11 1 L -ells k rw__ Phone.
Address: �J .5 �,c4,e__ DrLv<, 6/4/30
Supervisor's Construction License: C S -I 0(o3L[,r
Home Improvement License: I _T� k U
Exp. Date: to� S 1 1-7
Exp. Date: wi I
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT., $12.00 PER $1000-00 OF THE TOTAL ESTIMATED C ASED ON f 124.00 PER S.F.
Total Project Cost:$ FEE:
Check No.: 1-1 Receipt No.
NOTE: Persons contractine with unregistered contractors do not have access to tWe guarantyfund
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Location 16 2 fA
7-:5
No. _LI�50- 2o\� Date
Check# )-� 6 1
0 U >
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
Plans Submitted"e, Plans Waived Certified Plot Plan SVfMp�_-d Plans
TYPE OF SEWERAGE DI-SPOSAL
Public Sewer Tanning/Massage[Body Art SwimmingPools
well Tobacco Sales
El FFoo7dPackagiugg/Saijes� '�Elii-,
Private (septic tank, etc. Permanent Dumpster on Site, r]
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
I
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature'.
'CONSERVATION Reviewed on Si
gnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection Driveway Permit
DPW Town Engineer: Signature:
;;q; Z;:T::: Located 384 Osgood Street
r um
Film" Epn�,, TIFUENT. P§ter- omsite,�k- -.yes
K - MIP L
cate at 1
iMnS?j!eeVt
a menN, 4 p,
,�ignatureigatp)nn �Qj
14�1;# 4W, Y_510
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NT
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M E.
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions. -
Total land area, sq. ft.:
ELEGTRIGAL.- Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGE I ZONE LITERATURP" Yes No
MGL Chapter 166 Section 21A—F and G rnin.slao-si000 fin
Doc -Building Pennit Revised 2014
#
ppropriate permit to be obtained.
The following . is a list of the required forms to be filled out for . the a
Roofingg Sidingg Interior Rehabilitation Permits
,4: Building Permit Application
4. Workers CoMp Affidavit d/Or C.S.L. Licenses
, Photo Copy Of H.I.C. An
4,
Copy of Contract 0 nterior Work
Floor Plan Or Prop sed 1 4 -
Engineering Affidavits for Engineered prodUCLO Permit
mits require sign off from Fire Department prior to issuance of Bldg
JOTE: All dumpster per
Addition Or Decks
Building Permit Application
Certified Surveyed plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
copy of Contract n of Proposed Work With Sprinkler Plan And
Floor/Cross Section/Elevationpla
Hydraulic Calculations (if Applicable)
Mass check Energy compliance Report (If Applicable)
- Eng . in - eering Affidavits for ngineere pro ance of Bldg Permit
OTE: All dumpster permits require sign off from Fire Department prior to issu
New Construction (Single and Two Family)
Building Permit Application.
Certified Proposed plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit To Be Returned) to Include Sprinkler Plan And
Two Sets of Building Plans (One
Hydraulic Calculations (if Applicable)
Copy of Contract
66 2012 IECC Energy co
4� Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
al permit was required the Town Clerks office must stamp the decision from the Board of Appeals
In all cases if a variance or speci of Deeds. one copy and proof of recording
that the appeal period is over. The applicant must then get this recorded at the Registry
must be submitted with the building application
Doe: Building Permit Revised 2014
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On Duty Chimney Sweep, LLC
On Duty Chimney Sweep, LLC
19 Stodge Drive
Ashburnham, MA 01430 US
(978)696-7933
info@ondutychimneysweep.com
http://www.ondutychimneysweep.com
Joe Francis
1520 Forest Street Extension
North Andover, Ma 01921
Estimate
Date
Estimate #
01/22/2016
1489
• Parts and Materials - Stainless Steel (304) Heavy Gauge Smooth Wall
Exp. Date
2,000.00
Activity
Quantity
Rate
Amount
• Parts and Materials - Stainless Steel (304) Heavy Gauge Smooth Wall
1
2,000.00
2,000.00T
Liner [6"x35']
• Labor - Breakout of existing tile and disposal.
1
550.00
550.00
• Labor - Chimney Liner Installation
1
450.00
450.00
• Parts and Materials - Liner Insulation Wrap
1
250.00
250.00T
• Labor - Wood Stove Installation
1
200.00
200.00
Thank you for choosing On Duty Chimney Service. Here is your estimate for work
requested. Please contact us with any questions.
SubTotal
$3,450.00
Tax (6.25%)
$140.63
Shipping
$50.00
Totall
$3,640,613
n
Accepted By Accepted Date
A 50% down payment is. Are uired prior to scheduling or ordering of materials.
M
The Commonwealth ofMassachusetis
Department ofIndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual):
S
Address: QbhAe, 'OrIV'e�
U
city/state/zip:_A,6�,; rp, �-Am A, o(q,?C) Phone #: 7 3
Are you an employer? Check the appropriate box:
Q� �am a employer with ___q employees (full and/or part-tirne.)_
2Q I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp- insurance required]
3.E] I am a homeowner doing all work myself (No workers' comp. insurance required.] t
44-11 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 arc sole
proprietors,%vith no employees.
5.E] I am a general contractor and I have hired the sub -contractors listed on the attached sheet
1hese sub -contractors have employees and have workers' comp. iDsurance.t
6.n 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.]
Type of project (required):
7. E] New construction
8. F1 Remodeling
9. D Demolition
10 E] Building addition
I I.FJ Electrical repairs or additions
12. F1 Plumbing repairs or additions
13.E] Roof repairs
14.[UAher Ck)_zAkA1f_,4_
t liv.— lltskLo
*Any applicant that checks box #1 must also fittout 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 now affidavit indicating such
tContractors that checkthis 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 munber.
Iam an employer that isproviding workerscompensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Q? Expiration Date;
.;2 —,5K ti
Job Site Address: f 15) 2, 0 :a e2_4: -,c, - ek City/State/Zip: Kky�k I f' Arl 0 q �, (
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.
Idoherelycert!fyunderthe ains andpenalties ofpeijury that the information provided above is trite and correct
Sianature: Z� �n Date: 6Z�/I/A/,
Official use only. Do not write in this area, to be completed by city or tmpn official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone #:
'IV
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city!Dr town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
;A4C0RE0 CERTIFICATE OF LIABILITY INSURANCE
I ilk.� -
DATE (MWDDNYYY)
1 10/09/2015
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: Michael Ware
PHONE TFAx
UVC, No. Ext): (978) 343-4853 1 (A/C, No):
CHOICE INSURANCE AGENCY INC
E-MAIL
ADDRESS: mware@choice-insurance.com
INSURER(S) AFFORDING COVERAGE NAIC 9
376 SUMMER ST.
INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666
FITCHBURG MA 01420
INSURED
INSURER B:
INSURERC:
LEBLANC BRYAN DBA ON DUTY CHIMNEY SWEEP
INSURER D:
INSURER E:
19 STODGE DRIVE
INSURER F. -
JASHBURNHAM MA 01430
COVERAGES CERTIFICATE NUMBER: 4864 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
LTR
TYPE OF INSURANCE -_
ADDLSUBR
POLICY NUMBER
POLICY EFF
(MMIDDNYYY)
POLICY EXP
(MMIDDNYYY)
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
CLAIMS -MADE 1:1 OCCUR
DAMAGE To RENTED
PREMISES (E. occurrence) $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
N/A
GENI_ AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $
PRO- 0
POLICYFJ JECT LOC
PRODUCTS - COMPIOP AGG $
$
OTHER,
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NIA
BODILY INJURY (Per accident) $
NON -OWNED
HIREDAUTOS AUTOS
PROPER DAMAGE
(Pr..Z 'I $
UMBRELLA LIAB
IOCCUR
EACH OCCURRENCE $
EXCESS LlAo
I CLAIMS -MADE
N/A
AGGREGATE $
DED PrTENTION $
$
A
WORKER COMPENSATION
S
AND EMPLOYERS' LIABILITY YIN
ANYPROPFZIETOR/PARTNERIEXEC.,��E I NA1
OFFICER/MEMBER EXCLUDED?
NA
NIA
6HUB51355440615
08/13/2015
08/13/2016
ER OTH-
T TU
X FsFA TE ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE- EAEMPLOYEE1 $ 100,000
(Mandatory In NH)
If yes, describe under
E.L. DISEASE - POLICY LIMIT I $ 500,000
ON OF OPERATIONS below
7
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more spare is required)
Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to
employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date ofthis
certificate of insurance. The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at
www.mass.govAwdtworkers-oompensation/investigations/.
LEBLANC BRYAN has elected coverage.
CERTIFICATE HOLDER ramrr-I I ATInti
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Cleghorn Plumbing
ACCORDANCE WITH THE POLICY PROVISIONS.
142 Clarendon Street
AUTHORIZED REPRESENTATIVE
Fitchburg MA 01420
Daniel M. C y, CPCU, Vice President — Residual Market — WCRIBMA
�4
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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313/20-16 Office of Consumer Affairs & Business Regulation - Mass.Gov
The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR)
Consumer Affairs and Business Regulation
Home Consumer Rights and Resources Home Improvement Contracting
HIC Registration Complaints
Registration 173166
Registrant ON DUTY CHIMNEY SWEEP
Name BRYAN LEBLANC
Address 19 STODGE DRIVE
City, State ASHBURNHAM, MA 01430
Zip
Expiration 09/10/2016
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund histo! -y.
Back To Search
@ 2012 Commonwealth of Massachusetts.
Mass.Gov@) is a registered service mark of the Commonwealth of Massachusetts.
Home Improvement Contractor
Registrabon Home Page
kArd (19py watkAl C)rN +4vA
hftps://services.oca.state.ma.us/hicAicdetails.aspx?bctSearchLN=75045 1/1
Date -2
Town of North Andover
Your permit has be7 k to you for the following reasons:
Check amount incorrect
4-Ij / Lo j oe-
42)�Ntio copy of current license -e -e -
3) insurance Binder not on file or expired
4) No Workers' Compensation Insurance Affadavit Form
Please call with any questions 978-688-9545. Fax 978-688-9542
Workers� Compensation Form and Schedule of Fees can be found on the Town of North Andover
Website under Building Department.
MailingAddress:
600 Osgood Street, Building 20, Suite 2035, North Andover, MA 01845