HomeMy WebLinkAboutMiscellaneous - 42 BANNAN DRIVE 4/30/2018 (2) i
42 .0-011 DRIVE
210/038.0-0110-0000.0
THEMORFOLOC5�DEDHAMGROLIN
February 26, 2015
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
Building Commissioner, or Inspector of Buildings
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Board of Health or Board of Selectmen
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Fire Department or Arson Squad
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
RE: Our File No.: P1588277
Insured: GUILLERMO VICENS
MARTHA VICENS
Address: 42 BANNON DRIVE, NORTH ANDOVER, MA
Policy No.: H1170075A
Loss Date: 02/25/2015
Loss Type: Building or Other Structure Damage
A claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be
applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct
it to my attention and include a reference to the captioned insured, location, policy number, loss
date and claim or file number.
If no reply is received from your office within ten days, we will assume you have no liens of any
type against this property, and the claim will be paid in our customary manner.
Sincerely,
Marie J. Landers
Property Claim Examiner
1-800-688-1825 x1136
NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109
DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825
FITCHBURG MUTUAL INSURANCE CO. p Fax:(781)329-1818
Location
r /
No. .�
�' Date
�oRTN TOWN OF NORTH ANDOVER
3? ° CL
` Certificate of Occupancy $
�' b'••'°�''�� Building/Frame Permit Fee $
�SsncMuse
Foundation Permit Fee $
Other Permit Fee 5 i K $
TOTAL $
Check #
9 t'1?
Building Inspector
NORTH
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAINANATION
SAC HU-'
Permit No: Date Received:
Date Issued:
IMPORTikNIT: Applicant IIILI.st conlPlete all Items oil this pa4,,).e
LOCATION6(_
—P R 0 P E RT Y 0\ NE R MOD(A&)i
Print I
i MAP NO.: P,\RCEL:-_,)/' ZbNING'DlSTRicT: j
TYPE AND USE OF BUILDING HISTORIC DIS I TRICT VES 0
TYPE OF IN/IPROVENMENT PROPOSED USE
Residential Non- Residential
New Building One family
family Industrial
Two or more fai
_ Addition
✓Alteration No. of units: Commercial
Repair, replacement Asse ssory Bldg
Demolition
N Others:
loving_(relocation) Other
Foundation only
DESCRIPTION OF tiNORK TO BE PREFORNNIED
Identification Please:rype or Print Clearly)
OWNER: Name: Phone:
S mature
.Address:
C-ONTRACTOR Name: AC- j--4'kC, Phone,
Address fif_
fic
Supervisor's Construction License: —Exp. Date:
Ho Impro%cmcnt LiCCIIISC:_ _Exp. Datc:
I V I I C [...I N i Phone:
Address: Reg. No.
F*EE,SC'HL,'DL!LE:BLLDLN,GPER,I,IIT. 510.00PER 51000.00 OF THE TOTAL ESTIJL4 TED COST&ISED OA
S125.00PF.RS.F. x10.00 FEF.:,S
'notal Pro'j-.:ct
Check No.: __Receipt No.:____
J �__� - _ - - - _._
I
TYPE OF SEW ARGE DISPOSAL
Tanning;''vlassage Bod} .%It S��inlmin�� Pools
Public Sewer i
i
ell – Tobacco Sales -- 11 Food Packaging.Sales j
Permanent Dempster on Site
Private(septic tank,etc.
! i
i I
MOTE: Per onv contracting with unre isfered contractors do hot have access to the;;uaraall,%tend
Sicnature of Agent Owner Signature of Contract
Plans Submitted Plans Waived !:!! Ccrtitied Plot Plan i ! Stampe Plans �
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF- U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT 5 J
i Water Shed Special Pen-nit
1_1 Site Plan Special Permit
10 Other
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION i
COMNMENTS
DATE REJECTED DATE APPROVED
HEALTH r7l �
COMMENTS r'
Zonin,! Board of'Appeals: Variance. Petiticm No:
-Z-onin Decision,receipt subnlittecl yes— --
l'l;.ltllllll"
Board Derision: C;nunents.-- --------------- -----
�vI1;iCl'batlUll Licl'ISIUn: Commults ---
\Alater& Sclncl•cUilllectlotl SlrllatLll-C S,', date
Temp Dunlp�"M*on site yes no Fire Department siunature'dat --_-
13uilclin�. Permit ,approved and lsst.cd bv;
I
I
NORTH
Town of t 4Andover
No. Va .
_A dover, Mass., ' 12 ' 0
o = L
TRO
COCHIC'..WICK`y
ORATED PQa
K BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT....... rf
...... ................ .............. " . ,... Foundation
has permission to,�eEr...S...�.o��.�.,►!.. . b ildings on ............ '. ....... .1^h.. ...... �. Rough
1
to be occupied as..,S.�.y .. ....���.� ....�e1'>,Orm
. Chimney
.. . . . . . . . .. . . . .. . . ...............provided that the person � p mgthis permit shin every respect to the terms of the application on file in Final
this office, and to the provisions of the Codes and y-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. 115/110
PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION DARTS Rough
Service
L"z BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous -Place on the Premises — Do Not Remove RoughFinal
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.
Feb 24 06 12: 25p Wendi Roy (9781 975-0085 p. 1
):10 pm F (778) 6OG-72GS AG WAtariq)a [np- dba j0*0 Vinyl sitting TM.M: 002 Or 002
AC Exteriors, Inc.
dba Joe's Vinyl Siding
PERSONAL AGREEMENT
---- --- -- _ _ Ptsepo w Agrpease7tt
Sirbn ft- To
�ero.t Ja►l�aeer
• �Ct'�
aw.Spain a zip lob S..e.t»n
�otFla•us
We bmeby propose to fwniish all materiels ted U&w as necessary for Me complmion ofow following products in
a�w w,it�ll�ge_e�tp,�seificat"�p�eu•d dr'uw�ings.<:a �r�S�ctly► G 3j�{' Y TrSu.1�t����1 QnG
Wie
.t�l,t:1'►A�rr��► .�i-t,�iaC'..1�*.
Total Coe trim Fria 15: �=�c,r!�''Cr7 ��l�aer � •c�P fli�rar�rp�-dallers is i� �v�)
paytzreoix to be ngde as foltawz: -ti ti ,.e t• �� " s 4.o
All—wrial is guaametmd to be as apccified.All work to bo cumpletod in a workman-like manner zccw tlg to the
4,Mfoeatiwrs substtoW per sta Wwd preectiet&Any dWauoa or dev*wn from above zptx rw=Knts involving cXhu oust
will be exm arced only upon wrkku tudets and will btcan>G an exttz dharge over and above Me csfimemc-AU agreemau
content upon*Alas.accideutt.or dein).bcyond our control.Owner to szrry lure,tomado and other naoe=q
i»staaonccs.
No.. This pmpow may to+vit?ldrawn by this>f
,�►wtlor�ed 5ira
(lot sacepted+vbin days.
ACCEPTANCE OF PROPC SAL—The abaft prices, syecifllagions end cwditkm are satisfactory and arse hereby
act:tpted.You are audwizi d to do the work as specirm!.Payment to be paid as.cudtined a
signature
Date of Acctptanac
U
Signamm
I
,x
pq
'.r+a..404"" 'lZ
-«� ``T..
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BoardofBuFldmgl2eg�IAtwnsand
S66dAA u a
t X License or registration°vand�For mdmdul use oply I
s HOME IMPROVEMENT CONTRgCTOR
R g�t�rration 1376{4ox 'most X A` before[he ezp�at1on d"ate If found return to a {Y
Board of Butitl�n Re ulattons and`StaiNY 4
dards ''" f
ERpitafion a a g g
r � 312006' "ENO I
One Asf�burtoR place Rm 1301
NC
Type Pnvate Corporation Boston,Ma 02108 £+
MCAAC EXTERIORS I
ANNA CURRAO
x 67 LOWELL BLVD k' :GG
ME7Hl/EN MA 01844 ✓ +
,.� � � �� � _„ � t vaittl without stgtiature
""° �.�.-... ... w .�s w�.,.,,.✓µ �'�,++t.�.,� :' �~-"*�� ::wpm"^"";'� .''""i �! .
FEB-22-2006 03:57P FROM: TO:19786867265 P.1
AGORDn CERTIFICATE OF LIABILITY INSURANCE 02/22/2006
PRODUCER FAX THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION
DeAngelis Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
283 Merrimack Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER-TALTER-THI COVERAGE AFFORDED BY THE POLIC ES BELOW.
Methuen, MA 01844
INSURERS AFFORDING COVERAGE NA1C 6
INSURED Joe's Vinyl Siding INsuRERA: National Grange Mutual Ins Co 42
33 Booth Road INSURER
Methuen, MA 01844 INSURER 0:
INSURER D:
INSURER E:
OVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
7PERSINBR D' TYPE OF INSURANCE PODGY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY MP027049 10/22/2005 10/22/2006 EACH OCCURRENCES 300.000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ S00,000
CLAIMS MADE a OCCUR MED EXP(Any one person) S 10.00
A
ONAL 9 ADV INJURY S 300,000
GCNERAL AGGREGATE S 600,000
GEML AGGREGATE LIMIT APPLIES PER PRODUCTS•COMPIOP AGO S 600,00
POLICY r7
PRC LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) S
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Perpercan) S
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Par accident) S
PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGO S
EXCESaIUMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR FD CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE 5
RETENTION S E
WORKER8 COMPENSATION AND WC STATU• DFR
TH•
EMPLOYERS'LIABILRY E.L.EACH ACCIDENT S
ANY PROPRIETOMPARTNENEXECUTIVE
0 PPICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEq S
if yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 16
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
ertificate is issued in the interest of the named insured and Certificate holder below.
ertificate is subject to all Company conditions and exclusions.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Town of North Andover 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: Bldg Inspector BUT FAILURE TO MNL SUCM NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
27 Charles Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESEffLTMS.
North Andover, MA 01845 AUTHORIZED REPRESENTATIVE
David Se al M
ACORD 26(2001/08) FAX: (078)423-1364 ®ACORD CORPORATION 1988
t �
Building Setback (ft.) i
i
t Front Yard e i SidYard
i Rear Yard i
Requited Provided Rcquurcd Prortdes j Required Provided
r
' I
II DIMENSION
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area,sq. ft.:
i
NOTES mid DATA—(For department use)
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Building Department
I
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 `
Debris Removal Form ,
Workers Comp Affidavit _
Photo Copy Of H.I.C. And/Or. C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior ��'ork
Addition Or Decks
j Building Permit Application
�j Form U
Surveyed Plot Plan
Debris Removal Form
Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
j 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)
New Construction (Single and Two Family)
a Building Permit Application
j Form U
j Certified Proposed Plot Plan --
j -Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
J Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydral.
Calculations (If Applicable)
3 Copy of Contract
3 '.-lass check Ener,; Compliance Rocpoft
;n .ill case; if a rai lance ur special permit was rc ttilired lite'Town Clerks office ,ii9ist >I:mlp the de.i;ion from the a3oard of
,,,f;eals that the appeal per9od is liver. 'The appfic:uat must then „ct dais ecce rc,cd ,it '!tc '�c!;atiy a)t't?(((Is. 1011C COPY auul pen
of recordinu insist be submitted with the building .implication
`,F.It%:(Es IIE11MI S'V F:NT:I PFC-U105
_ - --� - � - -- -- -- - -- - � - -- �_ L.
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Location �.�/��
No. Date s
NpRTM TOWN OF NORTH ANDOVER
0 9
Certificate of Occupancy $
Building/Frame/Frame Permit Fee $ 7w�
s�cwust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
18859
B i Ging Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCTREP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
s'x" x:
BUILDING PERMIT NUMBER:/ DATE ISSUED: X
SIGNATURE:
"Building Commissioner/I r of Buildings Date Z
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Map and Parcel Number: O
i�o j0
Map Number Parcel Number
S
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
v
1.7 Water Supply M.G.L.C.40.11 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
public 0 Private 0 Zone Outside blood Zone ❑ Municipal ❑ On Site Disposal System 0 J
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No m
2.1 Owner of Record 1
Name(Print) c Address for Service: ,
�7cb ��t c
Signa re Telephone
2.2 Owner of Record:
fCl ra /uA.1Vk'L<A S XJ�&U&Og D-r� , N'4) Vr_r p
Name Print �— Address for Service: z
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: b 9 b-2 Z 1 O
4 G t` V-1 1 n N b y License Number
ss ` d 'V
Ad f 1
S5LnD e
Expiration Date
SigInature Telephone
3.2 Regi Home Improvement Contractor Not Applicable ❑
Company Name Rim
egstration Number
A dresL�� L ' C 1 2� C>b Z
T35 S Explrmhon Date /1
Signature Telephone V
SECTION 4-WORKERS COMPENSATION(M:G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit. •
Signed affidavit Attached Yes....... No.......❑
SECTION 5 Description of Pro osed Work check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑
Accessory Bldg: ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work: ` p /
�P�C \a.ee Z3 �.l�iS �✓c� (`o��`e �v �cn��d��� J"-ew Ut,�yl
Wl N �. \}� CC (5��l CL-i N'?21 ��G Ge✓r �O T3
NO�('S i N �C��� �q•y L6wPT ��G����
-Ip CoU,cle p• d'vX f� S' 1C a<<ea�+ c�0m,C
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be bFFICI .USE O�1LY
.n �,^ i ze „aksttg x a
Completed b permit applicant
�
1. Building (a) Building Permit Fee
1 -7 8 d Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)X (b)
4 Mechanical(HVAC
) 00
Fire Protection V
6 Total 1+2+3+4+5 j 7 $ O O Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize A to act on
My be a in a 1 matters r lative.to work authorized b this building permit application.
OS
Sign,afore of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, K.� , �olj as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
4V` A
a
Print N
Sig2at&e of Owner/A e Date p'
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TMMERS iST2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GMDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF.CHEMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
All, >°omnaoncue ry�✓�� uGelta
1 BOARD OF BUILDI G REGULATIONS.
i License: CONSTRUCTION SUPERVISOR
Fo" g 1 t r e i
Number: CS 080721 I'
Birthdate: 04/29/1968 {
Expires: 04/29/2007 Tr. no: 13426
Restricted: 00'
KENNETH R ROY
1 CAMPBELL RD G—
N ANDOVER, MA 01845`
t Commissioner
7—
,per ✓tae �orvmo�r�� .,o�✓��aaoae/u�a�ta . .
- \ Board of Building Regulations and Standar ds-
HOME IMPROVEMENT CONTRACTOR
C - _ Registration:, 137557
Expiration: _11/26/2006
Type:s DBA
KENNETH ROY PROPERTIES'
.ROY .KENNETH
1 CAMPBELL RD
Ki aNnC)VER.MA01845 J Ad„,[nictr%tlir• '
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54; a condition of Building Permit
at: �o"�n 'ac', is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws.Chapter 148 Section
I 0A.
The debris will be disposed of in:
6 c a NA
(Location of Facility
Signatu e f Permit Applicant
Fire Department Sign off: f f
Dumpster Permit
Date
The Commonwealth of Massaelu(setts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
re
Boston, 11A 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Hanle (B(IS iness/Ur0anirittion/Individual): �e-%-V,\
Q�
Address: C �
Phone #: 10-( 5 '61 A S S �
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I ant a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner-
listed on the attached sheet. + 7• YM 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
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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#I must also fill out the section below showing their workers'compensation policy information.
+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 say 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 c. 152 can lead to the imposition of criminal penalties of a
tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a tine
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 t der the pains an res of perjury•that the information provided above is trite and correct.
Signature: Date:
Phone 'i: -7 $ $ 4 s5�f
Ullicial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
CONTRACT HOME REPAIRS OR REMODELING
f
Guillermo and Marty Vicens, Homeowners, desire to contract with, Kenneth Roy, Contractor,to
perform certain work on property located at 42 Mannan Drive,North Andover, MA 01845
1. Job Description
The work to be performed under this agreement consists of the following:to replace island
countertop with a similar size and color countertop with center tile sullied by Homeowners,replace
breezeway deck and lowering it approximately 6"with a new pressure treated deck,replace
existing front and rear French doors with new French doors,replace front door and front storm
door with new doors purchased by Homeowners.
2. Payment Terms
In exchange for the specified work,homeowner agrees to pay Contractor as follows: $7,900,
payable for all labor and applicable materials, in installments by check as follows:
A$$4,900 deposit is due upon the signing of this contract.
A$3,000 payment is due upon completion of installation of work described above.
3. Independent Contract Status
It is agreed that Contractor shall perform the specified work as an independent contract. Contractor maintains his or
her own independent business and shall perform the work independent of Homeowner's
supervision,being responsible only for satisfactory completion of the work.
Contractor may use subcontractors,but shall be solely responsible for supervising their work and
for the quality of the work they produce.
4. Change Order(Mid-Performance Amendments)
The Contractor and Homeowner recognize that:
• Homeowner may desire a mid job change in the specifications that would add time and cost to
the specified work possibly inconvenience the Contractor; If these or other events beyond the
control of the parties reasonable require adjustments to this contract,the parties shall make a
good faith attempt to agree on all necessary particulars. Such agreements shall be put in
writing, signed by the parties and added to this contract.
5. Additional Agreements and Amendments
a. All agreements between Homeowner and Contractor related to the specified work are
incorporated in this contract. Any modification to the contract.shall be in writing.
Homeowner: W Dated: at
1
Contractor: Dated: _ 5
1
CA goo
CONTRACT HOME REPAIRS OR REMODELING
Guillermo and Marty Vicens, Homeowners, desire to contract with,Kenneth Roy, Contractor,to
perform certain work on property located at 42 Mannan Drive,North Andover,MA 01845
1. Job Description
The work to be performed under this agreement consists of the following:to replace 23 existing
double hung windows with white Harvey replacement vinyl windows.
2. Payment Terms
In exchange for the specified work,homeowner agrees to pay Contractor as follows: $9,900,
payable all labor and materials, in installments by check as follows:
A$$5,000 deposit has been received.
A$4,900 payment is due upon completion of installation of the replacement windows.
3. independent Contract Status
It is agreed that Contractor shall perform the specified work as an independent contract. Contractor maintains his or
her own independent business and shall perform the work independent of Homeowner's
supervision,being responsible only for satisfactory completion of the work.
Contractor may use subcontractors,but shall be solely responsible for supervising their work and
for the quality of the work they produce.
4. Change Order(Mid-Performance Amendments)
The Contractor and Homeowner recognize that:
• Homeowner may desire a mid job change in the specifications that would add time and cost to
the specified work possibly inconvenience the Contractor;If these or other events beyond the
control of the parties reasonable require adjustments to this contract,the parties shall make a
good faith attempt to agree on all necessary particulars. Such agreements shall be put in
writing,signed by the parties and added to this contract.
5. Additional Agreements and Amendments
a. All agreements between Homeowner and Contractor related to the specified work are
incorporated in this contract. Any modification to the contract shall be in writing.
Homeowner: Dated:
Contractor: Dated: 1 '
1
NoKTH
Town of
VO
No. � y _
Y
o dover, Mass.,
o �.
11ADCOC WCME WICK
RATED PPP
'4S_ BOARD OF HEALTH
Food/Kitchen
PERMIT D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.......... .................... *..VS................. Foundation
has permission to erect........................................ buildings on ....... ; .. � I ... �.�••••••• Rough
to be occupied as................� ... JMX1fA'09WVX
.......�!!....... �.�!....... imney
provided that the person accepting t i respect co orm to the to s of the appli 1 on ile 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
^ D ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO TARTS Rough
.................. ....... R
Z... 4Service
BUILDING
Final
Occupancy Permit Required to 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.
At
Location Y,2 ,� e _ a
',No. � 3 Date
NORTp TOWN OF NORTH ANDOVER
Aim
Certificate of Occupancy $
+ ; + Building/Frame Permit Fee $
-Foundation Permit Fee $
14
�e�e
Sewer Connection Fee $ —"
Water-Connection Fee $
. ` 44
Building Inspector
6055 Div. Public Works
PER.-,& NO. ' / APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. foe,-/PAGE 1
MAP d40. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK PAGE
ZONE I SUB DIV. LOT NO. I
LOCATION PURPOSE OF BUILDING
OWNER'S NAME i e- NO. OF STORIES SIZE X
OWNER'S ADDRESS y>n��4 I\r BASEMENT OR SLAB
ARCHITECT'S NAME /J Y SIZE OF FLOOR TIMBERS 1S �I ND 3RD
BUILDER'S NAME � �Cj i� /^I � C SPAN
4CJ C J-�'o
DISTANCE TO NEAREST BUILDING /[J DIMENSIONS OF SILLS -�CT-
DISTANCE FROM STREET 5-c; [,/ " POSTS
DISTANCE FROM LOT LINES-SIDES _1� ' REAR " " GIRDERS
AREA OF LOTS/ FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW • . SIZE OF FOOTING X
IS BUILDING ADDITION IVO MATERIAL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ®(.,1 IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY C� - IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST
PAGE I FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PER P6. FT.
PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM
,
! SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
4
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DAT LED
BOARD OF HEALTH
SIGN TURE OF O ER OR AUTHORIZED AGENT
OWNER TEL.# l0
F E E CONTR.LIC.#
PLANNING BOARD
PERMIT GRANTED
19
I
BOARD OF SELECTMEN
i
60is BUILDING INSPECTOR'
I
1
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY I STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY _"OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA.
APARTMENTS I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE _ _ 3 1 2 13
CONCRETE SL K. PINE
BRICK OR STONE HARDW'D
PIERS PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT 11
AREA FULL FIN. B'M'T' AREA _
'L 1/1 °/. FIN. ATTIC AREA _
NO BM'T FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS -
CLAPBOARDS B 1 22 f 3
DROP SIDING CONCRETE I_
WOOD SHINGLES EARTH
ASPHALT SIDING HARDVJ'D _
ASBESTOS SIDING COMMCN
VERT. SIDING ASPH.TILE _
STUCCO ON MASONRY _
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIOR 1� POOR11
ADEQUATE NONE
5 ROOF 10 PLUMBING '
GABLE I HIP BATH (3 FIX.)
GAMBRELMANSARD TOILET RM. (2 FIX.)
FLAT 11 SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING _
TAR & GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING I 11 HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
II
7 NO. OF ROOMS GAS
OIL
B'M'T 2nd _ ELECTRIC
1st 13rd I NO HEATING :'
razom Residential Commercial
R S T CONSTRUCTION y
PROPOSAL
General Contracting
Complete Interior& Exterior
Remodeling& Construction . Page No. _of_ Pages
Insured Richard Grimes DESCRIPTION OF JOB
Lic. # 056324 1-508-m-'Ii ARCHITECT DATE OF PIANS
PROPOSAL SUBMITTED TO: roe
_ � r
( wl &KS�
/ ADDRESS
/� CrY � v CITY — STATE ZIP
.�Hoiv� ogre ,
1... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WEE SUBMIT SPECIFICATIONS AND ESTIMATES FOR: ` y ��C�
l ff__re tee, of -F� l ccC'(or- .1 /1 1�5 c t-�!�►t�,`,,t crvSP
(�ear- rc�b3` l." 1�S Fo l�r �r'�_ o��' 9 S G S%b l -fU
13,t-(rra^4� ^-� .1 C'� wa+c.r b�Tr`.e.r craSS ¢'f�� f cs�oGrC`' r Up_ ea
f L-
cfoc1ccm + t2i k r ",t
5 b-e,-,�lel .fi t ,ti +o_ e r� elf-
qQIV
0- ocSPf__s--1 _- A?!^��?J3-� _t��?
ee4 a-+!'L Q de tiC40 IV IeZT j=1e/' /kt lLe
e,5__._
We hereby propose to furnish material and labor, complete in accordance with above specifications,,_ for. the-
Sum of
he „surnof PVkoQ dollars(S_ U
I
with payment to be rrtade as follows: ___ - ._ �C_�/ Q �P ) ?� a "u __
All material is guaranteed to hr,ns specified.All work is to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from specifications Authorized '�, / ��-JJ
involving extra costs will be executed upon Written orders, and will become, an extra Signature ., "'t ,6
charge over and above the estimate. All agreements contingent upon strikes, accidents Note: This proposal may he withdrawn by us it not acrenrrri
or delays beyond our control. Owner to carry fire, tornado and other necessary
insurance,.Our workers are fully covered by Workmen's Compensation insurance. within 9O days.
[6011S
:WO
nce of Proposal - The above prices, specifications and condi- -
tisfactory.and are hereby accepted. You are authorized to do the
cified.Payment will be made as outlined above. Signature -------eptaflCP,: _..' -- ..... . . - _.. SlgnaturF .i- f - -- -..... ------ ------
I nnrn rrna r1 r RUSINFSS Pfx)K,na,krsh,WI F.,7906 t ROO 5!010"0'Ir,WI I nnn-742 r»4q i
O
OFFICES OF: . Town of
12() Main Street
i
APPEALS NORTH ANDOVER Nortlt Andover.
f�t111.1-)INC; �: �',• Masti.u'huscllsOtti45
C ONSLtZVA'1'1ON ss`""°` DIVISION 0I- Ui17)4ili i•477 i
H EALI'H
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON. DIREC"1'011
In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed
150A. solid waste disposal facility as defined by MGL e 111, S
'
The debris will be disposed of in:
(Location of Facility)
w
Signat re of Permit Applicant
/i '3�9 3
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector.
DEPARTMENT OF PUBLIC SAFETY
COMMONWEALTH 1010 COMMONWEALTH AVE-
OF
VE. y ,
MASSACHUSETTS BOSTON,MASS.02215 ENCLOSE CHECK OR MONEY ORDER
LICENSE FOR REQUIRED FEE,
DIRATION DATE CONSTR• SUPERVISOR
MADE PAYABLE TO
13111994 6 EFFECTIVE DATE LIC-NO.
STRICTIONS "COMMISSIONER OF PUBLIC SAFETY"
ONE ; 08/01 /1991 056324
1 I
(DO NOT SEND CASH).
RICHARD J GRIMES
534 CHICKERING RD
A 011-52-7425 N ANDOVER MA 01845
(BLASTING OPR ONLY) FEE: -
0.00
HEIGHT: NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY
STAMPED -OR-SIGNATURE OF THE COMMISSIONER
DOB:
1 /0211960 --� D �07 DETACH LICEM3-E STUB
THIS DOCUMENT MUST BE; IGNATui* OF LICENSEE ` SIGN NAME IN FULL-ABOVE SIGf�ATURE LINE
CARRED ON THE PERSON OF I
THE HOLDER WHEN ENOAO- OMMISSIONER
pg gl(iNT THUMB PRINT EO N THIS OCCUPATN'Nl
2$1$1429 ,
. .._ —'"uaT�a_«�r'P^.,�".:ii"-�:'.�""�"��!:`.:��a7T.�"ep��St�4-v a_'.'�T'�'."�'�,//sem�;n�_ �• _ _ .,< - ,
-- ✓�ee'�anvrxmeu�vall�i o�✓O(.rrklac�iitartC �� '£in.:'•r,- y�/ �_, - A •. .. .,. _ .
HOME IMPROVEMENT CONTRACTOR 1
Registration 106915
Type - INDIVIDUAL i
Expiration 07/28/94
Richard J. Grimes :
632 North Street ,
Tewksbury MA 01876 I "' �, < '
ADMINISTRATORSIT
• � r ,,,,i aM CII�1bMEl1 r,
NORTFI
( C E
o of �c � over
0
<<
No -
dower, Mass.,
%SDRATED
v,
H ` BOARD.OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THATI..�'. �s
........... ............................................................................................................................. Foundation
has permission to e�ect.+l.�.!�/r.0 0�...... buildings on ....... ... ..... . ... ...... .. .... ..*499 .. .. Rough
... .... .:..
to be occupied as.... �. ...................................................................
Chimney
�5',t /t.I...C.,_10". e
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN-6 MONTHS Final
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
Service
BUILD
LG INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough l
No Lathing or Dry Wall To BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
PLANNING FINAL �aa7 CONSERVATION FINAL Street No.
c�IAi�R /IAIAT�R FINAI (O GSmoke Det.
DRIVEWAY ENTRY PERMIT
Commonwealth of Massachusetts 'RECEV
City/Town of .
° System Pumping Record ���� '3u LUtt
Form 4
M s°° TOWN OF NORTH AN
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other f se , ut the
information must be,substantially the same as that provided here. Before using this form, check with your.
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health ouother approving authority.
A. Facility Information
1. System Location Left side of house, Right side of hous nt of ho , Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address JJ �
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stab ���-�lZ' Code
Telephone Number
B. Pumping Record
1. Date of Pumping . Date 2. Quantity Pumped: Gallon
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaf ere contents were disposed:
G.L.S.D L wel Waste Water
C?
Signatur of a er Date
t5form4.doc°06/03 System Pumping Record°Page 1 of 1