HomeMy WebLinkAboutBuilding Permit # 6/21/2016 .............
%AORTH
BUILDING PERMIT a D
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
AcHus
Date Issued: 061
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
MAP A, P A R C E L:,,Z i'c Print 100 Year Structure yes 0
ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
El New Building Pedine,family
[I Addition [I Two or more family Li Industrial
R'Alteration No. of units: 11 Commercial
ri Repair, replacement Li Assessory Bldg [I Others:
El Demolition F1 Other
'06
11011
DESCRIPTION OF WORK TO BE PERFORMED:
/lo"t Za"I 1wp/ Z I I "'Ce A X
4;r
6 6`j
Identification- Please Type or Print Clearly
OWNER: Name: Phone. 6 �il
Address:,K!/0
Contractor Name:�'Y-,,^ IS P h o n e: 3 d,,Z
Email:
Address".'"
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c 11
Supervisor's Construction License:/0-5--Wqv"!�—/t -Exp. Date:
Home Improvement License: Exp. Date:
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: $ roz 000 FEE: $
Check No.: Receipt No.: e
NOTE: Persons contracting with unregistered contractors do not haveaccess to the guaranty fund
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tkORTH
Town of Andover
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o : LAKE h Ver, Mass,
ell
COCHIC..!W.C.{ ,
®S RATED P.?�,`'�5
U BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT .................6111. .. ........ ... ..... .. ... .. ......................... ...............
BUILDING INSPECTOR
has permission to erect . buildings on .. ,.... , . ..f././,.� .. ............... Foundation
......................... . ........ ..... ..
Rough
to be occupied as . .....� ....... .. ... ... ........... ... .l.�r. ... /p .. .. ... ,. ............ 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
EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS Rough
Service
............... ............... . ..... ... Final
BUILDING ECT R
ti GAS INSPECTOR
ccupancV Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Massachusetts Home
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.
IRjTomcowQcr nfTU a.tlon • Contractor Information
Name Company Name
Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name
c",
Cityfrown statei. Zip Code Business Address(must include a street address)
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16) llfkvt�,me( /'VIA 9/, X�
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Daytime Phone Evening Phone City/Town State Zip Code
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P /Vi -7 7,rf`3
MailingAddress(It different from above) Business Phone I Federal Employer ID or S.S.Number
Home rropro—ot Conond.,R19.Number Fphii..data
L-requires thot most home
improvement W.do.have
vAd qr'
B1.11-ntm,be,
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 ifinecessary.)
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
excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work.
MGL chapter 142A.)
j2 /6 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:
2,0�00C` upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater)
by "„ / J or upon completion of
$_L1_0_1101 " by-2-J-2--4)�6_or upon completion of
0,_01',t' 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:(1)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.
L,xt)i.esswal.l.nll!y-f,q,q1texpi-essivii-i-aii!3!beiiiapi-ovidedbvtliecoiiti,actoi-? �No E]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 flarther agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this aereement
ContractAccep(ance-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.
• Dont be pressured into signing the contract.'Me time to read and fully understand it. Ask questions if something is unclear.
• Make sure the contractor has a valid Home improvement ContTactgLRegistration. 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 "proof of insurance"document.
• Knowyour 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 Tinprovement Contractor Law.
You may cancel this agreement if it has been signed at a place other Bran the contractor's normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mad 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 ofthis right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
'Lll� lea]co* of the contract in st be completed and signed.One copy should-a to the homeowner.The other copy should be kept by the contractor.
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Porneowner's Signature Contra 's Signature
Date Date
---------- ---------- ----- ----------------------------
Ray's Cabinet Shop Inc. Grasso
153 Foundry Street 210 Candlestick Road
Wakefield, MA 01880 North Andover, MA
(781)-245-0428 5/20/2016 01845
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---------------#4 201 3/4
The Commonwealth of Massachusetts
Department of IndustrialAccidents
d 1 Congress Sheet,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information // Please Print Legibly
Name (Business/Organization/Individual): ��'!/✓�— ���lG��s L�—�
Address: le' 6'
611114Vc✓ce JAZ- 7 s�
City/State/Zip: kt4411%, SIAy Phone#: �7V'-30,2-716 d
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.1 iq I am a sole proprietor or partnership and have no employees working for me in 8. remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
• 12.E]Plumbing repairs or additions
5. am a generacontractor and hhid thb ttlid thttachedht
I have hired sub-contractors listed on e asee.
❑I l 13.F1 Roof repairs
• These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.❑Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box 4l must also fill out 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 new affidavit indicating such.
tContractors 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-contracfors have employees,they must provide their workeis'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date: Vo✓ / d 0l 6
Job Site Address: CWla le-lc 1CY /U de/ City/State/Zip:AI ,,�1We/ 0/9- —
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.
I do hereby certify under thepains andpenalties ofpeijuiy that the information provided above is true and correct.
Signature: Date:
Phone#: 9Zf-3C, -7%s e
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#:
CERTIFICATE LIABILITY INSURANCE DATE(MMMONYYY)
06/03/2016
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: It 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 PAUL DEVIN
NAME:
ADVANTAGE INSURANCE AGENCY INC. PHONEFA%
(wc,Na,Exq_ 978-681-1055 (Arc,Na):978-794-4833
184 PLEASANT VALLEY STREET E-MAIL
ADDRESS:
METHUEN, MA 01844 INSURER(S)AFFORDING COVERAGE NAIC0
INSURER A:WESTERN WORLD INSURANCE COMPANY
INSURED INSURER B;BERKSHIRE HATHAWAY
PRIME BUILDERS, LLC ---- —
INSURER C:
18 COMMERCE WAY SUITE 7250 _......_ _
INSURER D:
WOBURN MA 01801 ---- -------_ ....._-.._
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.
LTR TYPE OF INSURANCEPOLICY EFF POLICY IEXP
INSR WVD POLICY NUMBER (MMIDD(YYYY) (MWDDIYYYY) LIMITS
A GENERAL LIABILITY NPP1427169 11/18/201 11/18/2016 EACH OCCURRENCE $ 2,000,000
COMMERCIAL GENERAL LIABILITY E 'HtN ENe) 10(j 000
X PREMISES(Ea occurrence) $ r
CLAIMS-MADE E—]OCCUR MED EXP(Any one person) $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE s 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPICP AGO $ 2,000,000
POLICY jE� LOC $ '..
AUTOMOBILE LIABILITY
(Ea accident) S _
ANY AUTO BODILY INJURY(Per person) $ '....
ALL OWNED SCHEDULED
AUTOS BODILY INJURY(Per accident) $
NON-OWNED DA �� E__—_.........._.___—_—_______.___........._._.......
HIRED AUTOS AUTOS (Per accident) S
UMBRELLA UAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
B WORKERS COMPENSATION R2WC600704 11/19/201511/19/2016 STAT - O -
AND EMPLOYERS'LIABILITY YIN -..- TORY LIMITS X ER 1,000,000
.�. _..__ ......_.........�—............_.
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OFFICERIMEMBER EXCLUDED? N/A _
(Mandatory In NHi E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(Attach ACORD 141,Additional Remarks Schedule,if mora space is required)
GENERAL CONTRACTORS, EXECUTIVE SUPERVISORS
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER
1600 OSGOOD STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING 20, SUITE 2035 ACCORDANCE WITH THE POLICY PROVISIONS,
NORTH ANDOVER MA 01845
AUTHORIZED REPRESENTATIVE
----------------------
cV 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
........
In Massachusetts -Department of Public Safety
MW Board of Building Regulations and Standards
Construction SuperN icor
License: CS-108209
RYAN GRASSO
12 BONNY LANE
North Andover 1VIA OT845
'A
Expiration
Commissioner 12107F2018
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991M )of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DP5 Licensing information visit: www.Mass.Gov/DPS
d,
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 185393
Type: LLC
Expiration: 6/7/2018 Tr# 289245
PRIME BUILDERS LLC
RYAN GRASSO
12 BONNY LN.
NO. ANDOVER, MA 01845
Update Address and return card.Mark reason for change.
SCA 1 20M-05/11
Address ❑ Renewal 7 Employment Lost Card
cam'
Office of Consumer Affairs&Business Regulation License or registration valid for individual use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 185393 Type: Office of Consumer Affairs and Business Regulation
Yp g
Mi� //"Expiration, 8/7/2018- LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
PRIME BUILDERS LLC