HomeMy WebLinkAboutBuilding Permit #525 - 313 SUMMER STREET 4/7/2009BUILDING PERMIT o�
X67 �•�
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
S
Permit NO: Date ReceivedArao "
9qo `
��SSACHUS �
Date Issued: -�r 0 f
IMPORTANT: Applicant must complete all items on this page
LOCATION = 5 )' M �Evz-
Print
PROPERTY OWNER Cr14A-- .Q a N MI Lt,L
Print
MAP NO -U �;C— PARCEL:4rf ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family 1/
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement 1/
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
2� =fit C5JV Sir's N 6 1 G -Q-,- 12 X, t (o
- I,j T it-- ly GtO =co " r2R-0y C)4 rQ0 O2 F'P-ohJ _3 -Sc��f-J iar"
ffY ./g0/,J fir, Lx,--,,u,-
Identification
x.` ,L, -Identification Please Type or Print Clearly)
OWNER: Name:_ TZiC,t1, 2�"1. ml LLA- Phone: GE51- VW4%
Address: '-,V3 SOil rmc& 91-- l`I, /-21-1DOvs-4 N
CONTRACTOR Name:'Pp1Ll ONJ-����' �-- Phone: 1)78 -- 470 -1 qL3
Address:6(o P.Q, P144 0/810
Supervisor's Construction License: poo Z6 f Exp. Date: ,3 /A3 )a
Home Improvement License: /S�� 1 S Exo. Date: 29/15'/ZGr->
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125 PER S.F.
Total Project Cost: $ 9 C3 FEE:
Check No.: 7,6 Receipt No.: OQI��—
NOTE: Persons cont acting w4 ii#registeredcontractors do not have access to the guaranty fund
ire of Agent/OwnerSignature of c
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 —U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning 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:
t_ocatea 364 us ooa ,street
FIRE DEPARTMENT" Temp Dumpster on site yes no
Located at 1:24 Main Street
Fire Department.signature/date
. COMME!NTS
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector
Yes
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 - Date
Doc.Building Permit Revised 2008
No
IM
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 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/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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
�' Location Jul � n� 4-,%-
1
NoDate ,.
TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
JACHUSEt� Building/Frame Permit Fee $
Foundation Permit Fee $
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L TOTAL $
Check #
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CONTRACTOR'S AGREEMENT
BRIAN LAWLER
F.I.D. #04-2960346
GENERAL CONTRACTOR
Registration # ¢ (v I I *
66 Wildwood Road
Mass Builder's License #000261
Andover, MA 01810
(978) 470-1983
Date: "179
CUSTOMER INFORMATION
Name and Address: %8
Home Telephone: 667 - 96�8
Si 09113 MC t -LC/-
' 1; -SUM nI U--ttS' 1 : %1C, Oy Work Telephone:
CONTRACT TERMS
IN CONSIDERATION OF THE PROMISES AND AGREEMENTS SET FORTH IN
THIS CONTRACT, LAWLER AND THE CUSTOMER AGREES AS FOLLOWS -
1) Services: The Customer hereby requests, contracts with and authorized Lawler to provide the
work and the materials described below:
2) Date of installation: The work under this contract is scheduled to begin on 5-/-//W
and to be completed on ,- . This time period may, however, be reasonably
extended by Lawler in thb event of inclement weather which precludes the installation or other
circumstances beyond Lawler's control. The Customer acknowledges that he/she has been informed of,
and consents to, this time for completion.
3) Cost to Customer and Payment Terms: The total cost of the services and materials to be
provided by Lawler is $ 9,Sb U. . This customer cost shall be paid as follows:
a) $ 3 '79; �" (33 1/3%) shall be paid upon execution of this Agreement.
b) $ ] (66 2/3%) shall be paid upon completion of the work.
4) Customer Cooperation: On the date for installation set forth in paragraph (2) above, as such
may be extended the Customer shall allow Lawler and his agents reasonable access to the premises at
reasonable times.
5) Warranty: Lawler hereby warrants that its installation shall be performed in a good and
workmanlike manner in accordance with accepted industry standards and further warrants the
installation against defects in workmanship for a period of one year from the date of installation.
Lawler, however, is not the manufacturer of the materials used in the installation and has not
made and does not make any representation, warranty or covenant with respect to the condition, quality,
suitability or merchantability of the materials in any respect or any other representation, warranty or
covenant, express or implied. Lawler will, however, take any steps reasonably within its power to make
available to the Customer any manufacturer's or similar warranty applicable to the materials. Lawler
shall not be liable to the Customer for any liability, loss or damage caused or alleged to be caused,
directly or indirectly, by the materials, by any inadequacy thereof or deficiency or deficit therein.
6) Arbitration
THE CONTRACTOR (Lawler) AND THE HOMEOWNER (Customer) HEREBY
MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT THAT THE CONTRACTOR HAS A
DISPUTE CONCERNING THIS CONTRACT, THE CONTRACTOR MAY SUBMIT SUCH DISPUTE
TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY
OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND
THE CONSUMER (Customer) SHALL BE REQUIRED TOS MIT TO ARBITRATION AS
PROVIDED IN M.G.L. c. 142A.
ian Lawler Customer
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE
AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY
THE CONTRACTOR. THE OWNER MAYINITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES.
7) RIGHT OF RESCISSION
YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY
THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELLER (Lawler), WHICH MAY BE
ITS MAIN OFFICE OR BRANCH THEREOF PROVIDED YOU NOTIFY THE SELLER IN WRITING
AT HIS MAIN OFFICE OR BRANCH 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.
8) Acknowledgment of Rip'hts
The Customer hereby acknowledges that he/she has been informed that he/she has legal rights
related hereto under the provisions of M.G.L. c. 142 A. and 780 CMR -6. Pursuant to M.G.L. c. 142A and
780 CMR all home improvement contractors and subcontractors shall be registered by the director. Any
inquiries about a contractor or subcontractor relating to registration should be directed to: Director,
Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108,
(617) 727-8598.
9) Necessary Permits
The construction -related permits which are required for installation are as follows:
4 '2N1 kQ 111(1'f r� si +2 c�"ICa+y RG 24"1 j
It shall be the obligation of Lawler to obtain such permits, if any, as the Customer's agent.
Customers who secure their own construction -related permits or deal with unregistered contractors will
be excluded from the guaranty fund provisions of M.G.L. c. 142A.
10) Miscellaneous
This Agreement is made and executed in the Commonwealth of Massachusetts and shall be
construed in accordance with the laws of that state. In the event that for any reason any provisions of
this Agreement shall be declared invalid or unenforceable, it shall not affect the validity or enforceability
of the remaining provisions. This Agreement sets forth the entire contract between the parties and it
may be modified or amended only by a written instrument executed both by Lawler and the Customer.
THE CUSTOMER HERE:BYACKNOWLEDGES THAT HE/SHE HAS FULLY READ AND
FULLY UNDERSTANDS THE TERMS OF THIS CONTRACT.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
SIGNED UNDER SEAL THIS -77-"� DAY OFi'i2�L
Customer:
e'�(LVA ) C'
fL
Printed name:
Brian Lawler
ACKNOWLEDGMENT AND RECEIPT OF COPY
The Customer hereby acknowledges that he/she has received a copy of this contract signed by
both the Customer and Brian Lawler.
)V&j
Cust8mer
The:Commonwealth o 1Vlasschusetts
Department of IndustHat Accidents
Off ce:of.Investigations
600 .Washington .Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu'eYs
ApOicant:Infor nation ._Please:pr
Name (Business/Organization/Individual):j� I� jj��� 4 ^LoLG - 6V -36/w
Address: L& 2i,
City/State/Zip: ^moa v�
� Q` 1 Q Phone #: 978-470
` 4 Z3
Are you an employer? Check the appropriate box:
Type of project.(required)::..
1. ®"I am a employer with 1
4. Fj I am a general contractor and I
6. ❑New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
T. [Remodeling
ship and have no employees
These sub -contractors have
g. [j Demolition
working for me in any capacity.
employees and have workers'
9 O Building addition
[No workers' comp. insurance
comp. insurance.#
5. Fj We are a corporation and its
10.❑ Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
11.❑ Plumbing repairs or additions
myself [No workers' comp.
right of exemption per MGL
12.❑ Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
13.❑ Other
.employees. [No workers'
coma. insurance recluired.l
'Any applicant that checks box #I 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.
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 providing workers' compensation insurance for my employees. Below is the policy and job site
information. .
Insurance Company Name: -r At -M L M c1' J U QM- /Al Sy 94N e F CJS M 9R^J5/
Policy # or Self -ins. Lic. #: W LY a 6 q7Z 82.0 J Expiration Date:
Job Site Address: 313 SV''i'iM G� 31, City/State/Zip: 1% /�PJiO G VC--.. M1q
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 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
/7�G�
Phone #: 97v-47® -113-3
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.
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 -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 ort own`Off1cif
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 perrmt/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.
townAcopy-of the affidavit that has been officially stamped or marked by the city or town may be provided,to the,;
applicantnas�pFoo€: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•ox.permit to burn leaves etc.) said person is NOT required to complete this affidavit..
The•Office of Investigations would like.to thank you in advance for your cooperation and should you have..any. questions,.: ,
please do not hesitate to give us a call.
Ihe.Department's address; telephone and fax number:
The Commonwealth of Massachusetts
L�gPartm nt of Industrial Accidents
.:Office of Investigations
600 Washington Street
Boston, MA 02111
:Tel.-#` 617-727-4900 ext 406 or 1-877-NUSSAFE
Fax # 617-727-7749
Revised 4-24-07
:. wwvv.mass.gov/dia
WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 89 0_415 J
(Ed. 7-1-87)
Atlantic Charter Insurance Company VDAC
POLICY INFORMATION PAGE ENDORSEMENT
Endorsement No. 1
Endorsement Effective 11/06/2008
Policy Number WCV00478205
Location Number 1
Insured Brian A Lawler General Contractor
Policy Period 11/6/2008 To 11/6/2009
Item 4. * Class, Rate, Other is changed to read:
NCCI Co. No 29211
Atlantic Charter Insurance Company VDAC
Policy Rating Period 11/6/2008 To 11/6/2009
Classifications
Code
No.
! Premium Basis Total
Estimated Annual
Remuneration
Rate Per $100 of
Remuneration
Estimated Annual
Premium
Masonry-noc
5022
If any
11.62 !
0
Plumbing-noc & Drivers
; 5183
i 13,220
3.88
513
Electrical Wiring -within Buildings
j 5190
( 19,300
3.17
612
Carpentry-noc
! 5403
i If any
11.92
0
Painting Or Paper`
5474
If any I
5.01 j
0
Carpentry -detached Private
15645
I 30,774 i
7.50 f
2,308
Carpentry -dwellings -3 Stories Or
! 5651
I If any
7.50
0
Excavation & Drivers
6217
I If any
4.17 !
0
Manual Premium
Increased Employers Liability 0%
Subject Premium
Merit Modifier 1.00
Merit Adjustment -5%
Modified Premium
Standard Premium
Normal Premium
Expense Constant
Terrorism Act Surcharge
Total Estimated Premium
DIA Assessment
Total Premium and Surcharge(s)
All other terms and conditions of this policy remain unchanged.
3,433
0
3,433
0
(172)
3,261
3,261
3,261
338
19
3,618
205
$3,823
Issue Date 03/16/2009 Page 1 of Last
(c) 1987 National Council on Compensation Insurance. Form: 1091t
/yam ✓fie �ommzorwiea.�i o�✓�iaaaaciivaei�d
Board of* Building Regulations and Standards s
HOME IMPROVEMENT CONTRACTOR
Registration: 156915
Expiration: 8/15/2009 Tr# 257'965
I
Type: DBA w .
BRAIN LAWLER-GENERAL CONTRACTOR
BRIAN LAWLER '
66 WILDWOOD RD.�Q^'
ANDOVER, MA 01810 Administrator
'-' - .J1JC i�I0977r7JJ6'ItfIJGlL��� /)�../!-`(.Ct':1�CffllC �Gui
Board of Building Regulations and Standards
Construction Supervisor License
�j License: CS 261
Expiation: 3/23/2010 Tr# 20087
lRestriction: 00
BRIAN A LAWLER
66 WILDWOOD RD.,
ANDOVER, MA 01810
Commissioner
f
/yam ✓fie �ommzorwiea.�i o�✓�iaaaaciivaei�d
Board of* Building Regulations and Standards s
HOME IMPROVEMENT CONTRACTOR
Registration: 156915
Expiration: 8/15/2009 Tr# 257'965
I
Type: DBA w .
BRAIN LAWLER-GENERAL CONTRACTOR
BRIAN LAWLER '
66 WILDWOOD RD.�Q^'
ANDOVER, MA 01810 Administrator
'-' - .J1JC i�I0977r7JJ6'ItfIJGlL��� /)�../!-`(.Ct':1�CffllC �Gui
Board of Building Regulations and Standards
Construction Supervisor License
�j License: CS 261
Expiation: 3/23/2010 Tr# 20087
lRestriction: 00
BRIAN A LAWLER
66 WILDWOOD RD.,
ANDOVER, MA 01810
Commissioner
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