HomeMy WebLinkAboutBuilding Permit # 11/18/2016 BUILDING PERMIT No�zrW
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TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION ''
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Permit No#: Date Received oR rEV
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Date Issued: L
IM ORTANT: Applicant must complete all items on this page
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MAP: PARCEI✓ Z ANO DlSTR1GT Historac D7str�ct des„ 1�0
Machine Shop Village ro
TYPE OF IMPROVEMENT PROPOSED USE
Residen ' I Non- Residential
❑ New Buildingne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ VIlatershed Dct
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❑1Nateil5ewer '
ESCRIPTION OF WORK TO BE PERFORMED:
dentification- please ype or Print Clearly
OWNER: Name: �C Phone: z
Address:
Contracta� Name
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Ernai
Atltlress "
5uper�isors Cnnstructiort License Exp Date � � �
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Home [rnproVemen License.. Exp... Dade .
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.,BULDINCY PERMI $92.00 PER$90 0.00 OF THE TOTAL.ESTIMATED COST BASED ON$925.00 PER S.F.
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Total Project Cost: $_ � _FEE: $
Check No.: Receipt No.:
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NOTE: Persons contracting with unregistered contractors do not have access te�he guaran fund
f.
Signature of AgentlOwner ' Signafu. o contractor;'
tkpRTH
own of 2Andover
No. �
1Y , -
t„K. h ver, Mass, 016
c0[glS..e WOCK �lk'
U BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT �S W,1 rV Cr• BUILDING INSPECTOR
................................i4............ ........... ............ ............ ...................... ....
. +�� Foundation
has permission to erect ...... building on �'S so I c�,..,....'s,I.................
.................... ..........................................
..Mr. . 0 R C A ooi' Rough
tobe occupied as ............ ..� ..... ..,.... .. ...................................................................... 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 IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION S. S Rough
...............
Service
.. .. ... ..... .................. ..
BUILDING INSPECTO:R Final
GAS INSPECTOR
OccupyncE Permit Required to Occupy Ruildin 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.
Page# of pages
CS # 022680 978-688-6737
HIC# 103358 A. J. Walsh & Sans or
159A Waverly Road 1-978-912-2853
North Andover, MA 01845
Proposal Spbikked To Job Name ' Job#
�r
Address , o�" j Job Location
Dates,
Ef,
Plan
Fhne# ,p � � q� Fax# Architect
hereby submit specifications and estimates for:-�.._����r�:"
"
We propose hereby to furnish material and labor—complete in accordance with the above specificatis for the sum of:
Dollars
i
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed on�+'upon written order,and will become an extra cargo over end submitted � ��� �� t°d°
above the estimate.All agreements contingent upon strikes,accidents,or delays
beyond our cohtrot. Note—this proposal may be withdrawn by us 9 not accepted within days.
�[cicle tatt�e,n� �� to
P
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e above prices,speoitfoations and conditions are satisfactory and areSignat,fi°reby accepted.You are authorized to do the work as specified.
Payments will be made as outlined above. P
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f
Date of Acceptanceg
Si Helot® � ��
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
This f0rm.satis54is`all basic rcquirements of the state's Home lmprovemeat Contractor Law(MOL chapter 142A),but doei not Include standard
language to prniectbomeawnerx. Seek,legal advice if necessary. Any poison'plannmg hotitc improvements shoulditisf-c ifain a copy of"a
Massachusetts oansutnarguida to harriaimprovement"bmfdro agreeing.to any work on yourresldenct.You tnay obtain a free copy by'calling the
Offico of Consttmer.=Affairs and Business Ragulation's Consumer lnfotmation Hodino abbi7-973'+8787 or 1„888;283-3757•
Homeowner Information CantYaetnr Itifortttatian
L�ora
sate PAY N Entre.
Street/A (do not us o Office cox addrag)- atractorl Sat +vn Name
... ���`
Cltyffown State Zip Cbde asiness Address(mast include a street address)
DaytimaPhoae Evening Mile ityffawn �tate ipCade
� Cs
Halling Address(It different from above) stain ss Phoria bde alFulployer or S.S.Fltuntier '
• Vv n;qu3rp lWl moa hemoimRome 7Cmtraqur aey�livgtier 6.[mr+iim M�'.. •:
wamt�m,soans®ber
The Contractor agrees to do the following work for'the}I
he nman nee: /
IkequiretlTerinits-The Miowing building permits are required Proposed Start anti Completit n.Schednle-The folEowiitg schedule will
and will be secuaed,by the eontraclar as the'bomeowner's agent; be adher d to`iltilo s circumstances i)ayoud,the contmatoftcontrol arise
(Owners who:.securetheir own permTw
its ill lie '
excluded<from:the::GuaranityF.tirid.provisionsof to codtrantorwill begin contradtedwork
MGL chapter 142A)
ate when contmrtcd .work willbasubstantially complete
Total Coniract Price and Payment Schedule
specified
The Contractor.agrees to pdrform Elle work,furnish the material and labor above forthe fatal sum o8
Payments will be made according to the fo'lowing schedule:
S L upon:signing cgntract'(not•fo ekceed 113 of the totateontract price,gr the cost of special order items,whichever is:greater)
S by^I l orupon completion of
S by / / or upon complepon of -
upon completion of the contract (law forbids damanding fled payment until contract is completed to both party's satisfaction)
1lefollowing mstedallequipmrntmustbespecial $ edfor
ordered before the'wutraMed'wnrkitegina in order S be paid for
tomeettlieooatplbtion sehedula(**) „
NOTES:(*)locluding all(mance charges(**)Law requires that any deposit or down-psyment rap&W by the contractor before wotk begins may,
not exceed the greater of(a)one-third orthe total contract price or(b)the actual colt of ariy special equipment or custom made anterial
which must ba special ordered in advance to meet the completion schedule.
�Ssprps warrant :.l am xnresa the epri keine arovlded by thetantractnr? No Ves_f},lf;tsrma of tha t �a �w he alta h_d M the caap�etl
Subcontractors-The contractor agrees to be solely responsible for cdmpletion of the work described regardless of the actions'orinsr(guild
partylaubcontractorutili=d by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
Materials and rund
Contract Acceptance-Upon signing,this document becomes a binding-coniracttmder:law. Unless otherwise notal within this document,the
carefully before signing this contract,
contract Abell net imply that any Tac or other security ioterat0m been placed on the residence. Review the following cautions and notices
• Don't be pressured into sighing the contract.Take time to r'cad'aild(Edgy understand it'Aek'r{uastioris if aoiisethlpg is Unclear.MPkc surd the cQ� cicrhas a vaii flpttle lmorovcrn zpt Conbaetnr Rwignr;�_„ •tea W requires most home improvement contractors and.
subcontractors to be registered with the Director ofHouie lmpravement Contraetoi Regititration, You may.inquire about.coanactor .
Mgistmtiou by writing;to the I)irwtor at:One Ashburton Puna,Room 1301.,Boston,-MA 02108 or.by.calling 617-727-3200 or
1-&00.223-0933.
• Does the contractor have insurance? Check to see that your contractor is properly insured
• Know your rights and r sponsibilities, Aead the Important luformatiOn on tltc inverse side of this folia and get a copy of the Consumer
Guido to the Home l4roverne'nt Contractor Law:
You may eanceE this agraement if it has been signed at a place,other.than tho contracthr s'notmal place of business,provided you notify the
coutractorin writing at his&armain of�e or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the.
thud business day following the signing of lhis agreement..See the attached notice of cancellation form for an explanation ofthis right,
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
11 o idwfial capim ofthe ar4arx m”be completed and signed One eepyahoatd go to tis bameow�aFr,7heolheraVy WbehrptbythcmotnaorLL/2�/ .
Hom`urwner's Euro Contras is Signatttrc
Data Date
�- ♦. The Commonwealth o 'Tlltssachusctts
Dt partment of lndltstrialItccident.s
Office of IIIvelaT"ations
.ir 600 Wa.shiltgtwi, Street
=+F" Bosion, .114 0.2111
IVIVIU.I1Il1S.S'.y O vIdia
Workers' Compensation Insurance Affidavit: I3liif(fei-s/Coiiti-aetoi-s/Eleeti-iciailsli'LUlilbet-s
Lk ) ilicant Information Please Print Leo fllv
Name (l3usincss%Ors anization'lndividu�tl?: � _
Address;
C:itviState'LiES:....-. _(fes ��GJ 1� Phone U: 4' �"
Arc j'o -atr erliployer? Check the appropriate boy: Type of project (required):
employer with 4. ❑ 1 atit a general contractor and
employees(full andlor para;-tittle)."
have hired the sub-contractors b• ❑ New coltstr•uction
2.❑ 1 1111 a sole proprietor or partnet.- listed on the attached sheet. 7. ❑ Remodeling,
These sub-contractors have
Ship and have no employees S. ❑ DemolitioEt
workinu for me in any capacity. '
cont insurartce_� 9. ❑ Builclln�L, addition
[No workers' comp, insurance P `
required,] �. ❑ we are a corporation and its 10.❑ Electrical repairs or additions
❑ 1 am a homeowner doing all Nrorl< officers have exercised their 1 1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemptioft per MGL 12. oofrepairs
insurance required.]` c. 151 §I(d). and we have no
employees. [No workers' 13.❑ Other
comp. insurattce required.]
"Any aPillica€at that checks boy«I must also fill out the section Mom sbo%N mL their�corl ers'compenstiion police information_
I lolieO\\i rs tcho stibniit this alfida+'it mdicat ing thov are doine,ill%cork and(lien hire oil sidc co IIlractors must silbInII it Ile%+ affidaril in(IicIIillR such,
-Con(ractors that cheek If box illus(attaclied an;I(Wit IDIM I sl)eel shn\cinL the nL111le of the sub-tontracwts anci state whether or not those entities hay e
emplo)ies. If the sub-contractors ha\e cIll)iocccs.the. nv.ist proNide IIIc it orkzrs'comll.pnlicc number.
1 um an employ ger that is providing workers'compensation basltrance far lilt,emploYeec. Below is the polict, cnld joh site
111 f bl•Inatloll,
dnsurance Company Name: Kj
Poficv , or Self-ins. Lie. :=: 7 e 1...Gll,_C���f�(�(} /�� l:.xpiration Date:
.lob Site Address: �/j / � GI�G�jL � Crt�`State%Zip:—t ;2.d_-�'����d[
Attach a copy of the workers, compensation police declaration poge(Showing the policy number and expiration date).
FailuE-e to secure coverage as required under- Section 25A of VIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprisonment_as wCll as civil penalties in the form ol'a STOP W'ORK ORDER and it fille
of tip to S250.00 a day against the violator, lie advised that a cope of"tins statcment may be Fors,arded to the Ofl=ce of
Investintions of the DIA Ior insurance covera=-c verificalion.
I do hereby, ccrfif' ltrler lire plrilis and penalties ofperjurt,that the irlfn-oration provided above is ti'ae dial cor•rec7.
P I?O I1 C
i CJf11C'111111.1'e(3111)'. Do Not Ivrite in this area, to he completed by' city oi-town of flcYlll.
City or ToNl rl: 11cr•niit/L.ic•ense #
[ssuilig Allihority (circle one): �^^- ------- -
1. Board of llca[th Z. BUiklillh [)c1mi-tment 3. (.ityl�t n4cn (Merl: 1. 1_]ectrical [n>pector i, 1'lclmbin lnspcct 11
G. Other
C:otitact Pcl•sou: __- - — Phone#:
I
AJWALSH-01 JONEILL
GATE(MMIDDIYYYY)
CERTIFICATE F LIABILITY INSURANCE
11/17/2016
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: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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).
CONTACT
PRODUCER NAME: _
Durso S Jankowski Insurance Agency P11C°NVo,Ext):4978)688-7000 FAArc, No):(978)68$-7001
11 Saunders Street E•MA€€-
North Andover,MA 01845 ADDRESS'
INSURERS I AFFORDING COVERAGE NAIC#
INSURERA:A.I.M. Mutual Ins Company
INSURED INSURER B
AJ Walsh&Sons INSURERC:
159A Waverly Street INSURERD:
North Andover,MA 01845
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. NO'T'WITHSTANDING 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,
INSR ADOL SU BR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE INSD VVV POLICY NUMBER IDDIYY DDIYY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE [--] OCCUR DAMAGE TO RENTED
PREMISES E or
MED EXP An one erson $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY )ECT LOC PRODUCTS-COMElQP AGG $
OTHER: -- O $
AUTOMOBILE LIABILITY CEaBc dDSINGLE..LIMIT $
ANY AUTO BODILY€NJURY Per arson $
OWNED SCHEDULED
AUTOS ONLY AUTOS BOOILY INJURY Per accident $
HIRED NppN-�WNED PROPERTY DAMAGE
AUTOS ONLY At7T0 ONLY Peraccidanl $
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS L€AB CLAIMS-MADE AGGREGATE $
DED RETENTION$ S
ST T TE FR
A WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN AWC40070146482016A 11/14/2016 11/14/2017 100,000
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $
FICEIRUIMEMBER EXCLUDED? NIA 100,000
0landaory in NH) E.L.DISEASE-EA EMPLOYEE $
Ifesdescribe under 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required)
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 suite 2035
North Andover,MA 01845
AUTHOR!-LED REPRESENTATIVE
ACORD 25(2016103) O 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Massachusetts Department of Public Safety
�- Board of Building Regulations and Standards
License: CS-022680
Construrtion Supervisor
ARTHUR J WALSH JR
159A WAVERLY lip
N ANDOVER MA 01845
Expiration:
Commissioner 08/09/2018
C.
rirri�ni�rpcnl/�r/CaLnllrii%r.Ir/
Office of Consumer Affairs&Rusiness Regulatio3l
HOME IMPROVEMENT CONTRACTOR
i -- j
Registration: 103358 Ty
pe:
Expiration;:- 7/7!2018 Private Corporation
A.J,WALSH&SONS;INC.
Arthur Walsh
55 Pleasant St
N Andover,MA 018.45 _--
Undersecretary