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HomeMy WebLinkAboutBuilding Permit #602-15 - 121 CAMPBELL ROAD 1/13/2015 I r E 3jOg t1`O oT 6��OL BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION - Permit NO: Date Received °9 - i ( �9SSACHIJ`'iF��`J Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION rAM62bel) PROPERTY OWNER i rLY� Print MAP NO:*— tPARCEL: ZONING DISTRICT: Historic District yesnn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSE D USE Resid ial Non- Residential ❑ New Building ne family 0 Ad 'tion 0 Two or more family ❑ Industrial ❑Meration No. of units: ❑Commercial epair, replacement ❑Assessory Bldg 0 Others: 0 Demolition ❑ Other 0 Septic ❑Well 0 Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer Identification Please Type or Print Clearly) r OWNER: Name: Phone. r Address: a-t CONTRACTOR Name: Phone: LJQJ lo Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 41v16 l � ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. OD Total Project Cost: $ FEE: $ Check No.: Receipt No.- I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner 11,4 Signature of contract Location a �� No. (� ' Date l . - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# '2841 Efuilding Inspector 1? r , NORTH - W" E c " ver o iIh ver, Mass, O Ir�cE 1. cocNicnewICK � j " wv ��AOR�7ED r`PP�,�S S U BOARD OF HEALTH PER L D Food/Kitchen - Septic System e ' BUILDING INSPECTOR THISCERTIFIES THAT .................... ................................... . ........................,.......... . ....... ... ...... Foundation has.permission to erect .......................... buildings on ..... wl .... ��.�••••.••••••.•••..•••• Rough to be occupied as ............ N. .... #..A........................... Chimney provided that the person accepting this,permit shall in every res ct 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S Rough Service ................. ...... .... ... ... ......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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 - Department of public safety Board of Building Regulations and Standards Construction Supervisor_Specialh License: CSSL-099840 ! t Jabs MOON 48 PAINE RD. r I . Cumberland RI 0286 ICAr Expiration Commissioner 03/23/2016 Restricted To: CSSL-WS - Windows and Siding CSSL-RF - Roofing CSSL-IC- Insulation Contractor. I - Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license.. For DPS Licensing information visit: www.Mass.Gov/DPS Oi'iic;--of Consunner Aflulirs and llusims Revulution 10 PA Plair.a-Suite 17(1) plostoll.NlasNachusells 2 116 Home 1111provelnell1 Colill-actor Registratioll 119535 Ime. Pnvpte Comombon Eximatlop, 71242015 Tr' 2.'2.1,,3 MOON ASSOC fNC JAMES MOON 1137 PARK EAST DR. WOONSOCKET. RI 02395 I p-.Satr-Lld-re-acrd rcEt:rn card.Marl,mawn for Adtf.-c" ttcnrs;Il 1:nlpi,.%lurni Lo-t Card & Licrime m.-rv2:%(vaE:-;a tr ind; idt;l ti%v only 40NE iMPROVEME T CD(4TRAC iGR Qegislraliocr: :1?j3j Ty r: ukaiall Offilm, .4cg Expu At Pali.Nkw.a 4,tilt5l-,u 11'»i=ARK DR. Not%.`ia wllmua t-:p-m:urc -7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street i Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: f� City/State/Zip: ) Phone#: 1 &7( r Are yo an employer?Check tppropnate box: Type of project(required): 1. am an employer with 4.0 I am a general contractor and 1 6.❑New construction 2.0 employees(full and/or part time).* have hired the sub-contractors .[]Remodeling 7.1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8.❑Demolition working for me in any capacity. employees and have workers' 9.❑Building addition [No workers'comp.insurance comp.insurance.$ required] 5.OWe are a corporation and its 10.❑Electrical repairs or additions 3.01 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12.�thel repairs employees. [no workers' 13. --��� comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy Information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Iam an employer that isproviding workers'compensation insurance for my employees.Below is thepolicy andjob site information. Insurance Company Name: _ Policy#or Self-ins.Lic.#: _ _ Ex iration.Date:.- - — P 0 ' ' Job Site Address: AA City/State/Zip: 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herby cerci under the pains and penalties of perjury that the information provided above is true and correct. Signature Date. rintName: ,_,_klypa-, Hin, Phone# Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#: Issuing Authority(circle one): i.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone M AC" CERTIFICATE OF LIABILITY INSURANCEDATE(MMfoDNYYY) 11/712014 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(ies)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 CNAONMEACT Jeannie Vas onceilos - Hunter Insurance, Inc. PHONEFAX 389 Old River Road, P.O. Box 1 AIC tic. o Ext:401-769-9500 (AIC No):401-769-9502 E MAIL Manville RI 02838-0001 ADDREss:ivasconcellos@hunterinsurance.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:AtainSpeciallyInsurance INSURED MOONA-1 INSURERB:New South/GMAC 7930 Moon Associates Inc. INSURERC:Beacon Mutual Insurance Co. 4017 DBA Moonworks Home 1137 Park East Drive INSURER D Woonsocket RI 02895 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:636112000 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. INSR TYPE OF INSURAWCE A DL1tUBR POLICY EFF POLICY EXP LTR INSR I Y✓V!D POLICY NUMBER (MMfDD1YYM I IMMMDfYYY`Y) LIMITS A GENERAL LIABILITY ..,IP209854 /23/2014 /23/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES TO RENTED Once 100,000 CLAIMS-MADEOCCUR MED EXP(Any one person) $5,000 _ PERS014AL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LlfdiTAPPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY�PRO- LOC $ B AUTOMOBILE LIABILITY 2002842715 /16/2014 /16/2015 Ea acciNED SI dent NGLE LIMIT- S1,000,000 person)ANYAUTO BODILY INJURY(Per p $ ALL AUTOS OWNED Ix ATE0.DGULEDBODILY INJURY(Per accident) S NON-OWNEDAMAGE $ HIREDAUTOS AUTOS PeraccideM $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ --- DED RETENTION S $ 1139278304274 --- - _— _ 0/1/2014 0/1/2015 AND EMPLOYERS'LIABILITY YIN TORY LIMITS OER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT 5500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIIJiIT S50D,OOD 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Home improvement operations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN moon Associates Inc. DBA Moonworks Home ACCORDANCE WITH THE POLICY PROVISIONS. 1137 Park East Drive Woonsocket RI 02895 AUTHORIZED REPRESENTATIVE I ©1588-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I 1137 Park East Drive R.I.Rea.e:12259(Moon Associates Inc.) Woonsocket Rhode Island 02E95 Conn.HIC0562725(Moon Associates Inc.) \\\ Mass.HI a 119535(Moon Associates Inc) Purchaser(s)Name: r 1 /� ca rW11SA Ilew Installation Address: Ma Ing Address/:: � pp��� L�Q ACZ;F A,4924 Home Phone: _!?�'E 0 Cell Phone: E-mail: a f*Q- (/r{r z 0/(�/ Year Home Built:_Customer Initials: Taxes Paid In Toni rn of: O./' 1/we,the above purchaser(s)("Purchaser(s))and the owner(s)of the property located at the ably ve Installation address,hereby jointly and severally agree to contract with Moon Associates,Inc.("Moonworks")to furnish,deliver,and Install of all materials as described in this agreement("Agreement'),the attached Spec Sheet(s)and diagram(s)which are incorporated herein by reference and made a part hereof.A Completion Certificate will be executed for all jobs at the end of the Installation. Order Number: -� �dV W)1`1 d4d Order Number: Order Number. Project Type: ProectType: ; Pr ctType: AgreementAmoun $ Agreeme ount $ ' Agreem Amount $ Less Deposit# $ Leu Deposit# $ Less Deposit# $ Balance Due On Completion $ Balance Due On Com Ion $ Balance Due On C pl. $ *Minimum 33%of Agreement Amount due upon execution. *Minimum 33%of Agreement Amount euponexecutlon. *Minimum 33%ofAareement Am rat due upon eucutbn. Indlate Payment Method For Balance indicate Payment Method For Bala Indicate Payment Method For B ria Due at Time of Instill Due at Time of Installation: Due at Time of Installation: ee- Est.Start Date: Est.Completion Date: Est.Start Date: Est.Completion Date: Est.Start-Date: Est.Comps ton Date: �✓Cs /-Z DEPOSIT/PAYMENT OPTIONS(Subject tofund vertiationynd/orcraft approval) I.Check,Cashiers Check or Money Order Ck A 3.Financing (Made payable to Moonworks) Acct# Approval Codex3-1�&P L Credit Card*(drcle) Visa aster Discover Acct q Approval Code ��� •1/We agree to allow Modnworla to charge the referenced credit card for the deposit amount Acct# Exp Date Security Code s(9(n indicated.Balance to be iharged to credit card upon completion of installation If noted above. Purchaser(s)hereby agrees to reimburse Moonworks for all permitting fees associated with this transaction ❑Yes ❑No Purchaserls)Initials R is agreed by and between the parties that this Agreement constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms of this Agreement.Purchasers)hereby acknowledges that Purchaser(s)1)has read the front and reverse of this Agreement and has received a completed,signed,and dated copy of this AFreemeM,Induding the two accompanying Notice of Cancellation forms,on the date first written above and 2)was orally Informed of his/her right to cancel this transaction.DO NOT SIGN THIS CO Cr IF THERE ARE ANY BLANK SPACES. P Purch er M rks Sign ure Sign re ,� r Signet >< xrLlir�GtYl a Print -�T- Name Print Name Print Name YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAYAFTER THE DATE OF THIS TRANSACTION.SEE THE NOTICE OF CANCELLATION FORM BELO#FOR AN EXPLANATION OF THIS RIGHT. t-----1 NOTICE OF CAN% LLATBON NOTICE OF CANCELLATION Date of Transaction Date of Transaction You may cancel this trap ton,without any penalty or obligation,within You may anal thl3 transaction,without any penalty or obligation,within three business days from the above date. N you cancel, any property three business days cam the above date.N you anal,any property traded traded In,any payments made by you under the Contract or Sale,and any In, any payments triade by you under the Contract or Sale, and any negotiable Instrument executed by you will be returned within 10 days negotiable instrument executed by you will be returned within 10 days following receipt by the Seller of your cancellation notice,and any security following receipt by Ithe Seller of your cancellation notice,and any security Interest arising out of the transaction will be canceled.If you canal,you Interest arising out Of the transaction will be angled.if you cancel,you must make available to the Seller at your resldence,'ln substantially as must make available)to the Seller at your residence,In substantlally as good good condition as when received,any goods delivered to you under this condition as when received,any goods deihrored to you under this Contract Contract or Sala;OF You may,N you wk+lb comply with the Inaructions of or Sala,or you may,If you watt,comply with the Insti ctlora of the Sellar the Seller regarding the return shipment of the goods at the Sellers regarding the return-shipment of the goods at the Sellers expense and risk.if expense and risk.if you do make the goods available to the Seller and the you do make the goods available to the Seller and the Seller does not pick Seger does not pick them up within 20 days of the date of your Notice of them up within 20 days of the date of your Notice of Cancellation,you may Cancellation,you may retain or dispose of the goods without any further retain or dispose of iIhe goods without any further obligation.N you fall to obligation.if you fall to make the goods available to the Seller,or If you make the goods avai able to the Seller,or H you agree to return the goods to agree to return the goods to the Seller and fall to do so,then you remain the Seller and fall to do so,then you remain liable for performance of all liable for performance of all obligations under the Contract.To cancel this obligations under tiff Contract.To cancel this transaction,mall or deliver a transaction,mall or deliver a signed and dated copy of this anallation signed and dated edpy of this cancellation notice or any other written nolle or any other written notice,or send a telegram to MOONWORKS, notice,or send a tel to Moonworks,1137 Park East Drive, oo et, 1137 Park East Drive, oon ,Rhode Island 07895,NOT LATER THAN Rhode Island 02$95,NOT LATER THAN MIDNIGHT OF /y MIDNIGHTC �/ '1 / (Date). (Date). I HEREBY CANCEL THIS TRANSACTION. 1 HEREBY CANCEL TF IS TRANSACTION. Consumers Signature Date Consumers Signature Date ROOFING . `- REMEMNT A—ioovwamaa.q ra0a�sr. /..dy.ryag,wp White Copy Moonworks (2)Yellow Copies-Customer Pink Copy-Project Specialist . i