HomeMy WebLinkAboutBuilding Permit #933-15 - 83 MIFFLIN DRIVE 5/18/2015Permit No#:
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
0
IF-
I IMPORTANT: Applicant must com-plete all items on this i)aRe I
LOCATION
PROPERTY OWNER
, 6,571 -
MAP PARCEL: ZONING DISTRICT
100 Year Structure
Historic District
Machine Shop Village
yes no
yes (� no
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Resident�igL
Non- Residential
0 New Building
L��e family
11 Addition
0 Two or more family
11 Industrial
El Alteration
No. of units:
0 Commercial
El Repair, replacement
0 Assessory Bldg
11 Others:
Demolition
11 Other
_0
0 Septic 0 Well
El Floodplain 0 Wetlands
0 Watershed District
El Water/Sewer
- Please Type or Print Clearly
OWNER: Name:
Address:
Contractor Name: 6�
Address:
Phone:
Supervisor's Construction License: —Exp. Date:
Home Improvement License: 163--3,
t—k Exp Da
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No
6
O�Foa
FEE SCHEDULE: BULDING #ERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
a"
Total Project Cost: $ FEE: $
,�l e I
Check No.: Receipt No.: 7-1
NOTE: Persons contracting with unregistered contractors do not have access to V guarantyfund
Signature of Agent/Ow ner 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
Lj 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
Li Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
Lj Floor/Cross Section/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)
Li Copy of Contract
Lj Mass check Energy Compliance Report
o 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: Building Permit Revised 2014
Plans Submitted [I
Plans Waived [I Certified Plot Plan 11 Stamped Plans El
TYPEOF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swinuning Pools El
Well E]
Tobacco Sales
Food Packaging/Sales El
Private (septic tank, etc.
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
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:
I Conservation Decision:
.Comments
Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
LOcaiea ot54 usqooa btreet
FIRE DEPARTMENT - Temp Dumpster on site yes
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 21 A —F and G min.$100-$1 000 fine
NU I t5 and UATA — (For department use
LJ Notified for pickup Call Emai
Date Time Contact Name
Doc.Building Permit Revised 2014
Location
No. Date
Check #
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ rk-j
Building/Frame Permit Feq $ S�> j
Foundation Permit Fee $-
Other Permit Fee $
TOTAL $
Buildin9v Inspector
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CS # 022680
HIC# 103358
=,Vropoml ==
A. J. Walsh & Sons
55 Pleasant Street
.North Andover, MA 01845
# Of
978-688-6737
or
1-866-AJWALSH
VTV =47 VAM I -a
Date of Plans
IM =,!�Oqrz
=Mff
"5 �W4 e 0 W -t e
4 ,
MP -90- MR
W, - - — - - - - - - - -
111111;' jfig5
We propose hereby to fumish maferial and labor — complete in accordance with the above specifications for the sum of -
00
Dollars
with payments to be made as allows:
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed only upon vnitten order, and will become an extra charge over and
ikes, accidents, or delays
above the estimate. All agreements contingent upon stri submitted
beyond our c6htrol. Note — this proposal may be withdrawn by us R not accepted within days.
The above prices, specificaflons and conditions are satisfactory and are /--�glgnature
hereby accepted. You are authorized to do the work as specified.
Payments Wit be made as outlined above.
Date of Acceptance Signature
MASSACHUSETTS HOME IMPROVEMENT CONTRACT
This forna. satisfies -0 basic r�(iuiiremcqlts of the state's Home improvement Contractor jAw WGL chapter 142A), hut doij nit include jnda�d
language to protect homeowners. Seek.legal advice if necessary. A pem , Is " h 6" . ' ' f "
ny . n p mung oine "provenitnts should ftf Obtami a copy 0 a
Massachuseftconsumer guide to home4inprovement" bebreapuing to any work on yourriiidined. You may obtain -a N6 . copy by'calling the
Dfficz of Consumer. Affairs and BusinessIogulationi Consulner Infbimation Hotline at -W -9734797 -or 1#888483-37�1-
T
Name
Street Address (do not use a Post 0 cc Box
e7)
Cityrr?,,, �e ta& f1f Zip Code
Daytime Ph e Evening!"hone V
. g,7
Mailing Address (it diflerent from above)
--------------------
The Contractor agrees. to do the following work for . the
W1 Lac WOM d ZZMplelea, SpecuyIng me lym.
Ikequired Perbdts - The-161lowing buildinj peimits am required
and will be scoured.by. the contract * or as the homeownelis agent�
(Owners who':secuire their own periiiits WHI he
excluded.from the tGuar.anty Fiindl of
MGL chapte r 142A-)
"Coniractor Intorlination .
�a street address
;_� I /2�1[*/�
717114
0107
Proposed Start add'Com&66 Schedule - The fifflowiiii; schedule will
be adherod todolesi. circumstances beyond the contmtoev control arise
when bontractorwill begin contracted work
--Date when contract6d work will:besubstantiallycompleted—
Total Contract Price and PaymWSchedule
The Contractoragmes to perform thowork, furnish -the material and labor specified above for theptal am of -
P
the C011t.ofspecio order items, whichever is greater)
��by __=t—=or upon com�lction of
or upon completion of
0— -Ir com pletion of the contract. (Law forbids demanding full payment until contract is completed to -both party!s satisfaction)
The following matmi0equipment must be special paid for
ordered before the contracW work'begim; in order e id Z
to mad the-compl6tion s&edule.(**) 5;2TVk_ pai or
NOTES: (*) including all finance charges (**) JAw mquires that any deposit or dovm_payment required by the contractor before ik I begins may
wo
not Wceed the greater of (a) one4hird of the total contact price or (b) the actual cost of any special.equipment or custom made material
which must be special ordered in advance to med the completion schedulc
Express Wirrouty - Is On expressmarranty belay provided by the eentractor
No Y ' (Q.te __e must'lij I�Qedtothecouftetl
h
"bed sofiheactions'ofsn�thfrd
Subcontractors - The contractor agrees to be solely responsible fbreonipletion oft2h. work ldoi!c�nl ;eh
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsiOle for all payments to all subcontrac f6j
matcrials and In un tons
Contract Acceptance - Upon signing, this document becomes a binding contract underlaw. Unless otherwise noted within this document the
contract SMI not imply that any lien or other security
carefully before siping this contract. 'ntc=1)w been Placed On the residence. Revit.w.thc following cautions and notices
DD111 be prcssuyed into sighing the contracL Take time to readand fWiy understand ii� Ask'q� uesdions ff'shm- a-iiiij is unclear.
MACRUIttlic contractor ASOYBiidH()Meimm-vcmcntContractoT.Remi The ld* requires most home improvement contractors and .
subcontractors to be registered with the Director ofH01110 improvement Coutracta Registratim You may inquir, about contrac r�
registration by writing to the DircctDrat-One Ashburton Place, Room 13QI,.Boston,.MA 02108 orby,calling 617-727-3200 Or to,
1-800-223-0933.
Does the contractor have insurance? Check to see that Your'coutnictor is properly insure&
Know Your rights and responsibilities. Rci.d the Important Information on die side of"
. . reverse forth and get a copy of the Consumer
Guide to the Home fthProvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractors -no pla ofbus , provid you th
third business day followingthe signing of this ;t ofthe.
cc or branch office by o ary mail s by In sent or liv ,
contractor in writing ai his/her main offi rulal cc iness ed notify
rdir PO teA te grain by de cry not later than midni
a9rc=0nL See the-attachW notice ofrancellation form for an =planation of.thi righL
W -,NOT SIGN THIS C9N li �ZtL :t �hfth-
TRACT IF THERE ARE ANY BLANK SPACES!!!
TW i ho pies oftht conemet must be ds*" Oncen"AbDulcigot0thchonowner. Theodweo"W=1dbekWbythtconft=.
1w
co;� ss
H
Z, �Hcr's Signature Con
Date
�2
Date
MAO -Z
Contractor Arbit3ritibW...
The Home -ImprovementiContractor L-aw-provides.horneown ,witb.the..nght�to�initiate-naibitrationacdon(asan
ers
alternative t6courtactidb) if they. have a,disg&pwith a contractor. The.same'nklifis i6i automatically afforded to4a
contractor, however,'-fic. contractor would have tp resolve any. dispute'belshe.lfai with a homeowner in court unless
�oth parties agree to the optional: clause provided below., This clause would give the contractor the same right to
a is afforded to the-homeowner,by -the Home Improvement Contractor Law.
arbitration as
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 hog been approved by.
the Seci6tary of the Executive Office of Consumer Affairiarld Business Regulation and --the consumer shallbe requind
�w rsu&mitto such arbbitrati asp idedInUassachusetts General Laws, chapto2k
ijireowner's Sigrulture Contractor's Signature
NOTICVThe signatures; of the parties above apply only to the agrtement of the parties to alternative dispute resolution
initiated by the contractor.. The homeowner may initiate alternative.dispute resolution even where this section is not
Horneowner's Rights
A homeownees tights undbf1ho.Homp'Improvernent Contractor Law (MGL chapter 142A) and other consumer
protection laws (ie. MGL chiptei 9A) may not be waived in any way, ev6 by agreement: However, homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeownm;p who secure their ' own building permit� are automatically excluded from all Guaranty Fund provisions of
the Home Iniprovement Contractor I.Aw. The contractor is responsible 'for completing the work as described, in a
timely andworkmanlike manner. Homeowners may be entitled to -other specific legal rights, if the contractor guarantees
or provides*.an express'warranty for workmanship oir materials . . In addition toguarant6es or warranties provided by the
contractor, all goods sold in Massachusetts carry an implied warranty of merchantabilit I y and fifiiess.for a particular
purpose. An enumeration of other matters on whicb.the homeowner and contractor lawfully agreemay be added to the
term of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questi ons, about
your c . onsumer/homeowner rights, contact the Consumer Information HoWne (listed �elow).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all'exbibits and reference ' d
documents have been attached. Parties are also advised not t6 sip 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 Inigmial contract must be in writing
and agreed to by both parties. Contracted m;ork may not begin until both parties havei, received a fully executed copy of
the contract, and the three day recission period has expired.
Accelerated Payments
A 6ontractor ingy not demand payintints in advanceof the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However, in instances where a. contractor deems him/herself
to be financially insecure, the contractor may require thatthe. balance of funds not yet due be placed in ajoint 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 orneedadditional information about the Rome Improvement Contractor Law or other
consumer fights, 9r,if you' wish to. obtain a free.coipy of "A -Consumer Guide to the Home Improvement Contractor
Law,� contact
1��sumer 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 . -Tegistration of a contractor or if you haveguesti6ris or need- additional information 0ecifidally,
about the contractor registration component of the Rome Improvement Contractor Law, contact:
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 infAbrinal mediatici n' of ditpUtes or to -register -formal complaints against a.busihdss-,�'eAll'
err6mplaint;Settiolf
Office of the Attorney, General
(617) 727-8400
-AIMIOR
Better Business Bureau
(508) 652-4800
(508) 755-2�48
(413) t4-3114
I -A
The Commonwealth qj'Ifa.vvwhusett�
Departmew ol IndustrialA ccidents
Qffice ofInvesti-ations
rje 600 f Vashin-ton Strect
T.�
Bo.�lon, JJA 02111
W I i I it". 111(iss. a5 0 J�ldia
I
Workers' Compensation Insurance Affidavit: 13uil(iet-s/Contractoi-s/Electricians/Illunibers
�kppficant Information Please Print Le,-,iblv
N d III C ( 13LA,ilICSS/Orgailiza I ion "I ndk i d Ila I):
Address:
0tv/State/7ip: ZY/Z/1
Phone
y eilliflover? Clieck the appropriate
F O'_
�ani
box:
.�Ir, , a employer with 4.
1 ain a general contractor and I
employees (full and/or Part-time).*
have hired tile SUb-contractors
I ain a'sole Proprietor 01, Partner-
listed oil the attached sheet.
ship and have no employees
These SUb-coniractors have
orking f'or file in an\ capacitV.
emploYces and have \\oi-kers'
[No workers' comp. 111SUrance
Coillp. IIISLII'MlCe.-�
5.17
We are a corporation and its
�j1"IqUired.]
I am a homeo\\ ner doino all work
officers ha\ e exercised their
myself. [No workers* comp.
1-101t of exemption Pei- MGL
IIISLII'alICC required.]
c. 152. § 1(4). and, we have no
employees. [No \\orkers'
C01111). 111SUrance required.1
—6 73
TYpe of project (required):
6. E] Ne\\ corlstructioll
7. E] Remodeling
S. 7 Dcri-folition
9. El 131.1ilding addition
10.E] Electrical repali-s of- additions
I I.F-1 PlUmbinE repairs of- additiolls
repairs
13.7 Other—
al)1flicallt thit checks box -'I mum also fill 011t the �,cclloll tw1o\\ drox\ ilia their \\orkers conil
)ensation polic\ information.
�.ollleo\\neis \Ow mibinii this affidn it indicaliq, thc\ -are doing all \\oj-k and thcri hire outside cormactois IlILIS1 SUbmit a nL\� affida\ it indicatillL, sLicii.
,rltractor,� tlllt c1leck- t1lis box MLISt attadl,�d 311 ddit ollal I
a I s leet sho\� ilia the naille of tile sub -contractors and state \\hethei or not tho,.;e eillitics ba\ c
Cl!lj)i0\CCS- If tile SUb-contr actors lia\e emplo\ces- thc\ must pro\ ide flicir \\or�eis comp polic\ number.
I ant an eniploller that isprovitling workers' Compensation illsal-alice -11,
fiol Y emploYees. Beloit, is the policY andjoh site
111SUrance Company Nanie:
Ic.
PoI10 4�' of- Self -ins. Li -.xpiratioll Date:
Job Site Address:
S_w�. ClLv,State /ip..--
Attach I cOl))' Of tile workers' coil, pensation Policy declaration [)age (showing tile policy number and expiration (late).
F�IlLire to secure coverage as required 1-111(iff Section 25A of MGL c. 1 52 can ica "to tile '1111'
d I )OSItioll of,cl-111111-tal Penalties ora
CHIC LIP to S 1.500.00 and/or one-\eaI* H171sollillelit. as ��ell as ci� if penallicS ill tile forill ofa STOP WORK ORDER and a Fine
OfLIP to S2�0.00 a da\ against the violator. Be ad\ ised Illat a cop\ of.,111s �tatemcilt ilia\, be for\\arded to the Offic of'
I C
Ir\ estioations ofthe DIA fo
Y iIISLIM11CO CO\ Verification.
I A hereby cer1q.j- un(ler the pains andpenaltieS qfpqjm-1, that the hilormatioll pl,ovi(led a -orrecl.
bove is true and c
lu-1 Da t c:
,pill-ione
F 7 r___
Q11icial use only. Do not wriie it, this area. to be completed h *
.1, (W.), or town officiul.
City or -Fo%% if:
Perinit/Licefise 4
ISSUill(y Authority (circle olle):
1. Board officalth 2. Milding Department 3. ( itv./Tomi Clurk 4. F!eclrical 111spectol
I'luillhillo Ilispedor
6. Other
( onlact Ile[ -Son:
____ I'llone 4:
From
01/12/2015 14:48 #151 P.0131016
0
CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDDNYYY)
01/12/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such andorsement(s).
PRODUCER 00775 - 001
Durso & Jankowski Insurance Agency Inc
198 Mass Ave Suite 101B
North Andover, MA 01845
5R41ACT
02%-E,t): (978)682-5175 (978)794-0313
Rnhss:
INSURFRISI AFFORDING COVERAGE NAIC #
INsugEg A A.I.M. Mutual Insurance Company 33758
INSURED
Arthur Walsh
A J Walsh & sons
55 Pleasant Street
North Andover, MA 01845
INSURER B
INSURER C
INSURER Q
INSURER E
IMM IRFR F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE
I D
WR
POLICY NUMBER
IMP&NVY)
APINSTYWI
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CON
CLAIMS -MADE F1 OCCUR
EACH OCCURRENCE $
DAMAGE TO RENTED
PREMISES iEa occurrenca)
MED EXP (Any one person)
PERSONAL& ADV INJURY
GENERAL AGGREGATE
E11L A.1
EN'L AGGREGATE LIMIT APPLIES PER:
LICY 0
0 OL'( C
PRODUCTS - COMPIOP AGG $
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
BINED SINGLE LIMIT
ICE0,Mccident)
BODILY INJURY (Per person) S
BODILY INJURY (Per accident) 3
OPERTYDAMAGE 5
(Per accidentl
UMBRELLA LIAS
EXCESS LIAB
OCCUR
CLAIMS MADE
EACH OCCURRENCE
AGGREGATE
DED I I RETENTION $
$
A
SPHRMS"LPA2% ECUTIVE Y L N
0192ROPMURMAMP
(Mandatory In NH) FY -1
I �AbMfPflft O&ERATIONS below
NIA
AWC-400-7014648-2014A
1111412014
11114/2015
x i �WTWI S OR-
E.L. EACH ACCIDENT $ 100,000.00
E.L. DISEASE - EA EMPLOYEE S 100,000.00
E.L. DISEASE - POLICY LIMIT $ 500,000.00
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, AddItIonal Remarks Schedule, If more space Is requIred)
The workers compensation policy does not provide coverage for Arthur J Walsh
Town Of North Andover
1600 Osgood Street
North Andover, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
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