HomeMy WebLinkAboutBuilding Permit #720-11 - 252 CHESTNUT STREET 4/27/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: e -
Date Issued: Z
IMPORTANT:
?u� SC.-, -roti
Date Received
must complete all items on this
Print
Print
MAP NO: �PAR.CEL: ZONING DISTRICT: M hine Shop Village yeric District s
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
yAlteration
❑ Repair, replacement
❑ Demolition
PROPOSED USE
Residential
❑ One family
❑ Two or more family
No. of units:
❑ Assessory Bldg
❑ Other
-
DESCRIPTION OF WORK
ice, -,mer P�f ,o oma_
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
tLIW eTlaIlQbS ,W vv a�ciau�u�
PERFORMED:
Identification Please Type or Print CIearly)
OWNER: Name. S AT -s so AJ Phone: X178
Address: )S.1 � � /) 0 �
CONTRACTOR Name:
Address: Yo `x
-�7_ A/0 1
/—k
Supervisor's Construction License: J t� �y3 Exp.�ate:
Home Improvement License: �3 Exp. Date:
Phone:7�0 ,5 7
1V A 0 / :?G
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $ ���
Q0 ( tS6'"t'ec FEE: .20
rhor-V Nn 1 ()0 1 Receipt No.: 040q��
I
Location �Sr1 11 CS -T s
No. �U r Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ _
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I Do —
2!; :, " i
Building Inspector
Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
FWe]I
WERAGE DISPOSAL
❑ Tanning/MassageBody Art ❑ Swimming Pools ❑
❑ Tobacco Sales ❑Food Packaging/Sales ❑c tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMME
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
0
DATE APPROVED
u
Reviewed on Signature
Reviewed on Signature
Zonh ig Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & 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 I
NOTES and DATA — (For department use
® Notified for pickup - Date I
Doc:.Building Permit Revised 2008
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 Perm
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/Crossection/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
NOTE: 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
Hydraulic Calculations (If Applicable)
To Be Returned) to Include Sprinkler Plan And
Copy of Contract
❑ Mass check Energy Compliance Report
Engineering Affidavits for Engineered products
10TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
I all cases if a variance or special permit was required the Town Clerics office must stamp the decision from the Board of Appeals
is t the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
u st be submitted with the building application
Doc: Doc -Building permit Revised 2008mi
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NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1 450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(7PJUB-023ON91 -9-11 )
POLICY NUMBER
GILBERT INS AGCY 137 MAIN'ST
READING
NAME OF INSURANCE AGENT ADDRESS
DUVAL ROOFING LLC
EMPLOYER
03-11-11 TO 03-11-12
EFFECTIVE DATES
MA 01 867
184 PARK STREET
NORTH READING
MA 01 864
ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY)
MEDICAL TREATMENT
PHONE #
DATE
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the workrelated injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
001638 W20NG02
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
U1 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual): Duval Roofing, LLC
PO box b3 t
Address: fin_ Reading, MA 01864
City/State/Zip:
Phone #: 9_2S'6& �% SY%
yo an employer? Check the appropriate box:
AW10am
1. a employer with
4. ❑ I am a general contractor and I
_;Ff
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. Q Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.®�oof repairs
13.0 Other
• Any applicant that checks box M 1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hue 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 employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 14
Policy # or Self -ins. Lic. #: P U 13 0 a 3Q/U `J/ W/ Expiration Date:/' 2//// /,;),
Job Site Address: t�s t� 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
i
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Sivnaturw:5 / c�G'� > %2X�l Date: /7' 47 -7 /f
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/Licenst #
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 #:
Massachusetts - Department of Public Safety
Board of Building Reuulations and Standards
Construction Supervisor License
License: CS 58443
Restricted to: 00
ary
KENNETH P DUVAL
PO BOX 190/72 NORTH ST
N READING, MA 01864
c --
J Expiration: 12/10/2011
( ununissi°Oe1 Tr#: 10475
,per ✓� ��� �.��r
Office of Consumer Affairs & B siness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:. 167338 Type:
Expiration: -9/10/2012 LLC
D AL ROOFINGILC -
KENNETH DUVAL
72 NORTH ST g y8
NO. READING, MA 01864=''` Undersecretary
Street Address (do not use a Post Office Box address)
/up A M-1�
City/Town State Zip Code
-0Ua 3
Daytime Phone Evening Phone
ilina Address (It different from
Contractor/ Salesperson/ OwnO Name
Business Address (must include a street address)
Zip Code
/V0 l �u
it
Cy/Town
Business Phone
Law requires that most home
improvement contractors have
a valid registration number
State
Federal Employer ID or S.S. Number
Home Improvement Contractor Reg. Number I Expiration date
I b -7 33K I � 110/12—
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional lssh�if necesss )
Q ? 6
Required Permits - The following building permits are required
and will be secured by the contractor as the homeowner's agent:
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of
MGL chapter 142A.)
Proposed Start and Completion Schedule - The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
Date when contractor will begin contracted work.
mate when contracted work will be substantially completed.
`a" 0 ) n 01 r(*)
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of:
Payments will be made according to the following schedule:
$ OU upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater)
d-00 b / / or upon completion of
$_���'" by / /— or upon completion of 'tn
$ upon completion of the contract. (Law forbids demanding full payment unfit contract is completed to both party's satisfaction)
/
The following material/equipment be paid for
equipment must be special $ ./
ordered before the contracted work begins in order $ to be paid for
to meet the completion schedule.(**)
ore
ork
NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment actual requiranb theeic equipment befor w m made mat rial
begins may
not exceed the greater of (a) one-third of the total contract price or (b)
thewhich must be special ordered in advance to meet the completion schedule.
Ex ress Warran - Is an ex ress warran bein rovided b ontractor. the c
❑ No Yes all terms of the warran must be attached to the contract
ss 01 Me
Subcontractors -The contractor agree taotbor solely
contractore for completion of the work furtheragrees to be solely responsible fore all paeyments t al subcontractors dfor
party/subcontractor utilized by the cont
ma rials 1 bor d r hi a Bementoted within
Contract Acceptance - Uanignin or othesecurity interest has placed on the residence. nRev ew thefollowing cautions sand notices
e
contract shall not imply thaty
carefully before signing this contract.
If to read and fully understand it. Ask questions if something is unclear.
• Don't be pressured into signing the contract. Take time
ab. Make sure the contractor has a valid Home Im rovement Contractor Re strati n. The law requires most home improvement contractors and
ation. You may inquire
ut contractor
subcontractors to registered
d with
othe
Director
Park Plaza, R imimprovement
r 170, Boston, Contractor
0 Re o by calling 617-973-8787 oor 888-283-3757.
registration by g to
Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document.
rtant Information on the reverse side of this form and get a copy of the Consumer
• Know your rights and responsibilities. Read the Impo
Guide to the Home Improvement Contractor Law.
Go C =in
greement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
htt t his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the
owing the signing of this agreement. See the attached notice of cancellation form for an explanation of this right.
For a �, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESit'.
T r
r���a V1-ro'register formal complaints against a business, call:
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 submit to such
arbitration as provided In Massachusetts General Laws, chapter 142A.
Homeowner's Signature Contractor's Signature
NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer
protection laws (i.e. MGL chapter 93A) 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.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement 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 rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a 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 duplicate 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 original 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 rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance 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, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the OCABR websitea httu://www.rnass.aov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the HIC website at h ://www.mass. ov/ocabr/
Go online to view the status of a Horne Improvement Contractor's Registration:
htti)://db.state.ma.us/homeimi)roveinent/licenseelist.asip
For assistance with informal mediation of disputes or to register formal complaints against a business, call: