HomeMy WebLinkAboutBuilding Permit #1302-2016 - 40 SALEM STREET 6/13/2016 4a'lly u:- BUILDING PERMIT 0 NORTH q
TOWN OF NORTH ANDOVER 0
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APPLICATION FOR PLAN EXAMINATION _
Permit No#: Date Received �ORA7E0 " �y
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION `�� "-A�c n
n Print
PROPERTY OWNERAe.��
,` Print 100 Year Structure yes no
MAP " 7 PARCEL:/JU 6 ac ZONING DISTRICT: Historic District ye no
Machine Shop Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑A tion ❑Two or more family ❑ Industrial
Iteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
El
Septic ❑V1Fell ❑ Floodplain q`Wetlands D 1Nate�shedi Distract
ti. Q Wat_e_r/Sewerm_ v
Z DESCRIPTION OF WORK TO BE PERFO MED:
1n rcarti ., S� l ccr ✓�� r.
Identification- Please Type or Print Clearly
OWNER: Name: \c,kkVt j Phone:
Address: 0 5\,- OIA- k Jar' YS
Contractor Name: oSL
Email:
Address: - Lul n&_7
Supervisor's Construction License: Exp. Date:. . Qd' G ll
. Date: � 'ate
Home Improvement License:. ��`��� Exp.
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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$925.00 PER S.F.
Total Project Cost: $ 2O GCS _FEE: $_2_=jCet—
Check No.: I ® Receipt No.:
NOTE: Persons contra ing with unregistered ontractors 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
. �. Flo
or/Cross Section/Elevation Plan Of Proposed Work With Sprinklerrinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
IN OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Pe
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 I ECC Energy code
Engineering Affidavits for Engineered products
l'i 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
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunuling Pools ❑ F
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑
I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
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: Comments
',,.;Conservation Decision: Comments
n
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town )Engineer: Signature:
Located 384 Osgood Street
`FIRE DEP"�►F�T�MENT emDumj�st rsiteyes r. no =
I Located ate X24 MainStreetb r. E .:8 M
Fre Depa mentos g§h tune/ate
COMMENDS '
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Dimension
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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
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DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$1o0-$1oo0 fine
NOTES and DATA— (For department use)
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® Notified for pickup Call Email
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Date Time Contact Name
Doc.Building Permit Revised 2014
4
Location "'-� �z
No. I�IaZ, l�vDate l� 1
• - TOWN OF NORTH ANDOVER
k� Certificate of Occupancy $
Building/Frame Permit Fee $ G�
Foundation Permit Fee $ t
Other Permit Fee $
TOTAL $
ti
Check#
30500
O. 'n
Enter construction cost for fee cal- North Andover Fee Calculation
Construction Cost
E $�
21 787110) m
$ - $ 261.44
Plumbing Fee $ 32.68
Gas Fee 100 comm. S 110'R...0;0)
Electrical Fee $ 32.68
Total fees collected $ 426.81
40 Salem Street
1302-2016 on 6/13/2016
Remodel two bathrooms
� NORT1i
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Town 3� ndover
O 0
No. �
h ver, Mass, LkN It
COCMIC.1WICK
SR^TED PPp��S
U BOARD OF HEALTH
Food/Kitchen
PE R 1 0 T& _ 11 Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT ........... .............................. .... .... ...... ............................. .........................
Foundation
has permission to erect .......................... buildings on .......: .... .l1: ..... ... . ............
Rough
,f��/ �p c
to be occupied as ........ ..� !+.4�.X..... .......... .... ... .. .. .i.".............................I...... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST CTI0 T Rough
Service
. ...... ... ... . . ..... ?I�N
... ........
Final
BUIL E TOR
GAS INSPECTOR
Occupancy Permit Required toOccupancy Permit Required to OccupyBuildin�Buildinn 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.
Smoke Det.
Quality Abatement Contractors LLC
DBA Rosario Construction Services
49 Blanchard St
Suite 205-2
Lawrence, Ma 01843
Tel: (617)756-5513
Fax: (978)258-8595
Email:Joser.pac@gmail.com
WWW.QAC-LLC.COM
Contract Agreement
Homeowner information:
Name: Matthew Barnett
Street Address:40 Salem St City/Town: North Andover State: Ma 01845
Phone Number:--X88-3.764- Ci ��- � - 6
c/77 _ 'W 1-0
Contractor Information
Company's Legal Name: Quality Abatement Contractors LLC (DBA Rosario Construction
Services)
Business Address: 49 Blanchard St Suite 205-2 Lawrence, Ma 01843
Phone Number: (617)756-5513 Email Address:Joser.gac@gmail.com
Home Improvement Contractor Reg# 184596 Expiration Date: 02/09/2018
Contractor License# 109723 Expiration Date: 02/07/2020
Contractor agrees to do the following work for Homeowner:
Per approved estimate.
Proposed start date and completion of schedule-The following schedule will be adhered to
unless circumstances beyond the contractor's control, arise.
Contractor will begin contracted work on or by: 06/13/2016 (Tentative)
Contracted work will be substantially completed on or by: 08/13/2016
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work,furnish all equipment,tools and labor as specified,for the
total sum of:$21,786.61
$6,535.98 30%of the total contract price is required upon signing contract.
$6,535.98 30%of the total contract price is required at the start of the project.
$6,535.98 30%of the total contract amount. This will be submitted upon completion of finish
phase. (all materials installed)
$2,178.6610%of the total contract amount.This will be submitted upon completion of any punch list
items.
General Provisions:
Any alterations or deviation from the above specifications, including but not limited to any such
alterations of deviation involving additional material and /or labor costs, will be executed only
upon written order for same, signed by owner and contractor and if there is any charge for such
alteration or deviation,the additional charge will be added to the contract price of this
contract. If payment is not made when due, contractor may suspend work on the job until such
time as all payments due have been made. A failure to make a payment for a period in excess of
30 days from the due date of the payment shall be deemed a material breach of this contract.
In addition,the following general provisions apply:
1. All work shall be completed in a workman-like manner and in compliance with all
building codes and other applicable laws.
2. The contractor shall furnish a plan and scale drawing showing the shape, size
dimensions, construction and equipment specifications for home improvements, a
description of work to be done, description of materials to be used or installed and the
agreed consideration for the work.
3. To the extent required by law all work shall be performed by individuals duly licensed
and authorized bylaw to perform said work.
4. Contractor may at its discretion engage sub-contractors to perform work hereunder,
provided contractor shall fully pay said sub-contractor and n all instances remain
responsible for the proper completion of its contract.
5. Contractor shall furnish owner appropriate released or waivers of lien for all work
performed or materials provided at the time the next periodic payments shall be due.
6. All in change orders shall be in writing and signed both by owner and contractor and
shall be incorporated in and become part of the contract.
7. Contractor warrants it is adequately insured for injury to its employees and other
incurring loss or injury as a result of the acts of contractor or its employees or sub-
contractors.
8. Contractor agrees to remove all debris and leave the premises in broom clean condition.
9. In the event owner shall fail to pay any periodic or installment payment due hereunder,
contractor may cease work without breach pending payment or resolution of any
dispute.
10. All disputes hereunder shall be resolved by binding arbitration in accordance with rules
of the American Arbitration Association.
11. Contractor shall not be liable for any delay due to circumstances beyond its control
including strikes, casualty, or general unavailability of materials.
12. Contractor is not liable for any hazardous materials discovered, its removable or
I
disposal.
Client agrees to pay all owed amounts to contractor upon completion of the contracted work.
Interests and finance charges will be charged to the maximum allowable by law or at 1.5%
per month, whichever is less on all account over thirty days past due.Time is of the essence.
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�dntractor's
Signature Date Homeowner's Signature Date
I
The Commonwealth of Masscchusetts
f Department of Industria-lAccidents
.l Congress Street,Suite 100
Boston,M4 02-114-2017
www.mass.govIdia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE 1FMED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le0bly
NaMO (Business/Organization&dividual): /Iuali .��,.ta v.n �,�txS LCC—
Address: f w.c,(-� S St kt,,ti,' C,6_
City/State/Zip: lvv, 1-iYl Phone.#:-61? - ';6 ss13
Are you an employer?Checkt&appropriate box: Type Of project()CeCXuired):
1.❑I am a employer with employees(full and/or part-time).* 7. =islig 2.QI am a sole proprietor or partnership and have no employees Working for me,in 8.
any capacity.[No workers'comp.insurance required.]
3..Q I am a homeowner doing all work myself[No workers'comp..insurance required.]t 9. F1 Demolition
4.❑T am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition
•
ensure that all contractors either have workers'compensation insurance or are sole 11.C1 Electrical repairs or additions
proprietors with no employees. i
• 12..0 Plumbing repairs or additions •
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof airs
These sub-contractors have employees and have workers'comp.insurance. � rep
6. are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have nq employees.[No workers'comp.insurance required.]
'm: . :
*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 submita 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. Tf the sub-contractors have employees tliey must provide their workers'comp.policy number.
X ani an employer that is providing worriers'compensation insurance for my employees.'Below is the policy and job site
information. 11 11 ''
Insurance Company Name: —
- -blyo G-(vv��,Q, ,��1-1)61,A
Policy#or Self-ins,Lie.#: 1 �j Expiration Date: 16
Job Site Address: -1 ) sz,. e,-, City/State/Zip: (J') vy
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 e. 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.
X do hereby certif under the pains andpenalties ofpesjury that the information provided above is true and correct.
signafore: _ Date: 6o
Phone
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): i
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws ci r 152 requires all employer, *o provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every poi An the service of another under any contract of lure,
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 enferprise,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'contractoi(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 Depaftment 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 1 cense 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 proofthat 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
2016-06-13 15: 14 Phil Richard Ins 9787741318 >> P 2/2
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,4L.o�ty� CERTIFICATE OF LIABILITY INSURANCE
0611312016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE'- MOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 'SEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCL DOCS NOT C STITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZeD
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If tho certiflcate holder Is an ADDITIONAL INSURED,the policy(ies)must ho ondorsod. If SUBROGATION IS WAIVED,subject to
Lho lorme and conditions of tho policy,certain policies may require art endorsement. A statemnnt on this Cortificato door not confor fights to tho
cortificato holder in lieu Of Such ondoroomont(S).
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Massr ay Insurance Selvlces, LLC; NAMN: _ —
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE Anpvr_DFGCRIRF.D POLICIES BE CANCELLED BEFOHE
Town of North Anflov(:r TIIE EXPIRATION DATF- THEREOF, NOTICE WILL BE DELIVENED IN
'1600 O-sgood vt ACCORDANCE WITH THE POLICY PROVISIONS.
North Andovf:r,MA O'l84h
AUTIIORITLUIiLMHLStNIAIIV&z
1988-2014 ACORD CORPORATION. All rights reservod.
ACORD 25(2014/01) Tho ACORD name and logo are regimcired marks of ACORD
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-109723
Construction Supervisor
JOSE ROSARIO
88 WILLOW ST.APT 1> h
LAWRENCE MA 01841
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Expiration:
Commissioner 02/07/2020
��e�rz�i?o�ar�erueall,/����aQoac�u�e�o 1
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONT
- Registration: ,`' CONTRACTOR
X184596 Type:
�. Expiration '
:279/2018 LLC f
QUALITY ABENT
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ATEMENT CONTRACTO
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JOSE ROS
ARIO '
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88 WILLOW STAPT
I LAWRENCE, MA 01841
Undersecretary '