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HomeMy WebLinkAboutBuilding Permit # 5/11/2016 ®�BUILDING PERMIT �aoca , t.�`'Eo gu 4'O TOWN OF NORTH ANDOVER ® APPLICATION FOR PLAN EXAMINATION Permit No#: �� !� 1 Date Received Arep " �SSgcHus�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION ° fes✓ Print PROPERTY OWNER 40r G-T; ¢ Print 100 Year Structure yes no MAP l2 2PARCEL:/ -'� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Mne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial "epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other gfSe`ticr ❑Well rFloodplam ❑wdtlands` ❑ Watershed District 7 77, i DES RIPTIO F WORK TO BE PERFORMED: :�qlr 1 Identification- Please Type or Print Clearly OWNER: Name: L— ' \IM kr I i4q Phone: � C - Address: ' Aydi ) r Contractor Name: r -Ill Phone: Email: Address Supervisor's Construction License: I Exp. bate:/ w �� Home Improvement License: c Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST&4SE1-Offl$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.:. NOTE: Persons contracting with unregistered contractors do not have access4a the gu fund r t Andover tk®RTH Town of4 a N" _; ai ® 4 �AK� ver, ass, s� • c COC "IC"I_CO ��• BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT -.. �:c BUILDING INSPECTOR has permission to erect buildings on �����`� v �� Foundation S 7�Ti� / Rough tobe occupied as ......................................................................................................I.............................. 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 Rough Service ............. ...... /....................................... Final BUILDING INSPECTOR GAS INSPECTOR Ccupa cE Permit Required to Occupy By Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathingor Dry Wall To Be one FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Massachusetts Rome Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Comp Name Street Adjr less(do not use a Post Offic x address) Contractor/Sales rson/Owner ame 1160010-1v- City/Town St_ Zip Code Busi essdd s ust include a street address) Daytime Phone Evening Phone Cilyfrown State Zip Code I f-0?-.5-197 Mailing Address(It different from above) Business Phone I Federal Employer ID or S.S.Number Homelmpmtementc-usaor Reg.Number Expirauan date Law nqulras that most bomc r� ...^^^ ImproZvement contncton have 1� - /� valid oratlan number V$ The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) frf p ,moo Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be ad ered to unless circumstances beyond the contractors control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of / Date when contractor will begin contracted work. MGL chapter 142A.) A� Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (*) Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by _/_/— or upon completion of $ by / / or upon completion of $ (� upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Lawrequires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or cusiom made material '.. which must be special ordered in advance to meet the completion schedule. Express warranty-Is an express warranty beine Provided by the contractor? ❑No Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner.The other copy shoo ept by the antrnctar. � ' " A . 0� Homeowner's Signa Co ctor's Signature Date Date CIX The Commonwealth of•Massachusetts f (Department of IndustrialAccidents _d X Congress Sheet,Suite 100 µ_'Y Boston,MA 02114-2017 .��,'•.••...yJ�Gt www.mass.gov1d1a '... Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ApplicantInforma.flon Please Print Ledb NaMe(Business/Organization&dividual): Address:_ JCM rwl1 City/State/Zip: I VIl&i2[Y- v Phone#: Are you an employer?C$ecktfie app,r"opriate ox: Type of project(xequired): 1.Er1 am aemployerwithIi employees(full and/or part-time).* 7• ❑New construction 2. 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3,❑1 am a homeowner doing all work myself.[No workers'comp.-insurance required.]t 9. El Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5. 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. ❑ I3. oofrepairs These stib-contractors have employees and have workers'comp,insrrrance.t 6.F] We are a corporation and its officers have exercised their right of exemption per MGL c. ld ❑Other 152,§1(4),and we have na 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 subnnlif this affidavit indicating they are doing all work and then hire outside contractors rriust submit a new affidavit indicating such. 1Contractors 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. 1 tae sub-contractors havo employees,1hey must provide their workers'comp.policy number.' 1a an employer Mat ispiovldiiigworlkers'compensation insurancefor•my employees.'.below is thepolley andjob site information. Tnsurance Company Name; Policy#or Self-ins,Lic.##:/l`Ge. '��Q W ����7�� f� Expiration Date: `/ rG-/� ' Ci /State/Zi i� Job Site Address: t3' p� Attach a copy of the workers'compensat on 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. Y do hereby cer • under•tli ins ndpenalties ofperjury that the information provided above is true and correct. Si nature: Date: Phone ",::� rL7 Official use only. Do not rvrite 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.PIumbing Inspector 6.Other Contact Person: Phone#: ® DATE(MM/DD/YYYY) Aar®I�® � CERTIFICATE OF LIABILITY INSURANCE 03/15/2016 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(les) 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 NAME:CONTACT Carla M Degnan DEGNAN INSURANCE AGENCY, INC. P"C"o . (978)688-4474 �c Ne: E-MAIL ADDRESS: cdegnan@degnaninsurance.com 85 SALEM ST. INSURERS AFFORDING COVERAGE NAIC# LAWRENCE MA 01843 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: JAMES DEBRECINI INSURERC: FAMILY ROOFING & PAINTING INSURER D: 2 TANAGER WAY INSURER E: LONDONDERRY NH 03053 INSURER F: COVERAGES CERTIFICATE NUMBER: 37186 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 ADDL SUBR POLICY NUMBER MMLDDmYY MMI-DD�YY LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F OCCUR PREM SO ESEaEoccu ence $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY FPRO LOC PRODUCTS•COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOSAUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ER H AND EMPLOYERS'LIABILITY -- — "-- ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 A OFFICER/M EMBER EXCLUDED? I NIA N/A N/A AWC40070259002015A 05/11/2015 05/11/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE1 $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space 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 of this 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.gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. 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 Bldg 20 Suite 2035 AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD 1 1 - t��e�o�+ta�t.ollt�eeall�o- Cldd�ic 1C[Jrilfv y Office of Consumer Affairs&Business Regulation E 1;,,AFTOVEMENT CONTRACTOR Type: jpCistration: 122385xpiration: 8/26/2016' DBA J&D WEATHERSEAL t= JAMES DEBRECENI 2 TANAGER WAY g LONDONDERRY,NH 03053 . Undersecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-099685 Construction Supervisor Specialty JAMES J DESRECENI 2 TANAGER WAY LONDONDERRY NH 03053 Expiration: Commissioner 12/0612017'