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HomeMy WebLinkAboutBuilding Permit # 6/22/2016 Identification- Please Type or Print Clearly OWNER: Name: 4L 0(Z Phone: S, A -Address: Contractor Name: P h o n e: Email: Z­ 61,n �4" Address: D Ie -:5� 7 7-) tJ7)cA,1%'R, Supervisor's Construction License: —Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: —Reg. No. FEE SCHEDULE.BULDING PERMIT.$IZOO PER$1000.00 OF THE TOTAL ESTIMATED COST jRON$125.00 PER S.F. Total Project Cost: $ `7 FEE: Osr Check No.: /9z, Receipt No.: E2 1 NOTE: Persons contracting with unregistered contractors do not have access to the Iguaranty fund If rus /s/i %A®R'T#j Town ofAndover 2 0 . ® �•P' ver, Mass, O �LA ,®S RAT@D U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT . .. 0 ... .................... BUILDING INSPECTOR ® has permission to erect .......................... buildings on .......... ... ...... .. . ... : .... ........ ... .................... Foundation Rough to be occupied as .. ....AMA, .. .... .. 401&.. .. .................... Chimney provided that the person acc pting this permit shall in every respect conform to the terms of t e 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 EXPIRESPERMIT IN 6 MONTHSELECTRICAL INSPECTOR UNLESSRough Service ...,. Final BUILDIN PEC R GAS INSPECTOR ccupancp Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises ® Do Not Remove Final No Lathing or Dry Wall To. Be one FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts 1 Department of Industrial Accidents � � 's Office of Investigations 600 Washington Street d Boston,MA 02111 !% www.mass.bgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PleasepPrintLegibly Name (Business/Organization/Individual): )\C.L—KLT— I—A NC`s V 1 �J �j N: A- Address: —I 9-4�_ D M'E S-7- city/state/zip: tJ o,-r4 Phone#: 9 7 G Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I ain a general contractor and I 6. ❑Newconstruction employees(full and/or part-time)." have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. # 7emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] employees. [No workers' 131-1 Other comp.insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit 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 their workers'comp.policy information. 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: Job Site Address: d 51®�-�h'i S--r— City/State/Zip: P,j - A-N Dymsik, m A _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' under lie pains and penalties of perjury that the information provided above is true and torr ect� Si ature: Date: Phone#: c1 -7 e:5' 3 6 ©- ®fficial use only. Do not write in this area,to be completer[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#: 1 _111 4,. :,;0; P0 0. EVINi Building& Remodeling ' Homeowner Information Contractor Information Name Company Name Pr jd� p v >aW� P F-V7 u �� � ,.ten 01 Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name Cityaown State Zip Code Business Address(must include a street address) Daytime Phone Evening Phone CityfFown State Zip Code Mailing Address(It different fro ab Business Phone Federal Employer ID or S.S.Number Home Improvement Contractor Reg Number F-xpiration date Lav requires that most home improvement contractors have a valid registration number 1 � 1 /^dA 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.) C,� �Y� D_' - 1 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 he excluded from the Guaranty Fund provisions of C�) Date when contractor will begin contracted work. MGL L chapter 14.2Ae) 0 r 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: $ � upo 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 forbid$demanding full payment until contract is completed to both party's satisfaction) The following materiaVequipment must be special $ paid for ordered before the contracted work begins in order to meet the completion schedule.(*'°) $ o e paid for NOTES:(i`)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 orderSOin advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor'slel.®Yes(all terms of the warrantv 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 docurrlent,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. o 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. may ` &� f d9 .. t 6 r DEBT LANGE 795 Dale Street North Andover, NSA 01845 f�cd D® CERTIFICATE OF LIABILITY INSURANCE /A (MhVDOiWrr) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDS .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($), 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 polioY,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). G1 Edward W Hays PRODUCER NAME: Hays Insurance Agency Inc. PNDNE . (978)686.3162 FAQ Ne; (979)689-4425 36 Hawthorne Ave. ADDA& haysinsurance(gIcomcast.net INSURrRM AFFORDING COVERAGE NAICO Methuen Ma 01844 INaURERA: Norfolk&Dedham Mutual Fire Insurance Company INSURED INSURER a Robert Langevin INSURERC: 795 Dale St INSURER D: INSURER E North Andover Ma 01845 1 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 DE-SCRI13ED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POU F POLICY EXP LIIllRS L TYPE OF INSURANCE eR POLICY NUMBER M —Off"" X COMMERCIAL GENERAL LIARIUTY EACHOCCURRENCE 3 1,000,000, CLAIMS•MADE 0 OCCUR :MIS Ea Occur nos) S 100,000- MEO EXP An one peTp S 5,000- A R0514357A 10/25/2015 10125/2016 PnSONALBADVINJURY S 2,000,000. GEN'LAGGREGATE LIMIT APPLIESPER: GENERALAGOREGATE S 2,000,000- PRO- PRODUCTS-COMPIOPAGG S 2,000,000. POLICY a JECT F]LOC $ OTHER: COMBINED BIN rr Ea accide t S AUTOMOBILE LIABILITY ,�-- --^-- BODILY INJURY(Por person) S ANY AUTO ALL OWNED SAu�SULEO BODILY INJURY(Par 80000M) S AUTOS - PROPERTY DAM g NON-OWNED Por aeCide HIRED AUTOS AUTOS S UMBRELLA LlAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE 5 S DED RETENTIONS PER OTH- WORKERS COMPPNSATION STATUTE R __ AND EMPLOYERS'UAaIUrY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE E.L•EACHACCIDENT S_ NIA A QFFICERIMEMBERExCLUDED9 (MandaloryInN14) EL.DISEASE-FAEMPLOYEE S itge deembe under E.L.DISFASE-'POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES(ACORD 101,Addillonal Remarke Schedule,may be elteChed IFmom space In roQV[red) Carpentry CERTIFICATE HOLDER CANCELLATION =� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE FXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORZEDREPRESEN $8-2014 ACORR CORPOFOMON. All rights reserved. ACORD 2 4101 ACORD name and logo are registered marks of ACORD Vlassachuset_s vePart~i �: _ � o is S�.,e_y Board o;Building Regulations and Standards License: CS-002685 ROBERT M LANGEVIN 795 DALE STREET NORTH ANDOVER MA 01845 Cn1 02/24/2018 Office of Consumer Affairs&Business Regulation (HOME IMPROVEMENT CONTRACTOR Registration: 111990 Type_ \\ _'PExpiration: 2111/2017 LLC ROBERT LANGEVIN BLDG&REMOLDING LLC. ROBERT LANGEVIN 795 DALE ST N ANDOVER,MA 01845 Undersecretary