HomeMy WebLinkAboutBuilding Permit #820-14 - 401 MASSACHUSETTS AVENUE 5/13/20140.
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BUILDING PERMIT
TOWN OF NORTH ANDOVER to
APPLICATION FOR PLAN EXAMINA N
Permit NO:/�"�I 1 Date Receivedn°
.�
Date Issued:
i �9sSACHt7SE�,(`'
IMPORTANT: Applicant must complete all items on this page
LOCATION I.-, e1nG1 M
PROPERTY OWNER Pri n#o A V 1U
t Print
MAP NO: 1� PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Villaqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
R n i
Non- Residential
New Building
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
Identification Please Type or Print Clearly)
OWNER: Name: 's -°w Phone: Jo70 o2 V11-2 D�
Address: C� SA VL
CONTRACTOR Namq.: ,, —Phone.: . CM 6
Address: V 13
Supervisor's Construction License:Exp. Date: .�
OSS `'l3 ice -/to b
Home Improvement License:I Exp. Date: /o /
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: SULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $d�'_"_ � FEE: $ S
Check No.: Receipt No.: 7`"7 �J 1
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owne ignature of contract
c �
d
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Iss
IMPORTANT: Applicant must complete all items on this pate
LOCATION
Print.
PROPERTY OWNER
Print 100 Year Old Structure yes no
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
.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:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name:
AririrP- -, -
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License:
Home Improvement License:
Phone:
Exp. Date:
Date:
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: $
FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor ?
Plans Submitted �� Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
L
Plans Submitted ❑ Plans Waived ❑: Certified Plot Plan ❑ Stamped Plans ❑
.:TYPE OYSEWERAGEDISROSAL"
Public Sewer ❑
Tanning/MassageBody Art ❑ .
Swimming Pools ❑
Well ❑
Tobacco.Sales ❑
Food Packaging/Sales 11
-Private: (septic tank, etc._ . ❑... _ _ ..-Permanent
D"uinpster on Site ❑
-THE-.FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
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:
Comme
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW 'To-vv.2 Engineer: Signature:
FIRE -DEPARTIlII:.ENT - Temp Dumpster on site yes
Located at 124 Mair. Street
Fire Departinei it signature/date � _
.COMMENTS
Located 384 O
no
Street
Dimension
Number of Stories:
:_Total land area; sq. ft.
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of. Meter, location;rllast-or service drop requires approval of
Electrical Inspector Yes No
DANGERZONE LITERATURE: Yes No
MGL-. 46pter166.Section 21A -F and G min.$100-$l000:fine
NOTES and DATA — (For d
LJ Notified for pickup - Date
Doe.Building Permit Revised 2010
use
Building Department
The foliewing is --a list of the required.forms to be filled outfor:the appropriate. permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Bluilding 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 apw• al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Building Permit Revised 2012
Location O `'� Q N A -A
No. �a Date ( -�s 1
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $La—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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Check #
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Buildin inspector
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Page No. of Pages
lar osal Builders License # 58443
Home Construction Reg. # 167338
DuvaIAL
6C
�RaofinffL
(781) 944-1994 (978) 664-2557
READING NORTH READING
P.O. Box 637, North Reading, MA 01864
Please visit us at www.duvalroofing.com
f � •moi �.(t ��
PROPOS LSUBMITTEDTO
PHONE
DATE
STREET t ! r i
CITY, STATE AND ZIP CODE
We hereby submit specifications and estimates for:
®Rip,/&Remove all existing roof related debris from roof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS
L1 1 layer of existing roof shingles ❑ 2 layers of existing roof shingles ❑ 3 layers or more of existing roof shingles
2i
NOTICE
TO
EMPLOYEES
NOTICE
m
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 -9-14) 03-11-14 TO 03-11-15
POLICY NUMBER EFFECTIVE DATES
GILBERT INS AGCY 137 MAIN ST
READING MA 01867
m= NAME OF INSURANCE AGENT ADDRESS PHONE #
o= DUVAL ROOFING LLC 184 PARK STREET
o=
o�
NORTH READING
MA 01 864
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
o=
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
UA—
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
004315 W2ONG02 TO BE POSTED BY EMPLOYER
:C�e;aa3as�apaR
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y9810 dW `ONIad3S 'ON
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_'O�l JNId002i -JV a
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vt.OVON6 :Uollejldx3 _
Oilwogealsl6ab a -
8££L96 -
:Wl 1NOO lN3W3A0?1dW1 aWOH
bOlOda aawnsUO3 30 33800
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Massachusetts - Department of Public Safety
Board of Building Regulations and
Standards
Construction Supervisor
License: CS -058443
KENNETH P DUV,L
PO BOX 190
72 NORTH ST
N READING MA +91864\ ,f
Expiration
Commissioner
12/1012015
K
The Commonwealth of Massachusetts
Department of Industrial Accidents
w Office of Investigations
" d 1 Congress Street, Suite 100
° Boston, MA 02114-2017
5°V www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Duval Rooifng, LLC
Address: P.O. Box 637
North Reading, MA 01864 Phone #: 978-664-2557
Are you an employer? Check the appropriate box:
1. M I am a employer with 8
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
(No workers' comp. insurance
comp. insurance.
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance rectuired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. Q Roof repairs
13.❑ Other
*Any applicant that checks box #1 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.
$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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Travelers
Policy # or Self -ins. Lic. #: 7PJub-0230N91-14
Expiration Date: 3/11 /15
Job Site Address: "7�� /—� City/State/Zip: a1'L'
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.e�" nder the pains and penalties ofperjury that the information provided above is true and correct.
Si a C n Date:
978-664-255
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 #:
Massachusetts Home Improvement Samole 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 bomeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A
Massachusetts Consumer (hide 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 EsElation's Consumer Information Hotline at 617-973.8787 or 1-888-283-3757 or on our website.
Homeowner Information
Name
Street Address (do not use a Post office Box address)
b/ u554cj ct Se-
Co d Salesperson/ Owner Name
\ (�J•�/ls/
City/1p'owu State Zip/Code
ess must iuc hide a street address)
4 - ✓ /�� 0
N,4
lCityrrown
O
Daytime Phone Evening Phone
020 -au - J01
N. ems.
State Zip Code
W 0
18,6G/
Mailing Address (It different from above)
Business honeFederal
Employer ID or S.S. Number
Law -= nutnnbbn
Bore Impmrmaent CoNrxtmlteg. M�mSer
Sgrunfion date
rpn
n anlld ngistraaan nnmbm
/V_ —7331(
/ Dt
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, specifyiagthe type, brand, and grade of materials to be used, We additional sheets ifn M.)
11
kY "r
ot Al -01 - V
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 be
excluded from the Guaranty Fund provisions of ���w contractor walluU " begin contracted w
MGL chapter 142/.) d
ate n co ted work wi�l be substanti ly completed.
Price and Pavmcat
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 a the cost of special order items, whichever is greater)
$ by> > or upon completion of
$ by _/ I or upon corn)hl on of
$ 66°� �1.lot con ` t ,ail,
u compheAoa the con (Law ids demanding full payment until contract is comp' ed to both party's satisfaction)
The following materhallequipment must be special $ to be paid for
ordered before the contracted weak begins in order
to meet the completion schedule.("'h $ to be paid for
NOTES:(*) Including all finance charges (**) Law requires that any deposit or down -payment required by the c tractor before work begins may
not exceed the greater of (a) one-third of the total centrad 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 antoo nrovid t by x contractor? ❑ No Yes ra
(an terms of the warnh mist be attnrJhed to the conUact)
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
inters and labor under this aereement
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 frdiy understand it Ask questions if something is unclear.
• Make sure the contractor has a v mid Ho m roti meat Contra for Reeisiration. 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 calling 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 of this form and got 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,
TA ?►TAT Oil'�1nT mm'
.,,. +a+lU WINxacA� l li int to aniAP1Y l3LA1VKSPACESiS1
identical copies of the contract areal be compktedrmd signed. One copyshanld go to the ho owner. The other
copy ahoutd bekept by the canitxtor.
_C ,�� meowner s Sign Contractor's Si ature l
OA�
yDate / /
Date
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 DI 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 such arbi 'on as provided In Massachusetts General Laws t 424,
er's store
OTICE: The signatures of tiie parties above apply only to the of of
e p Signature
PP Y Y 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 1424) 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 AIWLlq& 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 coact must be in writing
and agreed to by bOBr 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 contractcir may not demand payments in advance of the dales specified on the payment schedule in uses where the
homeowner deans him/herself to be financially insecure. However, ininstarrc�s where a contractor deem him/herself
lobe 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 hth>t4�e m1s� ==u�lnr +hr
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 U14,:�; ,16c+cabn
Go online to view the status of Home Improvement Contractor's Registration:
httn:j'db titat4,tlla us h<+tncunnrutclncnl'lie
entcetist tin
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
508-652-4800, 508-755-2548 or 413-734-3114
Version 2.1 - I1/22/28ro