HomeMy WebLinkAboutBuilding Permit #192 - 33 UNION STREET 9/2/2010 BUILDING-PERMIT oF�"°oTH'
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO•,
Date Received I4p°R,rEo
• Date Issued:
IMPORTANT: I complete-
App icant must c plete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more•family Industrial
Alteration No. of units: Commercial
epair, replacement Assessory Bldg Others:
emolition Other
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DESCRIPTION OF WORK TO BE PREFO MED:
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Identification Please Type or Print Clear y) P 1 ��� �����
OWNER: Name: X.(� Phone: b
Address: 5 1,Ca 4 XT 0-7
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ S,�() tC6 FEE:
Check No.: Receipt No.:
NOTE: Persons co tracting with unfeb�ster ntractors of have access to the arantp fund
-
,U _ xoP=.Sagnaueori� a or �, -
ev .
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
i '
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
l.Vl�lIIVICIY I J
l r
HEALTH Reviewed on Signature
COMMENTS
Zonins~y oard 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 384 Osgood Street
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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 2010
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
❑ BuildingPermit
Application
❑ Workers Comp Affidavit
❑ Photo Copy Of N.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
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ IVI"'ass 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
� .1.:r• r n Plot
n►
❑ �.ei Lill. r-roposed Plot Plan..
[3 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
o 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:Buildin.-Permit Revised 2008
Location a?2
No. t�'^�/ Date
2 -/v
D
opt„1
M'GTOWN OF NORTH ANDOVER
3? I•,h0
F w
* ; ; Certificate of Occupancy $
.�_,. .'
Building/Frame Permit Fee
SSRCH
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
B ' ing Inspector
The Commonwealth of Alassachuse
tts
Department o f rndust'ial Accidents
Offace oflnvesiivrations
600 Washington street
Boston, M4 62111
Workers' Compensation Insurance Affcla assgov/dig
An licant Information �t: Builders/Contractors/Electricians/Plumbers
PIease Print Legibly
Name (Business/Organization/Individual):
Address: `
City/State/Zip:
Phone#:�7�
Are you an employer? Check the appropriate box:
1•lil�am a employer with 4. ❑ I am a general contractor and I7�[]R=oL-hg
required):
?.[� employees(fuI]and/or part-time).* have hired the sub-contractors ruction
I am a sole proprietor or partner- listed on
the attached sheet t
ship and have no employees These sub`cOntmctors have
working for me in any capacity, workers coin . ' 8• ❑Demolition
[NoP insurance.
eqt workers' comp. inc�,rance 5. ❑ We are a co 0 9 ❑Building addition
required] rP ration and its
officers'lave exercised their 10.❑Electrical repair,3.[] I am a homeowner doing all work right of e °r�t10�
myself xemptson per MGL I l.❑Plumbingr
Y [No workers comp. c• 152,§I C4);and we have no ��or additions
insurance required] t 12•7 Roof repairs
employees. [No workers'
�, y,? c comp.insurance required,] 13.[] other
that checks bo:-1 ar_St also Cil get<W
Romeowneis a`fie'-'nom L=�OR'
who submit this affidavit indicating they arr dcW^ e "a er e s Cosy s";e^ is •. , •-----�a•
+Contractors that chi:; s bo.*.m•�:a' E aL wor'e an¢tnen hue outside
ooIIuart �G.
-•hed an additional sheet showing the ss submit a new athdavit indicating such.
game of the sub-con
tractors and their workers'romp-policy information.
I am an employer that is providing workers'compensation insurance or m e
informgdon. f Y mployeca Below is the policy and job site
Insurance Company Name: CO Cc�
Policy#or Self-ins.Lic. A� , Ccs
Expiration Date: ()Is log /I
Job Site Address:� f t l7'U `C
Attach a copy of the workers'compensation policy declaration age sho ,City/state/Zip;
P e ( wyag 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
fine up to$1,500.00 and/or one-year imprisonment as well as civil penalties of a
Of up to$250.00 a day against the violator. Be advised that a co Penalties to the form tl� of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification FY°f stat--went may be forwarded to the Office of
herebyI do «run angert r paus
Signature-' mors nd penalties of penury th¢t mon.provided above is true and correct
fate
Phone#: - ��
Official use only. Do not write in this area, to be completed by city or town ofjzciaL
City or Town:
Permit/License#
Fssuina Authority(circle one):
L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing
6. Other b Inspector
Contact Person:
Phone'-.
Information an- d Instructions
Massachusetts General Laws chapter 152 requires all employs to provide workers'compensation for their employers.
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 tine legal representatives of a deceased emplover, or the
receiver or trustee of an individual,partnership, association vg other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartnoL eIIts and who resides therein,or the occupant of the
dwelling house of another who-employs persons to do maintemance,constriction 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 building 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 umitil 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'comp enation 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&tire to sign and date the affidavit. The affidavit should
be ivtuiued t0 the vitt'or town that the auvllGaurJn for the V'err�2lt or li^.rT:ee L�being r-eglteSted rtClt$.^.-e.;1ep8ISTM,aIT.Of
Industrial Accidents. Should you have any questions regardi-b`„r law or, if you ;;-ed 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 per--riits 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would Bice to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone and fax.mumber.....
The Commonwealth of Massachusetts
Department Ofindustri.al Accidents
Office of Inresti ati-ons
600 Washington Street
Boston,IVLA 02111
Tel. # 617-72.7-4900 =4.0.6 or 1-97/ -MASS:AFE
Revised 5-26-05
Fan: n 617-727-7749
WWW.Mass- ov/dia.
09/02/2010 08:50 9786833147 PAGE 01/01
CC)Rbw DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCEx_/2/2010
7iIS CERTIFICATE ID ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
•CRTIFICAT5 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 Olt PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT. If the mm1ficate holder to an ADDITIONAL INSURED,the policy(Ws)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statemant on thla certificate does not Confer rights to the
Certificate holder In Him of Such endorsament(s).
PRODUCER UUNTACT
NAME:
M P ROBERTS INS AGCY INC PRONE
Arc No Exl (978)683_8073 p10 NG:(978) 683-3147
1060 Osgood Street
North Andowir, MA 01845 ADDREs8:aandi@mprobertsinsurance.com
INSURER(S) AFFORDING COVERAGE NAME
INSURER A:ACE PROPERTY & CASUALTY
INSURED PACY CONSTRUCTION INSURER 9:
JIM RACY D/B/A INSURER C:
15 UPLAND ROAD INSURER D;
ANDOVER, Moi 01810 INSURER I,;
978-4'74-4530 INSURER P:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY'rHAT THE POLICIES OF INSURANCE LISTED BELOW HAVIE 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 LSE; ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MSR TYPE OF AWDr POLICY EFFi PCLTRIUMT POLICY NUMBER MMIDD MM brn'YY LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY PREMISE8 fEa oommaron $
CLAIMS-MACE EJ OCCUR MED EXP(Any one rson) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGOJIMI
$
POLICY 7R0-
LOC $
AUTOMOBILE LIABILITY
Ea Accident $
ADODILY INJURY(Per person) $
ALLLL OWNED `�
WNSCWEOULEO
AUTOS AUTOS BODILY INJURY(Per accidont) $
.� HIRED AUTOS NON-OWNED
AUTOS $
Per aeeidenl
$
UMBRELLA LIAROCCUR EACH OCCURRENCE 8
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$
WORKERS COMPENSATION WC I - DT - $
AND EMPLOYERS'UAE ILITY Y LIMITS ER
A ANY
EXC UMDDXECUTIVE YIN� NIA NWC 046291980 05/09/10 05/09/11 E.L.EACH ACCIDENT S 500,000
(MandIfm,describe undwr ary ri NMI E.L.DISEASE-EA EMPLOYE' $ 500,000
Ifyea
DESCRIPTION OF OPERATIONS balcw E1.DISEASE-POLICY LIMIT $ 500'.000
DESCRIPTION OF OPERATIOtIS/LOCATIONS I VP!HICLES (Attach ACORD 101,Addlllonal RernerkA Sohedule,IF mom spars Is requlrod
FAX: 978-688-3542 )
CERTIFICATE HOLDER CANCELLATION
TOWN CF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING DEPT ACCORDANCE WITH THE:POLICY PROVISIONS,
1600 OSGOOD STREET
NORTH ANDOVER ,MA 01845 AUTHORIZFb REPRESENT E7
0 1 988-201 0 ACORD CORPORATION, All rights reservad'
1CORD25(2010105) The ACORD name and logo are registered MArks of ACORD
F NORTH
Town of - Andover
o =- A K E -0 dover, Mass. Z
; ` O� '
k.
COC MIC ME WICK I
S RATED PPf��•�5
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
'A•
BUILDING INSPECTOR
THISCERTIFIES THAT.....YLT.......... ...... ..JPS..............C........................................ ................................. Foundation
has permission to ereP�n
................................. buildings on ...*33......064.0-t.......................�.................... Rough
to be occupied as...... rA..I.C ......... . �i.......•...................... . . . . . . . . chimney
a VA
.. . . . . . . . ..............................................
provided that the pere ting this permlt s all 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 CONSTI ARTS
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. Burner
Street No.
SEE REVERSE S 1 D E Smoke Det.
Page t of 3
Neil Pavy --
From: "Nei!Pacy" -<np,acy c@comcast.net>
To: "Nei{Pacy" {npacygtcomcast.net>
Scat: Monday,August 23, 2010 4:31 PM
Attach. header,htm
Subjoct; Wgreement
15 Uplc'rO Rd
Andoiler, SIA 07810
(178)-590-3992
('97,Y)-469-9877
npctc;)�(ct.}c'urrrccts�,rr�}/ '
August 23, 2010
General ContructinglHomeowner infar,nalion
Pacy Construction
29 Hunters run Haverhill, ,MA 01832
Daytime phone (978)-590-3992: evening phone(978)469-9,577
Jean Kong, CMCA
ProveiV address
33 union st North Andover, MA 0.1845
` 4 (617)-973-6700 Fax 4 (617)-500-0968
Work to be perfi)rtaed and,Materials to 1?c used. .
Removal of existing decking, and railings, includes removing all lalluve, and pane
under deck, and all stair parts, excluding structural,
provided rov
stet b
Dispose of csld decking, rails, and trim into dum 1� P Y Pacy
Construction
Installed decking Materials will be
Timbertech XLMgrooved decking(color sand ridge), with Hidden,fastener
,system
.Rails will be Timbertech Radiance rail (color coastal
white) stairs will
8/23/2010
rage 6 of J
have Pvc type material f or skirts, and risers,
Perimeter of'deek will have skirt trim,
New vynle or pvc lattice with pvc trim picture framing aligned with posts,for deck,
Install pvc risers for stairs, with ThTibertech(color sand ridge) decking fur treads,
Pacy construction will provide all the materials needed to complete the job
Pacy Construction will supply all plans,permits, and licenses for Job
All dehris will be removed and properly disposed of
Pacy construction will keep a clean jobsite throughout the project..
Schedule
The following work will be adhered to unless circumstances beyond our control arise,
Work begin E'xpeeted date of'completion
Payment schedule.
1 amount due at contract signing, $2000.00
2 2nd payments when materials arc,delivered$2500,00
4payntent due on completion oi'deek and stairs with decking, and rails$2000.00
5 final payment due on completion of job$2000.00
6 Total payments. $000.00
Terms and conditions
1. Unless otherwise noted within this document, this contract shall not imply that any lien
or other,security interest has been placed on the residence
2. APLLICABLE LAW; This Agreement shall be governed and construed in accordance
with the laws of'the commonwealth q fMa,ssachusetts.
3. ENTIRE AGREEMENT: These terms and conditions represent the entire and integrated
Agreement between Homeowner/Goneral Contractor and Pacy Construction and
supersedes all prior negotiations, representations or agreements, either written or oral,
and may he amended only by written instruments signed by both Homeowners, and Pacy
construction,
4.LEGAL ACTIU111S. Should it become necessary.for Pacy Construction to enforce the
term of the Provisions of this Agreement, or to collect any portion of the amount payable
under this Agreement, then all litigation and collection expenses, including but not limited
to witness fees, court cost's, and attorneys fees shall be paid by the Homeowner
5,BINDING AGREEMENT, Homeowner, and Pacy Construction respectively, bind
themselves, their partners, successors, assigns and legal representatives to the other party
to this Agreement and the partners, .successors, assigns and legal representatives of.such
party with respect to all covenants of`this Agreement.
6SEVE.RABILITY. If any provisions of this Agreement are held to be in violation of any
law or ordinance, they.shall be deemed stricken and all remaining provisions shall
8/23/2010
Page 3 of 3
r .
continue to be valid and binding upon the parties,
7. INTEREST, Statutory interest of twelve percent (12%)per annum will be added to all
balances more than 10 days overdue.
In the event that any balance on any contract entered into between the above referenced
Llomeowner, and Pacy Construction becomes more than ten(10) days overdue, ,Pact'
construction reserves the right to cease all work being done,for Mat Homeowner until all
accounts are current
8. ADDITIONAL WORK: Any work not described in the above work to be Iyer;formed
description will be considered additional work, Pacy Construction and the Homeowner
will come to an Agreement on the cost's of Labor, and materials before starting..
1 UNDL,R,STAND THAT I HIS IS A LEGALLY BINDING CONTRACT AND NAVE REA0
A FILLY UNDERSTAND THE TERMS AND CONDTIONS CONTAINS THERIN.
a teowner or C'ontravied A nt Date
act' Construction data
Sincerely,
Signature
5/23/2010
tau u d u:i3Li'is ig Rcgu,l�t oattl St- Baa dg-
-- 'T CONTRACTOR_.
_- HOME 111PitOVEMEI�,. -
.. FRegistration 154925
EMpiration. 41{13/2011 Tr# 284838
{
Type: DDA
NEIL PACY CONSTRUCTION
NEIL PACY
29.HUNTERS RUN: :, .,
I IAVERHILL,-MA 01832``" Administratoi
• llati�aehu i*ftc--DePartmcnt +>F puliFic Sut'ct.
! Bq u d oi';Buildim-s Reg;ul iti�►n antt Sf.tntf.0 dti,
Construction Supervisor License
License: CS
65886
Restricted to: '00
i
NEIL PACY
29 HUNTERS RUN
HAVERHILL, MA 01832
Expiration: 11/25/2010
Tr#: 7916
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