HomeMy WebLinkAboutBuilding Permit #1166-2016 - 169 CHESTNUT STREET 5/10/2016 �� NORTH
IJ (J' TOWN
PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
�(p 1.
Permit No#: / Date Received ��ssacHus���5
Date Issued: I
I ORTANT: Applicant must complete all items on this page
LOCATION O AO ;�/41r
L Fl C`/�
PROPERTY OWNER �e4 6-cRT P7"�74;�=5
/ Print 100 Year Structure yes no
MAP &142 PARCEL: 7 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Reside Non- Residential
❑ New Building ne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
", D G IPTI N OF W RK TO BE PERFORMED:
I entif ation- Please Type or Print Clearly ��
OWNER: Name: Phone: f
Address: �✓�
Contractor Name: 1/ �/ �1 �G Phone: 41Pdc �
Email:
Address
Supervisor's Construction License: p. Date:
Home Improvement License: IA�.��J�/ Exp.
Date: 417A.-I
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
�' 00 10—
Total Project Cost: $ 01,306 ' FEE: $
Check No.: �MK Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have ac ss to the uar n f d
Location
i
No. I l��r = -, Date
. - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $`
Other Permit Fee $
TOTAL $
Check#
•
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TPO
TYPE OF SEWERAGE DISPOSAL
Public Sewer ElTanning/MassageBody Art ElSwhmling Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 3 sgood Street
FIRE,DEPARTMENT - Temp,Dumpsfer gn site yes : . ii' '
Located,at 1,24aMainrSt6eet
Fire-Departrne 1.signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Rueter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10o-$100o fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Bnilding Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
4. Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
�. Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4. Building Permit Application
Certified Surveyed Plot Plan
.4. Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
,4 Copy Of Contract
-4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
a, Mass check Energy Compliance Report (If Applicable)
;ra Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
iiBuilding Permit Application
4. Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
�. Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014
NORTH
Town Of �� : EAndover
O t
No.
11&4 - 2�61
lift
o h ver, Mass,
COC HIC Hl WICK 1'
�R^TEO ►'PP,`'�5
S V
BOARD OF HEALTH
Food/Kitchen
PERMqT T LD Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
.. .....• Foundation
has permission to erect .......................... buildings on .... .. .... � s��I ... ..
.................................................................... Rough
to be occupied as ......... . .... ........ .... .. .. Chimney
provided that the person accepting his 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 ARTS Rough
G�Cy�T Z�lL� 2 "�.......................... Service
.. .. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy 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 CONTRACT
This form satisfies all basic requirements of the state's Home Improvement Contractor law(MGL chapter 142A),but
does not lnclude standard
language to protecbhomeownera. Seek legal advice It necessary. Any person•planning hoine'i' provements should.5rst obtain a copy of"a '
Massachusetts'consumer guide to home-•improvement"before agreeing to any work on yourresidence.You may obtain-a free co
py Office of Consumer.:Affairs:and Business•Regulation's Consumer Information Hotline at617-973-8787 or 1.+886.•.283-3737: raling the
Homeowner Information Contractor Information
Name pmy
W4�y=
Street to use a P O ce Bo address) tractor/ er Name
City/Town /'� S Zip Code ^' usinesa Address(must de a street address)
Daytin 7�k EveaingPhoe ityRown Code
7m -�� v is
Mailing Address(It differ from above) usiness onetxleral F�ployer ID or S.S.Number
. lam tequi,ei am mon rnma;mI Ramo %,�)( IjCm�uut�at�aJq{�T�'hmhtr ax�dmd�r: •.
ta•�mtownsalon Wws /V`S��G_Jti.r�
' �eairvatim m®bC
The Contractor agrees to do the following work for the Homeo mer.
SPO-171119IRTY111715111in;350 gratic or as to no
Required Permits-The following building permits aro required Proposed Start and Completion Schedule-The following schedule will
and will be sectred.by the contractor'as the'hoineowuer's agent; be adhered to unless circumstances beyond:the contractoes°comrol arise.
(Owners who;secure their own permits will he
excluded'from the Guaranty Fund.provisions of Date whch'bontractorwill begin contracted work,
MGL chapter 142A:) 2
Date when eontracuid .work will-besubstantially completed.
Total Contract Price and Payment Schedule ,
The Contractor.agrees to perform the work,furnish the material and tabor specified above for the total sum of,
—� (s)
Payments will be made according to the f0owing schedule:
Sy upon signing contract(not:to exceed 1/3 of the total.contract price.2r the cost,of special order items,whichever is.greater)
or upon completion of
by / or upon completion of
upon completion of the contract (law forbids demanding frill payment until.contract is completed to both party's satisfaction)
W matco]SCC.. O
Ile following al/equipment must be special S '
bed for
ordered before the contracted work ]m
'begins in order 'S � In paid for
to meet the..completion schedule.(**)
NOTES:(•)including all finance charge,(")Lew requires that any deposit or down-payment required by the contractor before work begins m
ay
not exceed the greater of(a)one-third of the total contract price or(b)the actual con of any special.equipment or custom made material
which must be special ordered in advance to mat the completion WIledule.
Express Warranty-Is av expresswarranty Mein,provided by thewntnctor? No Yes fall terms of fire *�w had to me cpprnen
Subcontractors The connector agrees to be solely responsible for completion of the work desenbed regardless of the actions'ofany thiid
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 agreement
Contract Acceptance Upon stgnin&this document becomes a bindingcontract under law. Unless otherwise noted within this document,the
contract shall not imply that any lien or other security interest)w 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 snd fully understand it. Ask'gtustiotis if soreethirig is unclear.
• Make sure the contractor has a valid Hom mtrnovement ontraetor Re �t 'jibe lax:requires most home improvement contractors and.
subcontractors to be registered with the Director ofHome Improvement ContracWlr Registration. You may inquire about contractor
registration by writing to the Director at One Ashburton Piave,Room 1301,.Boston,MA 02108 or by.calling 617-727-3200 or
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 important Information on the ieverseside of"foim'and get a copy of the Consumer
Guide to the Home In1provement Contractor Law:
You may cancel this agreement if it has been signed at a place othir then the contractors 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
Two IF THERE ARE ANY BLANK SPACES!!!
ideeual poples of eomnet must be camploW and sWx d Ops copy.mhoutd go to the The other
Q� Dopy ahouW be kept by the eoptraetor. -
Ho is Signature Coatractor's Signa
Date
,Date
Contractor Arbitraition
The Home Improvement Contractor Law provides homeowners"with thenght4o4nitiate"an arbitration action(as an
alternative to court actioA)if they have a dispute with e'contractor. The same right is not automatically afforded to a.
contractor,however.•."The contractor;would have:�p resolve any,dispute 61she.has with a homeowner in court unless .".
both parties agree to.the optional clause provided below..This clause would give the contractor the same.right to
arbitration as is afforded to the•homeowner.by the Home Improvement Contractor Law. .
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been.approved by
the Secretary of the Executive Office of Consumer"Affairs"and Business Regulation and°the consumer shall be required
to sub i to arbi 'on as provided In.Massachusetts General LaZchaHomeowner's Signature Signature
NOTICE:'The signatures of the pa es above apply only to the agreement of the parties to alternative dispute resolution
initiated by the contractor.i T'hetomeowner.may initiate alternative.dispute resolution even where this section:is not
s amtely signed-bythe es::
Homeowner's Rights
A homeowner's rights undt -tbco,Hbme'Improvement Contractor Law(MGL chapter I42A)and other consumer
protection laws(i.e.MGL chapter"93.!)may not be waived in any way,even by agreement: However,homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeownetp who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Ialpmvement Contractor Law. The-contractor is responsible-for completing the work as described,in a
timely and-:workmanlike manner. Homeowners.may be entitled to.other specific legal-right's if the contractor guarantees
or provides an.express warranty for workmanship oi•materials. In addition to.guarantees or warranties provided by the
contractor,all goods sold in Massachusetts carry an implied warranty of merchantability:andtness_fora particular
purpose. An enumeration of other matters on which•the homeowner and contractor lawfully agree:may be added to the
terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about
your consumer/homeowner rights,contact the Consumer Information Hotline(listed Below)-
Execution of Contract
The contract must be executed in du lice a and should not be signed until a copy of all-exhibits and referenced
documents have been attached Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other kept by,the.contractor. Any modification.to the Inginal•contract must be in writing
and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of
the contract,and the three day recission period has expired
Accelerated Payments
A contractor may not demand payments inadvance.of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the.balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would"require the
signatures of both parties.
Additional Information
If you have general questions or.need.additional information about the Home Improvement Contractor Law or other
consumer rights;,of if you wish to.obtain a fi-ee.copy of"A"Consumer Guide to the Home.Improvemeat Contractor
Law,"•contact: .
Cgnsumer"Infonnation Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
(617)973-8787 or 1-(888)2833757
If you want to verify the"registration of a contractor or if you have questions or need.additional information 00cifically
about the contractor registration component of the Home Improvement Contractor"Law,contact:
Director of Home Improvement Contractor Registration
Bureau of Building Regulations and Standards
One Ashburton Place,Room 1301,Boston,MA 02108
(617)727-3200 ort-800-223-0933
For assistance with informal mediationof disputes.or to register formal complaints against a business,'call:
Con'bmer`ComplaintBeCtion
Office of the Attorney General
(617)727-8400
"AND/OR
Better Business Bureau
(508)652-4800
(508)755-2548
(413)734-3114
Page# ofpa es
01,
CS # 022680 j. 978-688-6737
HIC# 103358 A. J. Walsh A Sons or.
159A Waverly Road 1-978-912-2853
North Andover, MA 01845
Proposal Submitted To- !^ Job Name Job#
Address ff •r �_ V Job Location'
Date ,� f Date of Plans
Phone# CV�� __. �� _ /C, 1 ' ax# r Architect
•J L
We hereby submit specifications and estimates for
fhr�s�' �f�.r. �.Cf!��/✓ `/'?l�J��,`././ ,� ,/-� :1-��� �r.1.I�,�/ ..�.<'!f f./•+��(/.-I/
X � �_.- -.tet�C/ Com.iJ .fi✓ �/ /� -1 - / 1' fG.zJ
i
r 'U�!`s - � �"' t E fig[//:�'.i!'�'/ �.�1.. �_'".ti N i'-'•lc=�i' .._...
We propose hereby to furnish material and labor—complete in accordance with\the above specifications for the sum of:
$ � �?Gtr C.��;t� rt l' r�t':11,iL/ /ti's,: ✓ L�, c fX Dollars
with payments to be made as follows:) :422k ",
J
Any alteration or deviation from above specifications involving extra costs will be Respectfully �',x //r,�
executed only upon written order,and will become an extra charge over and submitted ' ! f• /, ' " �.
above the estimate.AN agreements contingent
ag ngent upon strikes,accidents,or delays
rherebyaccepted.
trol. Note—this proposal may be withdrawn by us if not accepted within days.
es,spedfloations and conditions are satisfactory and are mature
ed You are authorized to do the work as specified.be made as outlined above.
ptance Signature
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&Sons
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 Remuneration Premium
INTRA 40579
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $500 Total Estimated Annual Premium $500
GOV GOV Deposit Premium $500
STATE CLASS
MA 5403 State Assessments/Surcharges
$.00 x 5.7500% $
r--i-
This policy, including all endorsements, is hereby countersigned by11/05/2015
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.
1r
�-�
Board of Building
(ttlritl'l(CT{Ill} 4pi}C16iaU1'
License: CS-022680
ARTHUR a WALsAJR
159A WAVERLY-2D
N ANDOVER Mk 01845
Cot-imissioner 06/09/2016
e`'�.,`,-., Office of Consumer Affairs&Business Regulation
SOME IMPROVEMENT CONTRACTOR
k — Type:
Segistration: 103358
i r
expiration: 7/7/2016 Private Corporatio
A.J.WALSH&SONSJNC.
Arthur Walsh
55 Pleasant St
N Andover,MA 01845 Undersecretary
TOWN OF FORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No:
Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATIV S T
PROPERTY OWNERPrint
-----uunit#
Print
MAP NO: PARCEL: l ZONING DISTRICT:
Historic District yes no
mit Machine Shop Village yes no
100 year-old structure ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential
El Jew Building ❑ One family Non- Residential
❑Addition ❑ Two or more family
No. of
❑Alteration units: ❑ Industrial Repair, replacement ❑Assessory Bldg El Commercial
❑ Demolition ❑ Other ❑ Others:
-� n.
U fV dLi.,l/V(.4Y Vl
DESCRIPTION OF WORK TO BE PERFORMED:
I& poc)) o' ri ]�L>
ADD Fp
(Identification Please Type or Print Clearly)
OWNER: Name: HZR13H�y�'s
Phone 7Z$ 6g$
Address:_ l65 C��S7lucr,
CONTRACTOR Name: ADf 0M cA
Phone: 8$ - 79-- 1 .�
Address: X17 WAVC1KL )! R N o R-1-t.-I, AN Do
Supervisor's Construction License: 1 d y LI 2 g Exp. Date:
a�
1-1
Home Improvement License: _ ISR r,I�
Exp. Date: �
ARCH ITECT/ENGINEER_ Iy � /+ Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.•$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ x_pl) FEE:
Check No.: /O/ Receipt No. �p�
NOTE: Persons contracting with unregistered contractors do not have access to theuaran
g ty u
Signature of A ent/Owner
- _Signature of contractor 1.
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Per.
Addition or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
C OID1.r of controc+
❑ -iGGC/L,'-0sS6cli01-j =ievadon Plan Gj` i-'-foposea 0010 VVI'ir► dpfiFiKIC-f riall Ana
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi'
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
In all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Taming/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Perrnanent Durnpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
��ai fi.s lei as i` im .l .�6VICi�i li l:.l9 U1VIUIeGlU10�
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Sia nature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
Location /(d � �7✓%y7'
No. Date
TOWN OF NORTH ANDOVER
? �. . o
FA
Certificate of Occupancy $
sACMtISE�� Building/Frame Permit Fee $ <�U
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
1
{
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibl
Name,(Business/Organizationllndividual): ADAM F391 F K) 13j?) C0 IV ro
Address: PA A ISL.
City/State/Zip: V or-r H A►v i)oy6 � � Phone#: 9 7 - 971
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2G I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in an capacity. workers'comp.insurance. 9
y ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.4 Roof repairs
insurance required.] employees.[No workers'
comp.insurance required.] 13.n Other
*Any applicant that checks box 41 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employes that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify unjel-th epaiinns andpenaldes ofperjury that the information provided above is true and correct.
Si ature: r�;- - Date: 1
Phone#: 9Z5' - 1--I 7 9 t&2 6'
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Persoia: Phone#:
Co.
Building&Remodeling
Adam Brien CSL 104428
978-479-1526 HIC 168512
adambrico@gmail LLC
169 Chestnut st, North Andover, MA 01845. Contractor to repair roof
of 20' x 10' shed. Rebuild where necessary, re-roof backside and patch in
siding. The project is based on a time and material manner and is expected to
take three days of work.
The contractor agrees to perform this work in a competent and skillful
manner according to standard industry practices, and all work performed shall
be subject to final approval by Owner.
Dated:
Signature of Owner:
Signature of Contractor:
0
�la��achu,eth - Depar-tincnt of PuhliC 'sal et)
Board of Buil(lin�„ Rt•�,ulatium and titandard.
Construction Supervisor License
License: CS 104428
ADAM BRIEN 4V
417 WAVERLY ROAD
NORTH ANDOVER, MA 01845
Expiration: 5/12/2014
( nnmisii°i Tr#- 104428
-\ Office of Consumer Affairs&Business Regulation
j;;gHOME IMPROVEMENT CONTRACTOR
Registration: 168512 Type:
Expiration: 3/1/2013 LLC
BRICO BUILDING AND REMODELING LLC
ADAM BRIEN
417 WAVERLY RD
NORTH ANDOVER, MA 01845 a
Undersecretary
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overAnd
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_ o , dover, Mass., "
COC HICHE WICK
ORATEO PS
S U BOARD OF HEALTH
Food/Kitchen
Septic System
PE11MIT T
BUILDING INSPECTOR
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. .................................................................................................................
THIS CERTIFIES THAT....... . .........6Foundation
has permission to erect..............................:......... buildings on .�.. � ........ :+� c ................................ Rough
y ..�e.ee >t �'.'' Chimney
to be occupied as..............�..�:!.��P.—.�......�-�........................�.....--}�?....................................................................................
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final.
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 CONSTR Rough
...................................................................................... ...........
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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. Bumer
Street No.
SEE REVERSE S U D E Smoke Det.