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Building Permit #416 - 43 MIDDLESEX STREET 12/1/2009
TOWN OF NORTH ANDOVER APPLICATION FOR.PLAN EXAMINATION 011 Permit N0: a Y Date Received Date Issued• 4-0� IMPORTANT:Applicant must complete all items on this page LOCATfLy-vt� ±ft,, y Pant PROPE OWNER d�..i1 t� - , Pint w MAP N PARCEL: ONING DISTRICT: _ Historic District yes no Machine Shop Village des 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, eplacement Assessory Bldg Others: Demolition Other Septic Well; Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: I entification Please Type or Print Clearly) OWNER: Name:)-k'NC4CkpJ S � Phone: a'h Address: '�13 a I��C� LQ cl-l-AA S� N0ft CONTRACTOR Nam VIL C.-'"7 Phone: 01 Address: Supervisors Construction License: p Exp. Date. 1 Date: Home Improvement License: Exp. a (o ARCHITECT/ENGINEER vS el 1 N N Phone: C,t% - AS -i Yl Address:0 �N Ste ` a-� 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.: Z 7� NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fun ignature of Agent/Owner Signature of contractor 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: Doc.Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools , Well Tobacco Sales •*�'� � ,Ml ' 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: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood ood Street FIRE DEPARTMENT-r Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 2008 Location No. , , Date ,� r NORTIy TOWN OF NORTH ANDOVER 0 0 + ; . Certificate of Occupancy $ s+cMusEt� Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #/J OCJ 22662 _ Building Inspector NORTH ONM o _ Andover VA 414 Zdover, Mass.,' - o g -4S�A COCMICKEWICK\y�' 7��oRATED �7 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.........Vll�i.......LJ//.��I.. ? !s.: '............................................................................... Foundation has permission to erect........................................ buildings on .....�YJ......�.744: . .�!J�......S ............................. Rough to be occupied as.... ��d Chimney provided that the person ac pting this permit shall i every respect conf rm 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 CONSTRUCTIQN STARTS Rough Service ......... . ................................................................................................... BUILDING INSPECTOR Final Occupancy Permit Required t0 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 SIDE Smoke Det. ✓lae�oorvnu�uueal�o ✓L�avoac�zi:aetta Board of Building Regulatio s and Standai.ds HOME IMPROVEMENT CONTRACTOR Registration: 123553 - - - — Expiration-,316/2091 __ Tr# 282379. - - - Type: DBA' Preserve Painting_ Sean O'Connor 203 WASHINGTON St.0-256 SALEM,MA 01970 Administrator ^ € E t` BOARD t3F BUILDING REGULATIONS: I License. CONSTRUCTION SUP71 ERIS€3R Number; GS 093403 �v� � �� Birthdatef 12f3�f1969,." Expires 'I 13412009 I�estr�-ted- OU SEAN OCbNNOR i 26 bit STNUT ST SAI EM NiA 0#97Q . Cot��n�ss�oner - .I ACORID, CERTIFICATE OF LIABILITY INSURANCE OS/ 28/" I 2009 PROmmER 781 449-6786 FAX (781)449-4269 TMS CERTIFICATE tS 18$UED AS A(MATTER OF INFORMATION BOVNTON INSLqtANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 72 RIPER PARK STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE Pt?LlC1E3 BELOW. NEEI", NA 02494 INSURERS AFFORDING COVERAGE NAIC 4 Mum Kyron Inc INUIRERA. Nax Specialty DBA Preserve Services mtwERe Hartford Insurance- 203 Washington Street.#2SG INSURERC. Saiem,NA 01970 IISURER0, INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY ISSUED OR MAY PERTAINHINSURANCE AFFO.TERM OR RDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTOF ANY CONTRACT OR OTHER DOCUMENT WTH R TO ALL THE TERMS.EXCLECT'TO WHICH THIS LUU.4�3 AND CONTE MAYDITIONS OF SUCH POLICES•AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF19111RANCE POUGYNUMBER Wlrs GENERALLv►SM W013INN308 0S/23/Z009 05/23/2010 EACHOCCURRENCE a 1.000,00 X COMMERCIALG�RALLUIBILRY lVIwjfrw -- i�� cxAMMADE 01 QX OccuR tEaao�++rrrrb.) s 50 A MED ETP Ww om pmom) s 5 PERSONAL&ADVINAIRY a 11000,00 00 a GEN'IAGYiREGATELMRAPPLR:SPER cENERALAGGREGATE 2 PRooucTs-cDMwoPAGG s 2000. X POLICY m Loc AUTOMORM LIABILITY ANY AUTO CO LMR a ALLOWNEDA M Sd1EDtMAUTOS SODILYINM(PerP�) Y a HIRED AUTOS NON-OWNEDAUTOS mA I Y a (p DAMAGE i WAN LIAWN - ANYAVTO AUTOONLY-FAACCO M s EAACC i A TIOONL AGG ; EXCIAi f IIAYIRF1J.11 UABq.Iilf OCCUR CLAIMS MADE EACH OCCURRENCE i AGGREGATE a DEDUCTIBLE a RETENTION s i GUNPIRISATION ANDRIAPLOVERrumuTy YIN 014301392 05/20/2009 05/20/2010 X TORY R a ANYPROPR>E70R/PARTNER� LMR B ? E.L.EACH ACCIDENT a 100, _yahdo=PROWSIONS bakw E.L.DISEASE-EA EMPLOYE f 100. OTNER E.L.DISEASE-POLICY LIMIT f a S00 DESCfiNTgN OF ►TIONS f IACATIpItB t VEIBp tEg f E7(CLIla10NS ADoBY �rrf(PEAL Pitpt 1.000 BodS�y Injury and /or Property Damage DedENDOR8EA1uctible INFORNATMML PURPOSES ONLY. IF ADDITIONAL IS NEEDED PLEASE CONTACT THE AGENT. U=g U-#CATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DEMCIeW POUCM BE CANCELLED BSFORE THE EIIPRATWN 0 DATETHEREOF,THEISSUINGINBWERWILL ENDEAVOR TONAI. lO DAYS WRITTEN NOTIOE TO TH!CdNtTgG►Tt HOLABR NAMW TO THE LEFT,GW FALUAR TO DO eo GRALL IMPOSE NO QBUGAMON OR LIABILITY OF ANY IOIMUPON TIE INWRER ITs AaWM OR REPRITATRfEB 010111 AOTF�D IT MAY t70NCERN aCaRD fj ®1(188• ACORD COATIN. 11,TNghra reserved. The ACORD name and 1080 are mokfamd marks of ACORD *firs r k�, r a�� z f w v 203 WASHINGTON ST.#256 �� . PRESERVE SALEM,MA 01970 _ SERVICES carpentry I painting I roofing I gutters PHONE:978.745.8745 a g' ` F,ax:978.745.3476 � SALES@PRESERVESERVICES.COM Linda Dinsmore Date Bid:11/22/2009 43 Middlesex St Estimator:Sean O'Connor North Andover MA, 01845 (978) 683-7053 ROOFING ESTIMATE COMMENTS The below estimate is for the house and garage excluding the flat roof in front. PRIOR PREPARATION PERMITTING: All permits will be obtained in accordance with the law as required. DISPOSAL: A dumpster will be placed in a area designated by the homeowner. ROOFING PREPARATION COVERING: Tarp the exterior of the house so as not to damage the siding. SHINGLE REMOVAL: Remove all layer(s)of old shingles CARPENTRY* Remove the rear chimney down to the roof line. Plywood the opening. The exising gutters which have surface mounted hangers will be removed and re-attached. You cannot mount the gutters normaly because the eve has a molding profile near the roof which will not allow this. (you need a 5 inch flat facia board to screw the gutters on) UNDERLAYMENT ICE AND WATER SHIELD: Install ice and water shield on the entire roof of the house OTHER: On the garage we will install 151b felt under the shingles. FLASHING DRIP EDGE: Install drip edge on all perimeters. VENT PIPES: Install new boot or flange around vent pipes. ROOFING MATERIALS ASPHAULT SHINGLES: Install architectural shingle 30 year. Architectual PRICING Basic $ 10250 Discount $ -980 Total Price $ 9270 including Labor&Material 2?q, 1 Payment Terms: 20%deposit (day of start); 30%progress; 50%end of job McNisa/Amex Sean O'Connor Customer Signature *Above additional prices includes all discounts and coupons discussed prior to estimate. The above quote is valid for 60 days. *Warranty: Craftsmanship: Kyron Inc. DBA Preserve Services warrantees all work performed for a period of 2 years. If any problems occur we will cover the cost of labor and materials. For the warranty to be valid the invoice that was presented at the time of completion must have been paid in full. Materials: The duration of the manufacture's warranty is specified in the materials section above. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations qV 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual) iuo C— SE- k,\(\j Address: biA& N l 41. a4-6 City/State/Zip: ��Q�(�(\ Phone#3,�-1 Are ou an employer?Check the appropriate box: Type of project(required): 1 a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. I ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.F] Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL .1 LE]Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] Any applicant that checks box#1 must also ful 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. �.}��,� 1 Insurance Company Name: f J ��`" Policy#or Self-ins.Lic.#:_ (� �� X000 8O Expiration Date: �-3 1'0 Job Site Address: � 5 I t Vt-�CA U &Iplk � I City/State/Zip: P, 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 certify under the pains and ties ofperjury that the information provided above is true and correct Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offu;iaL 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 t10 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, 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 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 tovm 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-inured 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 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 bum 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. 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. #617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass.gov/dia TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: DAPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER LI vA a Di ri sm OI^e Print MAP NO:O 3/ 0 PARCEL:()0 �7 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 El Industrial ❑Alteration No. of units: ❑ Commercial ;<2epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ �'�-/ ,K—'E,tyg.. —r�� } e tib ®IViTell' ®FloodplaiI ®Wetlians ds, ®�WatershedlD strict 4' P� wx , Pr a DESCRIPTION OF WORK TO BE PERFORMED: ril( a_AuPJ.--fcrn ere,( o� ala✓at�e- , I' fae� S�ea- 6`�� 8� cc�ec���l���tles as h�dl� i Identification Please Type or Print Clearly) phone: q79• b 91 ' 71963 OWNER: Name: LI►�d a �l�5 M o re - Address: CONTRACTOR Name: NO$� COSf �o Phone: 478 Sbq '3sla Address: E0 I'-VX q7__ fin, 4doyn,- MA 01�4'� Supervisor's Construction License: CSS g(68$3 Exp. Date: Z�26 /2010 l�'3Dso Home Improvement License:� Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT-'=00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ J� DSD FEE: $ .31,a o 3� Check No.: ) o � Receipt No.: -" NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund of Agent/Owne_"r`; _ Srgnature 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 o 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) ❑ Mass check Energy Compliance Report If Applicable) p p ❑ 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 o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o 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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit a all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals tat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc-Building permit Revised 2008mi Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 Siqnature COMMENTS 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 COAUVIENTS 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 2008 t Location J13 //lt d✓t/l e.re k S No. �7`. 7"�U/� 111,201v Date TOWN OF NORTH ANDOVER f � � 9 Certificate of Occupancy $ /Frame Permit Fee $ :oda suwuBuildinst 9 r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 1 23752 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):fMC gea( 8-0N1 C*0r7iTYIG• hi De CD S�&Ml n 0 Address: tO 901C q2— 0 o i -4k Or"o velem M E 01 5; City/State/Zip: gyp- h Jwe,v , MK 0(84-9- Phone#: Q 7(3 - SZq 3577 Are you an employer?Check the appropriate box: Type of project(required): 1. ❑ I am an employer with 4. :1 I am a general contractor and 1 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors 7.Pemodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. C Demolition working for me in any capacity. employees and have workers' 9. C Building addition [No workers'comp. insurance comp. insurance. # required] 5�t'We are a corporation and its 10. f Electrical repairs or additions 3. n I am a homeowner doing all work /" officers have exercised their 11. C Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152, § 1(4),and we have no 12. L Roof repairs employees. [no workers' 13. 1 Other comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attach 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: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cer :fy rl d the ains and penalties of perjury that the information provided above is true and correct Signature: Date: ( Z ,W/0 Print Name: NO OSTWI700 Phone#: q 7$ °9b ' 3$7l 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 Heath 2. Budding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: Board of Building Regulations and Standards Construction Supervisor License License: CS 86883 Restricted to: 00 NOEL L COSTANTINO ; PO BOX 92 N ANDOVER, MA 01845 Expiration: 12/26/2011 ('nairoissi�mca Tr#: 12408 � Office of Consumer Affairs&B sines Regulation WANTI HOME IMPROVEMENT CONTRACTOR Registration: a143050 Type: Expiration: -45/.14/2012 DBA NO REALTY,+CONST:.', NOEL COSTANTINO t 13 PAULINE WINTHROP,MA 0184,1,%- Undersecretary NOV-29-2010 MON 09;09 AM FAX NO. P. 01 AcoRo. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYW) PRODUCER (617) 846-8600 11/29/2010 THIS CEERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION John M. Biggio Iiia Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 399 Winthrop Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. WinthropMA 02152- INSURED INSURERS.AFFORDING COVERAGE NAIC# FMC Realty A Construction Inc. INSURER T: "rl svill® Worcester 15 Pleasant Place INSURER B: INSURER C: Lawrence INSURER D: � Q1�40 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABC)VE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEt:'T TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 111E TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADVL LTR I SRD TYPE OF INSURANCE POLICY NUMBER POLICY EPFECTIYE POLICY EXPIRATION DATE MMIDDlYY DATE MMfpDAN LIMITS •A GENERAL UASILITY / / X COMMERCIAL GENERAL / / EACHOCCURRENCE S 5001.000 LIABILITY DAMAGE 0 RENTED PREMI CLAIMS MAGE �OCCUR CB eJ1971 SE Em occurrence $ 100,000 10/04/2010 10/04/2011 MED EXP An one rson S 5,000 PERSONAL 8 ADV INJURY $ GENT AGGREGATE LIRRMoo1TAPPLIESPER: / / / / GENERAL AGGREGATE $ 11000,000 POLICY JECT LOCPRODUCTS-COMP/OPAGG $ 110001000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED Auros (Ea acddent)/ / / / SCHEDULEDAUTOS BODLYINJURY (Perperson) $ HIREDAUTOS NON-OWNED AUTOS BODILY INJURY (Per eccideni) $ PROPERTYDAMAGE (Peracddent) $ GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT S OTHER THAN EA ACC $ EXCESS/UMBRELLA LIABILITY AUTO ONLY: AGG S EACH OCCURRENCE S OCCUR �CLAIMS MADE AGGREGATE g DEDUCTIBLE g RETENTION WORKERS COMPENSATION AND $ EMPLOYERS'LIABILITY I I I I T% L11 ITS 0 ANY PROPRIETOMPARTNOVEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $ If yes,describe under / I I / E.L.DISEASE-EA EMPLOYEE S SPECIAL PROVISIONS below OTHER I / I / E.L.DISEASE-POLICY LIMIT I I / DESCRIPTION OF OPERATIONSILOCA7IONSNEHICLE&EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ( } ( SHOULD ANY OF' THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WIIITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Town O f North Andover10 TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INS REM US AGOM OR REPRESENTATIVES. AUTHORIZE R E:SENTATI North Andover MA 01845— ACORD 25(2001108) ni INS026(0108).05 ELECTRONIC LASER FORMS,INC.-(800)327-01145 0 ACORD CORPORATION'1988 Page i Of 2 Massachusetts Honie Lmmovement Sam le Contract This form satisfies all basic requirements of the state's Home Impmvement Contractor Law(MGL chapter 142A),but does not'include standard r laxge to protect homeowners. Seek legal advice if necessar . An p g P g Y } person lannin home improvements should first obtain a copy of"s ; Massachusetts consumer guide to home imprpvement"before agreeing to any work on your residence Office of Cons .You may obtain a free copy by calling sConsumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8797 or 1=888-283-3757. Homeowner Information Contractor information Name' ompany ame n S of SMC (' nc ryc+i an Street Address(do not use a Post Office Box addre ) Contractor/Salesperson/OwnerName • Ci Wawa O City/Town State Zip Code usiaess Address(must include a street address) Ili• A � r A, N , 13 Ise -D�-e� ��iDaytime Phone /� Evening Phone ityrro\wn State Zip CodrepL�'/ j W ft krp Mailing Address(It different from above) usioess Phone ed Employer ID or S.S.Number law redreg that most home ba- Home runvemeahcontnetar set.Nttmher fixpcatian date rymvemeat contractors buve a Ln regisumdon tmmher The Contractor agrees to da the work for the Howell oar: kL M'Fcri a to e w r• o mp e e specs g e e, ran e o I . an ece s Required.Permits-The following'•buiIdifig permits are required Proposed Start and Completion"Schedule-The following schedule will and till be see ured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractoes control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions'ofWOL Date when contractor will begin contracted work. MGL chapter 142A.)' Ll-*b Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Connector agrees-to perform the work,furnish the material and labor specified shove for the total sum of: `�_(�C,- V (*) Payments will be made according to the following schedule: S P✓ upon signing contract(riot to exceed 1/3 of the'total contract price err the cost of'Special order items,whichever is greater) 00 $ by 12-/' I /D or upon completion-of S- by --:or upon completion of 5� upon cornpletion of the contfact. (Law;arbids demanding full paymentuntil contract is completed to both party's satisfaction) The following materia]/equipment must be special 5 to be paid for ordered before the contracted worl'begins in order $ to be paid for to meet the completion schedule.(**) • 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 otdere(Lin advance to meet the completion schedule. Express Watteau-1s an exortss warrntity belne prmided by the contra!:!! o Yes all terms of the warrantymust be attac ed o the contract Subeantracturs-The-contractor agrees to be solely responsible for cont on of the work described regardless of the actions of any third paitylsubcontractor utilized by the contractor. The contractor further agree$to be solei �res•bnsib atelias and lab Y p le for all payments o u der this er e P Ym to all subcontractors rs fir 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 carefully before signing this contract g and notices • 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 Contra r R.ealstretion 'The law requires most home improvement contractors and subcontractors to be registered with the Director of Horne Itnprovcnlcnt Contractor Registration. You may inquire about contractor registration by-writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 61Z-727-3200 or 1=800-223-0933. • Does the contractor have insurance? Check to see tha Know your rights and responsibilitiest your contractor is properly insured. • . Read the Important information on the reverse side of this 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 elle contr'actor'snormal 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 See the attached notice of cancellation fonts for de explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY •r Two identical copies oftho•contactmust becompleted and signed one copy should go tothbhe'41w"ncr.The BLANKSPACES!!!py should be keptby the connector. HContragnature Q Date �� Date Contractor Arbitration "' ` The Home Improvement Contractor Law provides homeowners withthe right to initiate an arbitration action(asan . alternative to-court action)if they have a dispute•with a contractor. The same right is not automatically affordeq 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 agin advance that in'the event the contractor has a dispute concerning thin contract,the contractor may submittheree dispute to a private arbitration fifin 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-at provided In'Massachusetts General Laws,chapter.1 ' homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the 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 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 Ipgal 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 adde�to the term's of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questionsabout Your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract . The contract must be executed in du licate 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 lie given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed ,. by both parties. Contracted work may not begin until both parties have received a fnily executed copy of the contract;and the three day recission period has expired. Accelerated Payinents 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. 11owever;in instances where a contractor deems hirml erself 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 worlc 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,or1f you wish to obtain a free copy of A Cons Law,"contact: umer Guide•to the Home Improvement Contractor Consumer Information Hotline Office of Consumer Affairs and Business'Regulation .10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787'or 1-(888)2833757 If you want to verify the registration of a contractor or if you have questions or need additio about the contractor registration component of-the Home'Improvement Contractor Law,connal information specifically Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One-Ashburton" Place,Room.1301,Boston,MA 02108 (617)727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section l ~ Office of the Attorney General - (617)727-8400 AND/OR -Better Business Bureau (508)652-4800 .(508)755-2548 (413)734-3114 raaC I 0I Z The Official Website of the Office of-Consumer Affairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Home>Consumer>.Home Improvement Corfm ....................____.......I................ cting> .. ... ......................................._......................................................................... ................ SamPle Home ImPrOVeMent ContraGt 4 - ------------ Contracts-all contracts over$1,000(one Thousand Dollars)Must be in writing. The law requires the following FOURTEEN items RELATEDIINKS registered home improvement contractor to be included in any co latxmct between a'homeowner and a for home improvement work subject to MGL C.142k Yon Gid Konsomat6 I. The complete agreem *b I Massachusetts you Reparasyon eat between the contractor and the Owner and a clear des nan Kay which are part of the agreement description of other documents I I2. The*fall names,federal I.D.number(ifapplicable),addresses(NOT P.O. contractors registration number,the name(s)of the sal-pertou(s)involv13ox numbers),of the parties,the0300000DE-00DE Gufa para el Consumidor de executed by the parties. ed,if any and the date the contract Was. Massachusetts Para Mejoras en el Hogar 3- The date on which the work is scheduled to begin and the date the work is ally completed. Gma Para el COnstunidor de -tailed description of work to be done and the materials to be used. Massachusetts paia Me* 4. Ade scheduled to be substantially .10ras en 5. The total amount agreed to be paid for the work to be performed under the contract el Ho-par 6. A time schedule of payments to be made under the contract and the amount of each paymerit stated in dollars, ----------- including any finance charges.Any deposit required to be paid in adva ceofthes of the work, the total contract price or the actual cost of any n . tart e SHALLNOT exceed One-third of made nature,Which must be ordered in advance ofmaterial or equipment ofa special order or custom schedule. No Seal start of the work to assure that the project Will proceed payment shall be demanded until the contract is completed to the satisfaction of on all parties. 7. All parties must sign the contract 9. A clear and conspicuous notice stating: a.That all home improvement contractors and subcontractors shall be register d t any inquiries about a contractor or Subcontractor relating to a registration should be directed to: ed an that Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,AM 02116 Phone.:(617)073-8700 b.The contractor's registration number must be on the first page of the contract. C.The homeowner's three day cancellation rights under MGL c 93 s 49; MGL c 140D s 10 or MGL c 255D s 14 as may be aPPlicable- d-All warranties on the owners rights under the provisions of and MGL c,142 A, e.In ten Point bold type or larger,directly above the space provided for Do NOT SIGN THIS the signature,the following statement: CONTRACT IF THERE ARE ANY BLANK SPACES. f Whether any lien or security interest is on the residence.as a consequence of the contract 9- An.enumeration of such other matters upon which the owner and contractor may lawfully. agree. 10. Any other provisions Otherwise required by the applicable laws of the conamonwealth. "' Permit Notice:Every contract shall contain a clause informing the owner of a•any and all necessary construction-related permits; thefollowing; o 11ow ing. b-that'it shall be the obligation of the contractor to obtain such permits. c.that owners who secure their own construction-related permits or deal with unregistered contractors excluded from access to the Guarantee Fund er talk httP=//www.mass.gov/?pagelD=ocaterminal&L=3 &L0=H6me&-LI=ConsuMer&rL2=H0Mf. 12. Acceleration of payment: No contract shall contain an acceleration clause under which any part or all of the balance not yet due maybe declared due and payable because the holder deems himself to be.insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of funds-duo under the contract,which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contactor and the owner for withdrawal. 13. No work sball begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. 14. Arbitration: If the contractor determines that iri the event of a dispute,the contractor wishes the dispute to be settled by arbitration,this fact must be signified on the contract and both the contactor and owner shall sign this clause separately. The following format is acceptable(in 10 point type or larger); "The contractor and the homeowner 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 Office of Consumer Affairs and BusinessRegulation and the consumer shall be required to submit to such arbitration as provided in MGL c I42A. Owner.- Contractor: NOTICE.• The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. ©2010 Commonwealth of Massachusetts http://wu w.mass.-,ov/?pac,eID ,3 =ocaterminal&IRL0=Home&L1=Consumer&L2=Home... 1/27/2010 '7771-- �Vs1NC.. Phone:= 978-569-3519 x'ax 978-824;2319::,: E-marl: noel fmcconstruction.biz Online, www:frnccanstruction.i�iz Ma: 7 LP.<O. Box 91; 'N ort, -Andover, MA:;oi845 .4 Job No, 175,:. - Date: 11/17/26,10 4 Customer: a Linda Dinsmore 43 . . Middlesex Street. - North Andover,MA 0184 Description of Libor t 1. Remove sidewall shingles from right hand corner.of garage and approxi 30 lineal feet of shingles tetiveen comer and side door 2: Remote sheathing where necessary to,access damaged studs and sill 3. Provide support for garage:door and track,replace damaged wall:studs at front corner of' garage. . 3 4: Remove`approx 16 feet of sill between-front,corner of garage and side door 5. Replace,with-*ssure-treated sill stock and bolt in,place,re attach':studs to new Sill ! 6. Install new%7 plywood sheathing where necessary garage 7. Install new 1x4 Mini piece at right hand side of a door ' a mto`existing siding 8. Install new white cedar shingles where recess and VVeav Payment Schedule: F a The cost to bAld the above project is$3,050, `This is a labor and materials quo based upon the initial consultation. A non-refundable deposit;in the.amount o 00 i will be required in order to schedule the project., The remaining payments wil made as follows: > First day of,construction1475 Completion of project 1475 JA0� 4LiCENSED View example's of ou ,work at 'ww:w.fmcc.onstructon.biz Ill r , .. •',, , � ti, "" 1 Terms and Conditions: Permit fees associated with the project are•the custom er's.responsibility and' will be added to,the final billing FMC isnot responsible for any-eslstittg defects,..structural'or cosmetic,that are undisclosed or undiscovered prior to the start-of the project :Any such undisclosed or"hidden"damagescould result in a project delay Hang e*t ng;defects arise and do hinder the projects progress a labor and; materials quote to remedy the issue will be-preseated to the homeowner in it timely fashion Any delays with permits or inspections could result in a.project delay ➢ Any delays with special orders of materials,coruld.result in a project delay Any delays with payments could result in a project delay n 9 All waste materials will be disposedof into an on-site ter,or removed off-site-to a transfer facility No assumed work beyond the specifics ofthis proposal will be performed ➢ Hadditional work for this ro'ectis desir p ed,a separate labor and,materials quote will be provided and must be agreed upon by FMC and customer . before additional work is performed ➢ FMC reserves the right:to photograph ail'aspects,.of.theproject from start to. finish,and may use the"ima es.for Y g promotion In the event of a project cancellation,all project i,re expenses incurred to date;*Hl be applied to the most recent payment and customer may incur additional costs FMC reserves the right to terminate theproject if:paynnents are neglected or Ignored,without notice,for a period of seven days past due ` Reasonable care will.be:taken not to damage any landscaping surrounding theperimeter of the home or property however FMC is not responsible for . - , any minor damage that may occur as a result ofahe-Construction process , Homeowners shall not depositanydIi*g non-projettrelated into the on-site container unless permission has been granted by FNIC ➢ FMC contracting work willmeet all state and local building codes ➢ The customer reserves the..right to reject any lumber dr building materials deemed unacceptable or of poor quality After.atlEirty dap period,prices of this comtract are subject to revision I,the customer;hereby understand and agree to the terms and conditions contained in this contract for FMC'services h. Customer SignatuDate1 Contractor Signature Date . I