HomeMy WebLinkAboutBuilding Permit #716-16 - 247 GREENE STREET 12/11/2015,Wt.# /co-< < io
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Y� / Date Received
tJ
Date Issued:
ANT: Applicant must
all items on this
h
`� nD [o[r��c�ewrt• E/
q 1•
LOCATION
J Prigt
PROPERTY OWNER a��� �� S
Print 100 Year Structure yes no
MAP Ci 15 PARCEL:690Y(- ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential,
Non- Residential
❑ New Building
0 06e family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
El Demolition
❑ Other
❑ Septic; ❑Well
❑Floodplain �jWetlands
^ ❑ Watershed District `
P�Water/Sewer
OWNER: Name:
Address:
Contractor Name:
DESCRIPTION OF WORK TO BE PERFORMED:
- Please Type or Print Clearly
Com. ry Siw
�— ZJ-k --,�, 73
Supervisor's Construction License: C✓ Exp. Uate:� �(g
Home Improvement License: /Q , `� ;'r� Exp. Date: 717" ____
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PEBJWV. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
G- �C� FEE: $ 6�2�,
01
Check No.: L�f 7 Receipt No.: � IJ
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
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)
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
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: 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
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On
Signature.
COMMENTS
CONSERVATION Reviewed on Signature
n
C;.MMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Connection/signature Date Driveway Permit
DPW Town Engineer: Signature:
Located 38,4, -Osgood Street
FIRED .. ,
EPAR�TtMEN ► umpst nisi
ti �T T..empD q }a �Yesz �.._ nog
er ite;
Qiocated�at�124 Main Street
SFire�Department��`ignafure/date � _ 1 �.�` r
COMMENTS y '
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)
Ll Notified for pickup Call Email
Date Time Contact Name -
Doc.Building Permit Revised 2014
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
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
M
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
r
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature.
CONSERVATION Reviewed on Signature
CnMMENTS.
HEALTH
COMMENTS
Reviewed on Signature
v
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Commen
Conservation Decision: Comments
Wafter & Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
�TFIRE,DERARaTiMENfT, Temp�tD,umpster,on+site; eyes'. Located�0
sgood Street
'Fire�Department�sgnature/date _ ,.. ' ' `
COMMENTS
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
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
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (if Applicable)
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)
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
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
Ned 7
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: tl� �l Date Received
t % I
Date Issued:
'ANT: Applicant must complete all items on this
LOCATION
PROPERTY OWNER
Print
MAP (915-
PARCELAO I� ZONING DISTRICT:
100 Year Structure
Historic District
Machine Shop Village
INN
yes no
yes no
yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential-
Non- Residential
❑ New Building
g,06e- family
❑ Addition
El Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Wate{rshed Distrac3t+
Water'%Sewer".
4�
OWNER: Name:_
Address: G
Contractor Name:
DESCRIPTION OF
TO BE PERFORMED:
- Please Type or Print Clearly
0 �47��hone:
Phone:
WIC
Supervisor's Construction License: C✓ Cd Exp. Date: G,/S &
Home Improvement License: /Q , ' ' Exp. Date: ;7 z f/�-
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PE $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ Gj�GC� FEE: $ 6�2�, �
01
Check No.: Receipt No.: �
N l J
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location i�� �4
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
d 1 Congress Street, Suite 100
Boston, MA 02114-2017
y�$ www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual):
Q
Address: �-��J / G 4164 L V _&
City/State/Zip: 1YQ MO�!lf �k / "/7 ne 01 737
A71.
n employer? Check the appropriate box:
1. a employer with_employees (full and/or part-time).
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.. Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insruance.t
6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.❑ Electrical repairs or additions
12.0 Plumbing repairs or additions
13. Pi <o_of repairs
14.E] Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
f 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 musfiattached 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.
I am an employer that is ppoviding workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name:
/�, lie) 411-4,14& i A)s c."o
Policy # or Self -ins, Lic. #: d 7 4� Wd h)-od 1(�4 Expiration Date:ZZZ/�_
�J�,L
Job Site Address: q7 City/State/Zip: //V/T'/ I ,'/
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
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 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 hereby certify, Cander d a pains and/p�en�altiesiofpeijury that the information provided above is true and correct.
�ismature- ✓1��` �ry Gi,��" Date:
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 Person: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
i ..7.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth, for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-'contractor(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub=contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
The Commonwealth of Massa. chusetts
. Department of IndustrialAccidents
r_� d 1 Congress Street, Suite 100
Boston, MA 02114-2017
- V.t www mass.go-vIdia
yv Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIVHTTING AUTHORITY.
Name (Business/Organization/Individual):
Address: X- 5 71 Gc' R 4164 L 1�c
City/State/Zip: 1YQ / lS��C�d elk / "/7 ne 2f�'"��'�'��3�
An employer? Check the appropriate box: Type of project (required):
1.711, a employer with _employees (full and/or part-time).* %. ❑ New constriction
2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity. [No workers' comp. insurance required.]
9. El Demolition
3.. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
10 ❑ Building addition
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I 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. oof repairs
These sub -contractors have employees and have workers' comp. insurance.t
6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. F1 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 their workers' compensation policy information.
i Homeowners who submit this 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 -contractors have employees,' they must provide their workers' comp. policy number.
I am an employer that is pioviding workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name:
0
Policy # or Self -ins. Lie, #:d / 7 y �oZUd �(� ExpirationDate: -
Job Site Address: L/-7! CN& ' 1 `�� City/State/Zip: /1t�/T'' 6
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
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 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 hereby cert nder tl a pains anddpenalties of peijnry that the information provided/// above is trues and correct.
lei&d ( ��V, �
Signature: lADate: /,4 v / o
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 Person: Phone
CS # 022680
HIC# 103358 A. J. Walsh & Sons
159A Waverly Road
North Andover, MA 01845
# Of
978-688-6737
or
1-978-912-2853
Proposal Submitted Job Nam Job #
Address Job tion
Date Date of Plans
Y d.3"
Phone # ax # Architect
We hereby submit specifications and estimates for -
--
We propose hereby to famish material and labor — complete in accordance with the above specifications for the sum of:
0
DD',�r� x! 4 t 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. AN agreements contingent upon strikes, accidents, or delays
beyond our cohtrol. Note — this proposal may be withdrawn by us 'd not accepted within days.
acceptance of apoa�
The above prices, specifications and conditions are satisfactory and are Signature
hereby accepted You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance —1 _9 -'Y)�L Signature
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
This form satisfiesall basic raqucements of the state's Home Improvement Contractor Law (MGL chapter 142A), but doer not hiclude standard_
language to protect homeowners. Seek legal advice if naeisary. Any person planning home'nprovtrneats should fitaf obtain a copy of ea
Massachusetts: consumer guide to home improveutett" befom agreeing toany work on yourtesidetce. You may obtain e fi ce copy by'celling the***
Office of Consnmer.Affadn and Business Regulation's Conner Information Hotline ao617-973'4787or 1:868:.283-3757.
Homeowner In
ane/
Street Address (do net use a Pon (Moe
. A Y7X--/p cc
atyffo" State
Moe 06
Dayft Icon Eva
ss) tract/ Sala
)de Address
The Contractor agrees- to do the following work for the H
lConttactor Information
aeraon/ owns Norse '
(must include a street address) . . .
14 4Ur.441elle L
46
% xS,e %%7%1� .
Required Perinits- The following building permits ere required Proposed Stara grid Cotnpdedon Schedule -The fdllovvifig schedulo will
and will bescoured by the contractor as the homecwne's agent be adhered boiinlesi circumstances beyond:the contractoet control arise
(Owners who,secure their own permits will be
excluded from the -Guaranty FundproWsions of Dace when coiitractorwill begin contracted wodt
MGL chapter 142A.) O F %4'c.`Y(467�
artyi—Dau
when contracted.wo*will.besubstudially.romplated
Total Contract Price and PaymentScbedule , _41 10
The Contrsctor.sgrew to perform thework, famish tire material and labor specified above for the total sum of.
payments will be made according to the folio ' schedule:
uron.signiug (mtao exceed 1/3 o�Pthe totfacipria !u this cosiest special order Tuever ms, whichis greater)
S - — by--t=-i= or upon completion of
S E
S liby _7=% or upon completion of
d � upon completion of the contract (taw forbids demanding full payment until is
completed to boot party's utisficdon)
7tla following materfaUequfp®eat must be rpedalS to be paid for
ordered before the contracted wo*Ugins in order S to be paid for
to meet die completion sebedule.(•')
NOTES: (7 including all finance charges (e•) IAw requires that any deposit or down-peymtmt reqs bW by the contractor befort work begins may
not exceed die greater of (a) one,6drd of the total contract price or (b) the actual cost of any gMdW.equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Exoress warranty -Is as eaoress.warranty being provided by the cewtraetor? No Yes 1L re�a of s► b « t !4 the eau.ncct
Subcontractor -The contractor agrees to be solely reapoturble for compietron of the work described ngudlas of the actions ofany third .
Party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all sobcosm actors fol
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
contntet shaU not imply that any lien or other security intarW)w been placed on 0te residence. Review the following cautious and notices
carefully before signing this contract
• Don't be pressured into signing the contract Take time to read and fully understand it Ask'gttestiooi if aonSeithiog is uinclear.
• Make surd the contractor has a valid Home Issnomment Contractor Registration- The Iriv requires most home improvement contractors and .
subcontractors to be registered with dieD rector ofHome improvement Conttactob Regitltration. You may iuytri:e about Contractor . .
registration by writing to the Dimcror at One Ashbiuwn Place, Roam 1301, Boston,'MA 02108 orby.trsUing 617-727-321)0 or
1-800223-0933.
a Does the contractor have imaumnce? Check to ser that your•contractor is properly insured
P Know your rights and responsibilities. Reed the Important Infam>atlon on the *reverse side of this f6 t'and gets -copy of the Consumer
Guide to the Home Improvement Contractor Law:
YOU may artcel this agreement if it has been signed at a place other than the comractor's'normel place of business, provided you notify the
contractor in writing at hislher main offi•8e or branch office by OnUuary mail postel, by telegram sent or by delivery, not later than midnight of tbe.
third business day following the signing of this agreement . See the amched notice of eaueellation form for an axplanation of this right
DO NOT SIGN THIS CONTRACT IF THERE ARF ANY 1RLANit coAt- elft
TweeOenOnieppia tNthe O.aevaatatut be mo�kted ads*" Omeepy.ahmddsotothebo "WW. Th*0dWeopyah Wbebeptbythe=nb aw.
wner's Signature Con�tracto?s srgnsum
Date Dna;
y_ 1 0
AC"R� CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDDNYYY)
01/12/2015
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 00775-001
Durso & Jankowski insurance Agency Inc
198 Mass Ave Suite 101B
North Andover, MA 01845
NQ€ACT
A]8, -1o, Ext : (978)682-5175 kxc. No.: (978)794-0313
�iEss:
INSURER(S) AFFORDING COVERAGE 1
INSURER A. A.I.M. Mutual Insurance Company
INSURED
Arthur Walsh
A J Walsh & Sons
55 Pleasant Street
North Andover, NA 01845
INSURER B
INSURER C:
IN SURER D:
E:
-INSURER
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. 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 PAID
STIR
TYPE OF INSURANCE
INDSR
v6�
POLICY NUMBER
CCyyB��Y���
MMIDD/YYYY
ppCLAIMS.
MM/DD/YYYY
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE F__] OCCUR
EACH OCCURRENCE $
DAMAGE TO RENTEDREMISES fE. $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
EN'L AGGREGATE LIMIT APPLIES PER:
OLICY RO- OC
PRODUCTS - COMPIOP AGG $
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
COMBINED SINGLE LIMIT(Ea accidentl $
BODILY INJURY (Per person) S ,
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
r i n $
$
UMBRELLA LIAB
EXCESS UAB
OCCUR
CLAIMS MADE
EACH OCCURRENCE $
AGGREGATE $
RNETENTION $
$
A
y�pRKDEERDg CpM
pAryNyD ERM�PPLRO�YEETRp3R�� PAR�3Lry4Ef��yEX
OFFICERIMEMBER EXCLUDED? ECUTIVE
Y
(Mandatory In N�e1 H))
699`s9 I IPA OF vPERATIONS below
N / A
AWC400-7014648-2014A
11/14/20
11/14/201&
yyC g U TH
X TORY LIMITS OER
E.L. EACH ACCIDENT $ 1 QQ,000,QQ
E.L. DISEASE - EA EMPLOYEE $ 100,000.00
E.L. DISEASE - POLICY LIMIT $ 500,000.00
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required)
The workers compensation policy does not provide coverage for Arthur J Walsh
Town Of North Andover
1600 Osgood Street
North Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE (/
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
Massachusetts - Department of Public Safety
Board of Building Rcgulations and Standards.
Construction Supervisor
x�
License: CS -022680 y..
ARTHUR J WAI,�A JR.
159A WAVERLY�RD" s
N ANDOVER MA 01$45 ,
/
Expiration
Commissioner 06/09/2016
C��e Lanr.�no�zrve�clf� o�C����raa«clu6e%ls
Office of Consumer Affairs & Business Regulation
_ ME IMPROVEMENT CONTRACTOR
a egistration: 103358 Type:
_ ;expiration: 7/7/2016 Private CorporatOo
.v
A. J. WALSH & SONS,INC.
Arthur Walsh
55 Pleasant St—
N Andover, MA 01845 Undersecretary