HomeMy WebLinkAboutBuilding Permit # 7/29/2016 tkOF?Th
BUILDING PERMITb�'�o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION o
Permit No#; I Date Received ppgATEOWp"4R`�
gs$s�cHUSEt
Date Issued: Zai
PORTANT: Applicant must complete all items on this page
LOCATION � �
Print
PROPERTY OWNER
Print 10Q Year Structure yep n
MAP .-)Of PARCEL S ZONING DISTRICT: Historic District yes no
Machine Shop Village yes Cnol
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Buildingne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DF�SCRIPTION Ol= WORK TO BE, ERFOR�D: _,.., � -
Identification- Please Type or Print Clearly
OWNER: Name: zy
19
VaL GCS Phone:
Address:
Contractor Name:
4&s %4 e' Phone:
Email: -
Address:
Supervisor's Construction License: �, Exp. Date: he
Home Improvement License: / Exp. Date: .Z
ARCHITECTIENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:SULDIN MIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS�.T�BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.: `1�
NOTE: Persons contracting with unregistered contractors do not have ac ss o th guar my fun
4 NORT#1
own of i _ : Andover
No. M_ _ �-
h ver, Mass,
A04A-rEU
`S U BOARD OF HEALTH
PERM T LD Food/Kitchen
n - Septic System
THIS CERTIFIES THAT �'+�` C Com,,... BUILDING INSPECTOR
" Foundation
has permission to erect..........................buildings on ...�....� . -. C .... .. , ..
.�, po Rough
to be occupied as ......... ... ....�+ . ... .... �r .......................................... Chimney
provided that the erso�ce tin his ermit shall In every respect conform to the terms of the application Final
P p p p
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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONS Tl Rough
Service
...... ..... Final
I G 1NSP CTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Ro6gh
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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Page# _ Of Pa es
GS #022680
Vropoal978-688-6737
HIC# 103858 A. Jr Walsh Sans or
159A Waverly Road 1-978-912-2853
North Andover, MA 01845
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Job#
proposal submitted To
Address pate
of Plans
Date ' Architect
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ax
Phone#
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We hereb submitspecifications and estimates for
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We propose hereby to fumish material and labor—complete in accordance with the above specifitions for the sum of:
Dollars
with payments to be made as follows:
An alteration or deviation from above specifications involving extra costa will be Respectfully
Any
executed only upon written order,and will become an extra charge over and submitted r r ,��✓
above the estimate.Ali agreements contingent upon strikes,accidents,or delays days
beyond our control.
Note—this proposal may be withdrawn by us if not accepted within _____
cce��ali�ce c>I� �u�a��rY �
The above prices,specifications and conditions are satisfactory and are i Signatur8
hereby accepted.You are authorized to do the work as specified."
Payments will be made as outlined above.
Date of Acceptance Signature
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
This fort satiaQas'all basin retquiramepts of the state's Home fmprovemenf C4ntmotor Law(MGL.chapter 142A),but doer+not Include stsadhid
language to pratectbomeowners.Seek lege[a6vlce if necessary. Any pepon'planuin home4aprovemctits sltould first obiain a copy of"a
Massachusetts'.oonsumerguidotohome,improvotnent"befdre agreeing to any work on yourresideno:4 You may obtain a free copyby'callingthe'
Office of Consumer-A(fairs and Business.Regulation's Conautnor lnfonnsdon Hotline st 617.973?8787-or 1x888-283-3757r '
Homeowner Information Contractor Information
(itoiG 1wY
8trectA doaot ostOf cc Box *O§) Contract e/.6 Name
Cityff State Zip Cada usiness s(most include a street address) .
Daytm6Phone Eveningrhositi I Ity/rown State Zip
MailiogAddress(It di—mulfromabove) us;ae Phodn edoalEmpieyermorS. .Number ,-
lar mqulrts nulmo)I Somelml Hama ICmewarag�NrnM RnN�a"s.
The Contractor agrees-to do the following work for the Homed Here
01 7TF Da wouno WHOM M
N
Required Pe -its-The following building pcimits are tegisired Proposed Steri add Completlaa ScLedetle-The fdllowiitg schedule will
and will be secured:by the contractor'as the'hotneowher's agent; abeadhoftrilassciroumatances Beyond=tha wntractors`cnntrol arise
(Owners who.8ecure their own perMts w111 be
exeluded1rom:the-Guaranty Fuiid`provisionsofata whencoatraetorwillbegincontmatedwork
MGL chapter 142A.)
ate whom contracted .work will tie substantially completed..
Total Contract Price and Pa mentScbedule
The contractor.agtees to perform tlio work,furni4h the material and labor spccified above for the total sum of
Payments will be made ac@ording to the following schedule;
$ upon,signingepubwt(giottb,&xmdi/3of.thetotal.'oontmelpricekgI the cost.of spatial order items,ivhichavzr is greater)
S ------ by or uponeompledonof
S by ! /_or upon completion of
$ 4/0� upon completion of the contract (law forbids demanding full payment undl,contract is completed to both party`s satisfazoon)
The followiegmatedsVequipmetmust bespecial Sbe paid for
ordered befom tWoontracted'work'beginx in order S�bepaid for
to meat liao,cainpkbtiea sahadule.(11)
. . 'NOTES:(o)including all finance charges(—)law requires that any deposit or down-payment required by the contractor before work begins may -
notaxceedtbegreatarof(s)one•thirdofthatotalrontact priceor(b)theatidalcostofanyspecial_equipmentorcatommadematerial
which must be special ordered in advance to meet the-completion Irhedulc.
an extire3swarmarg helo uToyl0ed by the o Y r of o .th'.e
Subcontractors-Ma contractor agrees to be solely responsiblo for co6pletion of the work desenbe d ragerdlesa ofthe'ections`ofaoy third
party/subcontractor utilized by the contractor, The contractor further agrees to be solely responsible for all payments to ell subcontractors fon
materialsunder this nereernent
Contract Acceptance-Upon signing,thi's document becomes a binding contmctunderlaw. Unless otherwise noted within this document the
contract shell not imply that any lien or other security interest)m been placed on rho residence. Review the following cautious and notices
carefully before signing this contract
• Don't be pressured into signing the contract.Take time to read'iad fully understand k-Ask'4uoitiotis ifaonu'thiag is unclear.
The law requires most home improvement contractors and.
subcontractors to be registered with the Director ofHome improvement Contractor Registration. You may inquire about ontraetor.
registration by writing to the Diroctor at One Ashburton Place,Room I3Q1,Boston,MA 02109 orbyealling 617-727.3200 or
1-800.229.0933.
• Doers the contractor have insurance? Check to see that yourcontractor ispropody insured.
• Know your rights and responsibilities, Read the Lmportspt Lnformsdon on the raverse-sida of this fdim and gat a copy of the Consumer
Guider to the Home lalprovemrnt Contractor Law:
You may cancel this agreement if it hes been signed at a placeotherthan the aontmutdA,normal place of business,provided you notify the
contractor in writing at his/her main off&e or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight ofthe.
third business day following the signing ofthis agreement.See the auached notice of cancellation form for an explanation ofthis right
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!11
- TwaideadralrnpiesohOaecopyihould Soto lhoud bekept bythernnetwor.a -
`/ kiomcowner`s Signature .:Contractor's Signature .
O
Data Dafo
The Commonwealth of,Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/lndividual): ���/ lJ ` -�
Address:-
City/State/Zip: /"hone#: �' `�7
Are you an employer?Check th appropriate box: Type of project(required):
1. I am zmployer with 4. Q I am a general contractor and I 6. ❑New construction
empl es(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am i le proprietor or partner-
These sub-contractors haus 8. Demolition
ship ai ave no employees ❑
workin r me in any capacity. employees and have workers' 9 ❑ Building addition
o wo s' com insurance comp.insurance
p 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
requirecr,T-
officers have exercised their
3.❑ I am a homeowner doing all work 11,L]Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12. Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.—1 Other
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 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
they must provide their workers'comp.policy number_
employees. if the sub-contractors have employees,
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information. r
Insurance Company Name:
Policy#or Seff--ins.Lic.#: Expiration Date:
Job Site Address: City/StateMp,�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure.coverage.as requited 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 Gerd der t pains and penalties ofperjury that the information provided above is true and correct:
Signa J , Date:
Phone M.
Official use only. Do not write in this area,to be completed by city or town offwiaX
City or Town: . Permit/License#
Issuing Authority(circle one
1.Board of Health x wilding Departme .City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Phone#:
Contact Person
WORKERS COMPENSATION INFOREMPLOYERS MATION PAGE LIABILITY INSURANCE POLICY
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington,Massachusetts 01803-0970
(800)876-2765 NGCI NO 26158
POLICY NO. [_A-W—C-400-7014648-2015A
,PRIOR NO. AWC 400-7014646-20#4A
ITEM
1. The Insured: Arthur Walsh
DBA: A J Walsh&Sons FEIN:*k_***6792
Mailing address: y Road
No9lth Andovler,MA 01845
Legal Entity Type: Sale Proprietor
Other workplaces not shown above: See Location
2. The policy period is from 11!1412015 to 11/14/2016 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ _ 100,000 each employee
C, Other States Insurance: Coverage Replaced by Endorsement WC 20 03 05 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4 infrm an
premiumThon this d lacy will e determined
e rminverificationby our Manuals of
and change by Rules,Classifications,Rates and Rating Plans.
All
I Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
k — ,
i
INTRA 40579
INTER SEE!CLASS CODE SCHEDU E
Minimum Premium $500 Total Estimated Annual Premium $500
Deposit Premium $500
GOV GO'
STATE CLASS State Assessments/Surcharges
MA 5403 $.00 x 5.7500% $'
11/05/2015
This policy,including all endorsements, is hereby countersigned by - Authorized signature Date
Service Office: Durso&Jankowski Insurance Agency LLC
54 Third Avenue 11 Saunders Street
Burlington MA 01803 North Andover,MA 01845
WC 00 00 01 A(7-11)
Includes copyrighted material of the National council on compensation Insurance,
used with Its permission.
i
p
Massachusetts Department of Public Safety
' Board of Building Regulations and Standards
License, CS-022680
Construction Supervisor
ARTHUR J WALSH JR
159A WAVERLY RD
N ANDOVER MA 01846
(�Z, Expiration:
Commissioner 0610912018
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
} j Registration: 103358 Type:
�tr
1r Expiration .71712018 Private Corporation
A.J.WALSH&SONS'INC.
Arthur Walsh
55 Pleasant St
N Andover,MA 01845 Undersecretary