HomeMy WebLinkAboutBuilding Permit #294-12 - 381 SUMMER STREET 10/5/2011 TOWN OF NORTH ANDOVER
. _. APPLICATION FOR PLAN EXAMINATION
Permit NO: 9 Date Received
Date Issued:
IMPORTANT:Applicant must coEllete all items on this page
LOCATION
Print
PROPERTY OWNER
Print
MAP NO:L -7 PARCEL /4 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
t
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial,
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
[I Demolition - ❑ Other
� •A - �T-y�'' "'` " l�®}Floo�d""laui` Wetlands '�' u�`�® Watershed]DOM
®UPiPtj ❑SYYPill�« 4r.:_ i ..t -5 -*Cp . f 'v 'r +4 t ''•ti—_} aa.{ .ri
,� -sash � ar .�x
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OW
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please T pe or Print Clearly)
OWNER: Name: v0. Phone: 7
�k � �
Address S���s^
CONTRACTOR Name: __ Phone:
i �i/
Address: (Pr y �. (., d l cT i6 V
Supervisor's Construction License: 5-PH3 Exp. Date:
Home Improvement License:
J( 33o Exp. Date: /1 o/i
ARCHITECT/ENGINEER Phone:
t
Address: Reg. No.
FEE SCHEDULE:B ULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER SA
Total Project Cost: $ FEE: $
Check No.:
Receipt No.:
NOT Person ontracting with unregistered contractors t have access to the guaranty fund
ut•e�ofcontra _
Sigriafu�eTof�=9
Plans SubmittedEJ❑- Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
TYPE OF SEWERAGE DISPOSAL
-- Public Sewer ❑ Tanning/MassageBodyRrt ❑ Swimming Pools. ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ PermanentDumpster onsite ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING DEVELOPMENT ❑ ❑
1
COMMENTS `
- i
i
j
CONSERVATION Reviewed on Signature _
COMMENTS
HEALTH Reviewed on Signature
_ A
COMMENTS
�t
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
CONaffiNTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq.'ft.:
ELEGTRIGAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANT--=o TONE LITERATURE: Yes No
MGL Chapter 166 section 21A—F and G min.$10041000 fine
NOTES and DATA— For department use
® Notified for pickup.- Date
Doc:.Building Permit Revised 2008
6
Building Department
j 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
a 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
o 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 Engineeredirroducts
!VOTE: 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
j ❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
a 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 clerks office must stamp the decision from the Board of Appeals
to t the appeal period is over. The applicant mut then get this recorded at the Registry of Deeds. One copy and proof of recording
it st be submitted with the building application
Doc: Doc.Building permit Revised 2008mi
F" Location o / �i� 1-17
No. �lG/_ / 2- Date /D 5" /i
NORTH TOWN OF NORTH ANDOVER
OL
',r 9
Certificate of Occupancy $
Mu9
< Buildin /Frame Permit Fee $
s.KsE
Foundation Permit Fee $
t
Other Permit Fee $
G"
TOTAL $
4.
Check # —
yr,
24668 Building Inspector
NORTH
® Andover .,
_ /O � / F
o , � dower, IVlass., �
T O t- LAKE
COCHICHEWICK ,V
RATEO P'PA
�7 BOARD OF HEALTH
Food/Kitchen
RMIT T D PE
i
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.............,....�`�.. �`
tQj 1
........ ........ ......................� o...............�`.....�.........�..�............................ Foundation
s
has permission to erect.............:.......................... buildings on .. ............,......................................................-................. Rough
to be occupied asChimney
............................. ......... .................... ............................................................................
4
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final'
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONS ELECTRICAL INSPECTOR }
UNLESS CONSTRUCTION -START'S �
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 LathingD Wall To Be Done
or � FIRE.DEPARTMENT �
Until Inspected and Approved by the Building Inspector. Burner i
Street No.
I
SEE REVERSE SIDE Smoke Det.
-'" Massachusetts- Department of Puhlic Safet}
Board of'Building Regulations and Standards
Construction Supervisor License C
License: CS 58443
Restricted to: 00
KENNETH P DUVAL
PO BOX 190/72 NORTH ST
N READING, MA 01864
�- - —�� Expiration: 12/10/2011
(' mmiaiuncr Tr#: 10475
,per ✓� ,° � ���
\ Office of Consumer Affairs&B siness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:,,,,,;167338 Type:
Expiration: -9/1_012012 LLC
D AL ROOFING LtLC
KENNETH DUV iL�
. b� z
72 NORTH ST
NO.READING,MA 0186 - Undersecretary
�1
NOTICE N NOTICE
TO a TO
EMPLOYEES 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 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(7PJUB-023ON91 -9-1 1 ) 03-11 -1 1 TO 03-11 -12
POLICY NUMBER EFFECTIVE DATES
m—
GILBERT INS AGCY 137 MAIN ST
READING MA 01867
NAME OF INSURANCE AGENT ADDRESS PHONE#
o DUVAL ROOFING LLC 184 PARK STREET
NORTH READING
MA 01864
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
^
MEDICAL TREATMENT
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 work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
001638 W20NG02 TO BE POSTED BY EMPLOYER
The Commonwealth of Massa chusetts
Department of In dustrial A ceiden ts
i
— a� Office of Investigations
1
�= 600 Washington Street
Boston, MA 02111
`- www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): �) V )
Address: TO 63 AJuL M A
City/State/Zip: Phone
e you n employer? Check the appropriate box:
] Type of project(required):
Fiz;;)(_ I am a Pmnlnver yiith ( �— 4. ❑ I am a genes l ronYractnr and 7
r--
emp1oyee /�,n "ol_..� � � have hired the 6. New construction
loyees ti u�c niiw vi Nai t-iill�c). ..
2.❑ I am a sole ro rietor or a listed on the attache
. p p partner- d sheet. 7. E] Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp_insurance comp.insurance.t 9- ❑ Building addition
required-] S. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL l2 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 131:1 Other
comp.insurance required.]
*Any applicant that checks box#1must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:—
Policy or Self-ins:Lrc f) y d/`� � -1
P�IJ � � / . Exp"iratioti Date.
Job Site AddressAD
City/S!4te/Zip: LLrt
Attach a ropy oh the workers' compensation policy deet"aration page(shovviirg the policy number grid expiration date):
Failure to secure coverage as required trader 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 cinder thepains andpenalties of perjctry that the information provided above is true and correct.
Sip-nature:
/ Date f
Phone #:
Official crse only_ Do not write in this area, to be completed by city or town offrciaL
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: Phnna tt-
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 lire
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. 1- owever 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 certificates)of
insurance. Limited Liability Companies(LLQ 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 Cert m the event the Office of Investigationshas to contact you regarding the applicant. .
Please be sure.to fill in.the permit/icense:cumber which will be used as a reference number.. In addition an applicant
tliat.inust submit multiple peianit/license applications,in,any:given year,need.onlysubrnit one affidavit indicating current
er `Job Site Address"the applicant should write.Fall locations in (cityor
policy information(if necessary) and und
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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do nothesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-N ASSAFE
Fax # 617-727-7749
Massachusetts Home Improvement Sample Contract
This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard
language to protect homeowners. Seek legal advice if necessary.Any person planning home improvements should first obtain a copy of"A
Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information Contractor Information
Name . (,0 �_/-, any Name �
Street Address4¬ use a Post Office Box address) (' Conimctor/Salesperson/Owner Name �J/9\•//
I ��
frur- 0 12 iwlg-
City/fown „�� State Z}p HusiO Address(must include a street address)
DaytimePhoneJ�JjY_E/venin•'g Pone City/To State Zip Code
` -71 ,& -1A - fv-;[*� I N /4A J�� l
Mailing Address(It different from above) I Federal Employer ID or S.S.Number
Home I pmvement Co....Reg.Numb. 13,q an daze
law requires that most home
impmvemenl rn•tnnan have
a valid registration number
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,us_e additional sheets if necessary.)
1
&171y Q� ✓(-C -
__t4 I ..
Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will
and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will beL J N)VO
excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work.
MGL chapter 142A.) LkV4AA b. 1 povi
Date when contracted work will be substantially completed.
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:
$ ® upon signing contract(not to exceed 1/3 of the total contract price 91 the cost of special order items,whichever is greater)
$ by /_/_or upon completion of
$ by _/_/_or upon completion of
$yZsJ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment most be special $ to be paid for
ordered before the contracted work begins in order
to meet the completion schedule.(") $ to be paid for
NOTES:(`)Including all finance charges(•'°)Law requires that any deposit or down-payment required by the contractor before work begins may
not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material _
which must be special ordered in advance to meet the completion schedule.
Express warranty-Is an express warranty beine provided by the contractor? ❑No 07Yes(all terms of the warranty must be attached to the contract)
Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this a Bement
Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the ,
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
• Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear.
• Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by catling 617-973-8787 or 888-283-3757.
• 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.
• Know your rights and responsibilities. Read the Important Information on the reverse side ofthis form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the
third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
7 w identical copies oCthe contract mut be completed and signed.One copy should go to the homeowner.The other copy should be kept 6y the contractor.
G C
0 t/ Homeowner' Signature Contractor's Signature
Date Date
M Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A.
Homeown Signature ontractor's Signature
NOTICE a signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution' itiated 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 website at http://www.mass.gov/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 http://www.mass.gov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
http://db.state.ma.us/homeimprovement/licenseelist.MR
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-6524800,508-755-2548 or 413-734-3114
version 2.1-1112212010