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HomeMy WebLinkAboutBuilding Permit # 11/2/2016 �awTa� BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION $4 Z n o m _ �� Permit No#: � Date Received �� ' R'�s RATEO sACHUS Date Issued: 1. t IMPORTANT: Applicant must complete all ite�ts t��this page LOCATION 9&1 Print ".z �- , �, � �� PROPERTY OWNER �!! f' Print I D Year Structure yes Ino MAP PARCEL: 0 ZONING DISTRICT: Historic District yes Uno Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Buildingne family [I Addition F1 Two or more family [I industrial [I Alteration No. of units: [i Commercial epair, replacement ElAssessory Bldg [i Others: ❑ Demolition ❑ Other ,( r .., . _ DESCRIPTION OF WORK �: TO BE PERFORMED: Identificati© - Please Type or Print Clearly9 OWNER: Name: s t" Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's ConstructionLicense: Exp. Date: pDate -... Home Improvement License: < -- ARCHITECTIENGINEER P-honee Address: FEE SCHEDULE:BULDING PERMIT:$12.00 AER$1000.00 OF THE TOTAL ESTIMATT g� I$125.00 PER S.F. Total Project Cost: $ FEE $ Check No.: Receipt NC1_ _:3 `/:2 NOTE: Persons contracting With unregistered contractors do not av access to the gu ranty fund , .: ................ ............................................. .... OORY'�g q own of ndover O w"' �► No. 4 + soh ver, Mass, 6 [o[MiC ME w.L.f ry' 1 �,4 A��arFo ►' r7 S U BOARD OF HEALTH PERMIT . T LD Food/Kitchen Septic System THIS CERTIFIES THAT D4 ,�.�C C BUILDING INSPECTOR ................ Foun dation has permission to erect .......................... buildings on .....�.,�.`7..........�4.. " � . .......s.r�/ Rough tobe occupied as ........ . .. .....�`............I�„E..r� .................................................... 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 PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR . . UNLESS CONSTRUCTION,OVARTS Rough .......... .. .. ................................... Service Final BUILDING INSPECTOR GAS INSPECTOR ®ccu anc 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 Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements ofthe 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. /Homeowner Information Contractor Information d �f `Y V•ot '= 41-0 Camp � e fW f Street Address(do not use a Post Offt Box address) ntra CoSalesspjerso 0 erName - I .r4 42 try o Stat Zip Code Business Address must include a street address) 0� la S • Daytime Phone Evening Phone CitrtT State Zip Code 71 OX m J Mailing Address(I[different from above) Busintss Phone Federal Employer 11)or S.S.Number }Iamelmpsavemear Cont—L.r Reg.Nwabs Exphatlondate Law regalres that most home [mpern -- a wlfJ ughtntran uumher 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 if necessary.) 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 A&10 excluded from the Guaranty Fund provisions of ��ITlafe when contractor will begin contracted work. MGL chapter I42A.) rAl Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule RE The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum o. (*) Payments tsss will be made according to the following schedule: $ -' upon signing contract(not to exceed 113 of the total contract price or the cost of special order items,whichever is greater) $ by 1 l�or upon completion of $ f}}}by I /_ or upon completion of $ 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 $ Ld 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. Ex rens Warrart -Is an exprwarranty heinz provided by the contractor? ❑No EiWes(nl1 terms of the warrnz&must he 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 furUter 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 Cully understand it. Ask questions if something is unclear. • Make sure the contractor has it valid Home Improvement Contractor Rel istration. 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 ofthis 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. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two ideartcal copies of thecontsact must be comploled and signed.One copyshould go to the h er.T,ie othereopy shout .ep by the ntractor. r3 Home6vm/egr's Signature Co // gg ctor's Signature-1 Date bate The Commonwealth of Massachusetts Department of lndustrialAccidents 1 Congress Street,Suite.100 K Boston,MA 02114-2017 Fy,' www.mass gov/dia E Workers'Compensation.insurance Affidavit:Builders/Contractors/Li lectricians/Plumbers. TO BE FILED WITH THE PERMIT i'1NG AUTHORITY. Applicant Nformation Please Print Legibly Narrl.e (Business/Organizationgndividual): A245 r Address: 1.� ' �• City/State/Zip: C�(3iIC!p d' f Phone#: 57,1_6g_? Are you an employer?Che ekropriate box: Type of project(required)' l i 1,� am a employer with (full and/or part-time).* 7. E]New construction 2.01 am a sole proprietorGr partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself:[No workers'camp.insurance required.]t 10 []Building addition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. epalrs These sub-contractors have einployeos and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing then`workers'compensation policy information. t Homeowners who submi0bis 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-conic actors have employees,They niu t provide their workers'comp:policy number. I arta an entployer itiat is providing ivorkers'compensation insurance far my employees.' Belofp is the policy and job site information. Insurance Company Name: ............. Policy#or Self-ins.Lie. Expiration Date: L5 7 f1 w Jab Site Address City/State/Zip: / 11l �71f Attach a copy of the workers' 6ompep't9dion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 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 laei-eby c 'ify,under the p 'zs d nalties of pet jury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not xvrite in this area,to be completed by city or tofvn official.- City or Town. Permit/License# 1'ssuing 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#: DATE(MMIDDIYYYY) ,acorro CERTIFICATE OF LIABILITY INSURANCE 1 11/0212016 THIS CERTIFICATE 15 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 lieu of such endorsement(s). PRODUCER NAAME: Elizabeth Chavez DEGNAN INSURANCE AGENCY, INC. PHONE (978)688-4474 E-ADDREMAIL SS: echavez@degnaninsurance.com de naninsurance.com 85 SALEM ST. INSURER S AFFORDING COVERAGE NAICl/ LAWRENCE MA 01843 €NSUReRA; AIM MUTUAL INS CO 33758 INSURED IN5llRER B; JAMES DEBRECINI INSURERC: FAMILY ROOFING & PAINTING INSURER D: 2 TANAGER WAY iNSURERE: LONDONDERRYNH 03053 1 INSURER F: COVERAGES ��-_a --- CERTIFICATE NUMBER: 99599 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. ADDL SUER POLICY EFF POLICY EXP IL7R TYPE OF INSURANCE= POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE El OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PROJECT 1-1LOC PRODUCTS-COMPIOP AGO $ $ OTHER: AUTOMOBILE LIABILITY Ea accidennt51NGLE LIMIT $ BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED NIA BODILY INJURY(Per accident) $ AUTOS AUTOS NONI--OWNED PROPERTY DAMAGE $ HIRED AUTOS I AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MAGE NIA AGGREGATE $ DED RETENTION$ _ $ WORKERS COMPENSATION /\ STATUTE ERH AND EMPLOYERS'LIABILITY Y 1 N FlNYPROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1�0,�00 A OFFICERIMEMBEREXCLUL NIA NIA NIA AWC40070259002016A 05/11/2016 05/11/2017 EL.DISEASE-EAEMPLOYEE $ 100,000 (Mandatory In NH) If yes,describeunder E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below NIA DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES tACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only,Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in slates other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-comp(:nsationiinvestigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET BUIDLIGN1600 OSGOOD STREET BUILDING 20 S AUTHORIZED REPRESENTATIVE CJ NORTH ANDOVER MA 01845 Daniel M.Cro y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts Department ot"PUblic Safety s ` Board of Building Regulations and Standards . License: CSSL-099685 Construction Supervisor Specialty f JAMES J DEBRECEN[ 2 TANAGER WAY LONDONDERRY NH 03053 'Expiration: Commissioner 12/0612017 . %� nn Forrrrrrc, rrrrrnll�a��il�rttrsc�rerell� "' Office of Consumer Affairs&Business Regulation Q HOME IMPROVEMENT CONTRACTOR i7 Registration, .122385 Type. f Y�� J Expiration 81261201.8 DBA FAMILY ROOFING 8.PAINTING JAMES DEBRECENI i 30 RIVER ST. METHUEN,MA 01844 Undersecretary