HomeMy WebLinkAboutBuilding Permit # 9/8/2016 t%ORTFI
BUILDING PERMIT °�`zT`E° IQ6
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
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Permit No#: �• "' Date Received 9a�tr�o r=�"Ry
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Date Issuer. 0
IMPORTANT: Applicant must complete all items an this page
LOCATION
PROPERTY OWNERYC/ _. _.�C (��
,� Print 100 Year Structure yes no
MAP PARCEL:0, ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
w 'n K 0 Floor) lain ❑Wetlands ❑;llVatershed Dtstrrct <
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DESCRIPTION OF WORK TO BEP RPOR!KED:
Identification- Pjlggse Type or Print Clearly
OWNER: Nam/e:,
j / 1 /°� Phone:
Address: /4� i Mf
Contractor Name: Phone:
Email:
Address: / - l L..
Supervisor's Construction License: Exp. Date:
/9///
Home Improvement License: � `-5 � Exp. Date, l
ARCH ITECTIENGINEER Phone:
Address: Reg. No.
FRE SCHEDULE. BULDING�RMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
C
� � � b � —
Total Project Cost: $ FEE: $
Check No.: 4- Receipt No.: e
NOTE: Persons contracting with unregistered contractors do not have access,to the uaranty fund
41- - --
NORTH q
Town of -i , 6 over
0w .ys. 0
No.
i
� yah ver, Mass,
6W161"
cocN[c„[w�cr 1'
aRAYEo i`Pp '�5
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BOARD OF HEALTH
Food/Kitchen
PERMLI T L D Septic System
THIS CERTIFIES THAT ...........V ..31AC&= 'IK ..�IC . . . .... ....... .. .. BUILDING INSPECTOR
has permission to erect ....... ............I... buildings on .� ,,,,,�CI;!� .. Foundation
1 , Rough
tobe occupied as ........ ........ ... � ............................................................... Chimney
provided that the person accepting this permit shall in eve respect conform to the terms of the application every pp 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 CONST TION Rough
Service -
.... ......, ......., ............... .,. ..... Fina[
BUILDING IN EC OR
GAS'INSPECTOR
o t ..,._.,u ilclin�
OCelc,�a�teV Permit RequiredRequired �' ®CC,„�� By 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 Approved by the Building Inspector. Burner
Street No.
Smoke Det.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 26158
POLICY NO, AWC-400-7014648-2015A
PRIOR NO, I AWC-400-7014648-2014A
ITEM
1. The Insured: Arthur Walsh
DBA: A J Walsh &Sans
Mailing address: 159A Waverly Road FEIN:**-***6792
North Andover, MA 01845
Legal Entity Type: Sole Proprietor
Other workplaces not shown above: See Location
2. The policy period is from 11/14/2015 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 06 B
D. This Policy Includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration E Remuneration Premium
INTRA 40579
3 �
INTER SEE.CLASS CODE SCHEDU E
Total Estimated Annual Premium
i G V—GOV Deposit Premium
STATEiCLASS,
MA I 5403 State Assessments/Surcharges
$.00 x 5.7500% 4 $
This policy, including all endorsements, is hereby countersigned by �C "'�� �-" '- '� `-� 11/05/2015
Authorized signature Dale
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.
f ,
"Page# ofpages
CS # 022680 978-688-6737
HIC# 103358 A. J. Walsh & Sans or
159A Waverly Road 1-978-912-2853
North Andover, MA 01845
j Proposal Submitted TV-
Job
Job Name �P1N ,lob#
le
Address w Job l.Ot3ation
Date �e,/ - fate of Plans
Phone# w" Ls � r , Fax# Architect
We hereby submit specifications an estimates for: — –
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y accordance with the above specifications;or the sum of
complete in
^"00
prop labor—
We ro -se hereby to furnish material and la
o (. a° J'� "Aa� Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications Involving extra costs will be Respectfully
executed only'upon written order,and will become an extra charge over and submitted
above the estimate.All agreements contingent upon strikes,accidents,or delays
beyond our cohtrol. Note—this proposal may be withdrawn by us R not accepted within days,
The above prices,specifications and conditions are satisfactory and are
Signature
hereby accepted.You are authorized to do the work as specified, ,, f
Payments w111 be made as outlined above.
Gate of Acceptance Signature
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
This Form satisfies-all basic requirements of the state's Home lnrtprovemenf Contractor Law(MG4 chapter 142A),but does not include standard
language to protect homeowners. Seek,legal advice if necessary. Any petson'planning horitityihinprnvtments ahonld fiistobfam a copy of"a
Massachutetts';consumerguide to home improvement"before agreeing to any work on ynurrrsideace,You may obtain a firco copy by'calling the'
Office,of Consumer.=Affairs;and Business Regulation's Consumer information Hotline at617-973+8787 or 1+888=2834757;
Homeowner Information 'Contiractor Information
Name 0
L easy NoneStrectA ..
�. r
ddrass do not use a Post Office Box�address) ntracior/ al n/DwncrlName .
V All 419
ANk
ty�� StateCela us oras Address(mfisl include a street ,}
Daytime Phone Evening Phone ilyrro tato ip Code
'A abs k
Malling Address(It different from above) 3usiness phone edcra1 Empleyer ID or S.S.]Numbs '
Gw require tEst nog Lwoaim. Hama IWPMvemmf Caamdar
. t+a�co®I arntr�etmi Wwe� ) �"
sad rgWsda•n,m�Mr
The Contractor agrees to do the following work for the Homeo Her;
lkequlred'Pernsits-The following builtlin pormits arerequired Proposed Start and Completlon Schedule-The 161lowing scbedule will
and will be secured by the ottntractor'as the'hotncowner's agent; be adheredto'i riles circutnsmnces beyond:the contmotoes contmi ariso
(Owners who;secure their own permits will be
excluded:frotm,the,GuarauityFund.proAsionsof Datowhencohtmetorwill begin ontractedwork
MGL chapter 142A.)
ate when contracted ,work I be substantially-completed,,
Total Contract Price and Payment Schedule ,
The Contractor.agrees to perform the'.wofam
rk, ish the material and labor specified above for the total sum of
Payments will be made according tothe following schedule:
W 60
g uponsigning contract'(not,to exceed 1/3 of the total.eontract price,qr the coscof special order items,whiebever is greater) '
S bye /_ or upon completion of
$ m by / or upon completion of
� ,r�R=ltd upoit completion of the contract '(Law forbids demanding full payment until.contract is completed to both patty"a satisfaction)
The following material/equipment must be special $ to be paid for "
ordered before the'contracted Work'begins in order $ to be paid for
to meet tlie,completion sehadule.(••)
]VOTE$;(•)including all ftasaw charges(")Law requires that any depositor down-paymeat required by+thewotmaor before work begins may'
not exceed the greater of(a)one-third of the total contract price or(b)the actual con of any q=iatequipment or custom made material
which must be special ordered in advance to meet the completion schedule.
120 YSA all.t.r.. f, n .,....ed n
Subcontractors Tho contractor agrees to be solely responsible for completion of the work daacn'bed mgardleas of the actions ofauy t}ifrd
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 percetnent
carefully before contract"I ti imply that this any lion or other security interest)w been placed on the residence. Review the following cam s and
notices the
Contract Acceptance-Upon signing,this document becomes a bindm contmct under.law" Unless otherwise
gning
ons and notices
• Don't be pressured into signing the contract Take time to mad'and fully understand k'Ask'iiuestictis ifsi u`sethiiig is unclear.
• Make sure the contractor has a volidHome imurovemerytS ppusotor Reyistration The 9,v requires most home improvement contractors and.
subcontractors to be registered with the Director ofHome Improvement Contructcir Registration. You may inquire about.comractor
registration by writing to the Director at°.One Ashburton Place,Room 1301,Boston,MA 02108 orby calling 617-727-3200 ox
1-800.223.0933.
• Does the contractor have insurance? Check to see that your"contractor is properly insured.
• Know your rights and responsibilities. Read the bnporiaptluforrnation on the teveraeside of this foiain 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 conhactdr's'normal place of business,provided you notify tine
contractor in writing at his/hermain ofn6e or branch office by ordinary merit posted,by telegram sent or by delivery,not later than midnight of tha,
thifd business day following.the signing of this agreement",See the attached notice of cancellation form for an explanation of.this right
DO NOTSIGN THIS CONTRACT IF THE'RE ARE ANY BLANK SPACES!fr
Two idendatl eapim orthtmstnetmuatbeeamptetcd.andsianed One copy.alnuldgo tante haenrawa he other copy should be kept by the eentriaor:
L✓
eowner s Si rare12 ,
Z4,
✓ Contractor's Signa
Date
Date
_ The Commonwealth of Massachusetts
Department of IndustrzalAccldents
;, -u•- F 1 Congress Street,Smite 100
-Boston,MA 02114-2017
www.mass.gov/dia
orlters'Comp ansatiouInsurance Affidavit:Builders/Contractors/Electr:icians/PlAmbers.
TO BE FILED'Gi'1TIT THE PERMITTING AUTRORITY.
A itcantinforamati.on j J 1'1easePrint I,e 'b1
Nain.e (Business/Oxganizatlonl.Cudivzdual): � ✓
Address:
City/State/Zip phone
Are you an employer?Clzecktiie apliroprlate box: Type of project(VgquirW):
1.2<aemployer-with._:_/—i "ployow(full and/or part-time).* 7.- p Neva'colist7ructiOn
2.EJ i am a sole proprietor or partnership and have no employees working for me in 8. ❑Remo deug
any capacity.[No workers'comp.insurance required.] 9, Demolition
3 Q I am a homeowner doingall work myselz[No workers'comp..insuranca required.]t 10 0 Building addition
4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. Iwill
11.❑Electrical re airs or additions
ensure that all contractors either have workers'compensation insurance or are sole rep
*8
withno employees. 12. Plumbing repairs or additions
5.❑I am a general contractor and I hate hired the sub-contractors listed on the attached sheet. 13. Riso repaixs
'`hese sob-contractors have employees and have workers'comp.insurance.
• 14. Other
S.Q We are a corporation pad ifs officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no.,eoyees.Mp workers'comp,insurance required.]
Anyapplicantthat checksboxB1mustalsoidlloutthesectionbolowshowingtheirworkers'eempensationpolicyinformation
i Homeowners tibho subm if lvs affidavit indicating
they are doing aff work and then hue outside contractors must submit a now afdaYrt indicating snob
tContractors that cbeckthf box must ai#ac�red an additional sheet showing the name of the sub-contractors and stato whether or not those entities haV@
employees. Ifthe sub-coniracors liave employees,iliay rruast provide their workers'comp.policy number,
worliers'compensation insurance-for employees.`Beloip is thepolicy an
xar72 an erraployertlzat ispYovirYingdjob site
in -mation.
001
Insurance Company
�
I policy#or S elf-ins.Lic.a :
41 o01 V`6 Expiration.Date: ` l
rob Site Address: City/State/Zip: --
@ Attach a copy of thewoykers'compepsation policy difflaration page(showing the policy number and expiration.date).
B
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 ting of p to$250-00 a
o day against the violator.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
°s. coverage verifloation..
i do hereby cer " under.the pains arZZ�
lties ofperjury that the information provideve i tru cl correct.
Of
Si ature: Date:
Phone#:
Official use only. Do not sprite in this area,to be completed by city or'town officiaL
City or Town. Permit/License#
issuing Authority-(circle one): i
L Board of Health 2,Building Department 3.City/Town Clerk d.E,lectrical inspector 5.Numbing Inspector
6.Other
Phone#:
Contact person:
Massachusetts Department of Public Safety
Off[ceofConsumerAffaiis&Bnsinessite Regulation r Board of Building Regulations and Standards
( HOME IMPROVEMENT CONTRACTOR License; CS-022680
Registration. 103358 Type:
' Construction Supervisor
y Y� Expiration 7/7/2018 Private Corporation
A.J.WAL$H&SONS,INC ARTHUR J WALSH JR \
169A WAVERLY RD
N ANDOVER AVIA 01846
Arthur Walsh
55 Pleasant St
N Andover,MA 01845 Undersecretary
Expiration:
Commissioner 06/0912018