HomeMy WebLinkAboutBuilding Permit # 5/13/2016 ...........................................................
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BUILDING PERMIT '[,ED
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received A
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 13(;,f 6 4� /t/, A(y,
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building [] One family
n Addition El Two or more family El Industrial
El Alteration No. of units: El Commercial
[AlRepair, replacement El Assessory Bldg ii Others:
El Demolition 11 Other
,,Se tiFlood af
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly -6
OWNER: Name: (6,rol 6-00 Phone:?/f
Address: I 7 J> Rd /(J, Aficl,
Contractor Name: Phone: 61�lhfla
Email:
Address:
Supervisor's Construction License: tr Exp. Date:
Home Improvement License: ExD. Date: e,
ARCHITECT/ENGINEER Phone:
Address: Reg. No.--,
FEE SCHEDULE.BULDING PERMIT. $12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 4 FEE: $
Check No.:312).' Receipt No.: C? 'Z 7
t
NOTEq: Persons contracting with registered contractors do not have acre s' gnca ntyfund
F NORTH r9
Town ofAndover
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BOARD OF HEALTH
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ERMITFood/Kitchen
Septic System
09./' ,,J U"sBUILDING INSPECTOR
THIS CERTIFIES THAT ..... . 1................:
.... .......................................................... ........................
has permission to erect . buildings on ./:?l.. .. � C . . Foundation _
Rough
to be occupied as .............................. (G ....A,
................................................................................... 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
PERMITI ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
Service
......... ...
x................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Displayin a Conspicuous Place on the Premises — Do Not Remove Final
NoLathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Massachusetts Home 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 617-973-8781 or 1-888-283-3757 or on our website.
Homeowner Information Contractor Information
Nanw, Company Name
Street Address(do t use a Post Offic x address) Contractor/Sales rson/Owner Name
pip
City/r State Zip Code Business Address(must include a street address)
Daytime Phone Evening Phone City/t'own'/�/j ��ff State Zip Code
Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number
Home rmpro,emcnt Contnctorttq.Number Eapintion date
law requiter that mon home /•� J
Impmvementcontnrtonhavc q (g "1/_ `•P
—lid
regin /_,/ntion number �3"" �6G+
The Contractor agrees to do the following work for the Homeowner: <C✓
(Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.)
r Pt 1r-
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 adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be j
excluded from the Guaranty Fund provisions of / Date when contractor will begin contracted work.
MGL chapter 142A.) &//j__
40 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 o. �,�� M
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
$ 3-56 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(**)Law requires 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 custom made material
which must be special ordered in advance to meet the completion schedule. I V
Express warranty Is an express warranty being provided by the contractor? 11LyNo 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 shout kept by the contractor.
cJ t
w A- Z
Homeowner's Signature
Con tot's Signature
L
Date Date
,aCOR®® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
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 Ileu of such endorsement(s).
PRODUCER NAME: Carla De nan FAX
DEGNAN INSURANCE AGENCY, INC. PHONE 978 6884474 A/C No:
MAIL
ADDRESS: cdegnan@degnaninsurance.com
85 SALEM ST. INSURERS AFFORDING COVERAGE NAIC#
LAWRENCE MA 01843 INSURERA: AIM MUTUAL INS CO 33758
INSURED INSURERS:
JAMES DEBRECINI INSURERC:
FAMILY ROOFING & PAINTING INSURERD:
k�TANAGER WAY INSURER E:
LONDONDERRY NH 03053 INSURERF:
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.
ILT R TYPE OF INSURANCE ADDL SUER POLICYNUMBER MM/DDS MMIDD� LIMITS
LTR
COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $
NTED
CLAIMS-MADE F OCCUR PREMISES Ea occurrence $
MED EXP(Any one person) $
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY❑jECT F LOC PRODUCTS-CO AGG $
$
OTHER:
AUTOMOBILE LIABILITY EOM�d ntSINGLELiMIT $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $
AUTOS AUTOS
HIREDAUTOS
NON-OWNED
PROPERTYDAMAGE $
(per
e accident
$
UMBRELLA LIAB HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED I I RETENTION$-_ $
WO KERS COMPENSATION X STATUTE ER
AND EMPLOYERS'LIABILITY Y I N
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000
A OFFICER/MEMBEREXCLUDED? NIA N/A NIA AWC40070259002015A 05/11/2015 05/11/2016
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEEI$ 100,000
If yea,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
N/A
l
The Commonwealth ofMassachusetts
F department of IndlustrialAccidents
" - 1 Congress Street,,quite 100
Boston,M4 0.2114.2017
. www.mass.gov/dia
Workers'Compensation insurance Affidavit:Builders/Contractors/Llectricians/Plumbers.
TO BE FILED WITH THE PER141ITTING AUTHORITY.
Auplicant Information /- Please Print Legibly
Name(Business/Organization/Individual): dc"M S°✓� / � J�I
r
Address: �C ef(c
City/State/Zip: tooder Ali If Phone#:
Are yon an employer?Checkth;a propriate box: Type of project()Vequired):
l.�t am a employerwith _ employees(full and/or part-time)." 7, Q New construction
2.[I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself[No workers'comp..insurance required.]t
10FJ Building addition
4.❑I 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 are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.[_,J Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[j<oof repairs
These sub-contractors have employees and have workers'comp.insurances
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§1(4),and we have na employees.[No workers'comp.insurance required.]
`Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
Homeowners who subr6if flus 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-contractors fiave employees,'they lint prosde their workeis'comp.policy number.
I am an employer°that is pi opidiizg wor k6s'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name: A `% y
Policy#or Self-ins,Lic.#: A4 WO, 70 X579 61' Expiration Date: f 7
f /
�
L2 �� �
lob Site Address: b e �G /V 14r)City/State/Zip: / r)(/i /*
Attach a copy of the workers'compensation policy declaration page(sho-iving 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.
X do hereby c •tify un der tl in and penalties ofperjury that the information provided above is true andcorrect.
Si nature: Date 4
Phone#:
Official use only. 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#:
Massachusetts Department of Public Safety
tBoard of Building Regulations and Standards
License: CSSL-099685
Construction Supervisor Specialty
JAMES J DEBRECENI
2 TANAGER WAY - -
LONDONDERRY NH 03053 q -
Expiration:
Commissioner 12/06/2017
ell.V1.1),,d,,Vea��/alQ�Kawadte,4e4 License or registration valid for mdividul use only
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation.
egistration: 122385 Type'. 10 Park Plaza-Suite 5170
zpiration 8/ 612018__, DBA 1 .m,''�-Boston,MA 02116
J-&D WEATHERSEA t
r `
to JAMES DEBRECENI ,�� ->r
2 TANAGER WAY g
LONDONDERRY,NH 03053 Undersecretary Not valichthout signature
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