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HomeMy WebLinkAboutBuilding Permit # 4/13/2015 T%®RrH BUILDING PERMIT TOWN OF NORTH VE OtoL APPLICATION FOR PLAN EXAMINATION .ax Permit, No#: Date Received �R°°R,TE°WP""�5 �Ssgc wus'�� Date Issued: 1VIPORTANT: Applicant must complete all items on this page r r r' r r ' II,WIN! r r r t, �� � �n ��� / � � r�/ � (��/�J , i I ,��%/f///rIN((�F��1��r���l��✓���!i..1.1����ll"/���J1,4//�OniP.IJ/N�y6.///p�fl(�II�J11r1.tl,..YN���IAlllDlflfOl/19o,...lft�frll/I�/%��Nrl TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition El Two or more family [I Industrial Ll Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other %/,�iIt»frr,I.r»/.r,l!.ia,la,ur..l��l,,.,�,ur.fG'�,n r„,q.eu/I,o/r�,-r�1 y��i,,��r.rr�1r,r�rrr/:.re%,y!.1r..,'�o/i%1a�l�,,.,,o`r„i.,�rrl�"/l/,/r r�„/f�,1,/f/r%,,,//ri,//,A,r f�/,//�r/,Grr/i,r!ir%��./,,/y.�r/l/�;.,✓%//,�I�//r�/1/,k,r.0i.,a,,�er,,,;(��I„ri�,1.,-,,,,1„la�.ir l� rg �ffi/./„.//”X�I,J//l ,a Sr,1 �� e1dt / e r, i, ,,. ;.. DESCRIPTION OF WORK TO BE PERFORMED: Identificati n- Please Type or Print Clearly OWNER: Name: .. O Phone: Address: c �.,,r, ,U 1 ,,,/, 1,,, ,r ri UrjY'lr`Rl /„%✓'/%//!%/!/,r a j//// r // / /,//o �/ ////i %'/ /r `;j/r?/ %1/ Y�/ / � � Y >l11�i`l��f��f�%///; i JHS«� r 'm<' i s ,;«(- ' ' ✓ `r J f �����la �ll����i��U111,,Q„rne,��n:/I�1�, r�r�if„ ri 11111... r .Irl. �'I,110/rri„%/r o rE, ail,« ISBN, Ir IU ,� rr �f r ! Jr I, r r I � « � �, �!✓� �G % ,« NMI"¢ „'a ear ��{ µµ m � e e«J � 10111011111 Y�.,dr"1 tiln mim GfAii„ri✓�r. iIG�GrvRi�l�rv,�an6)m `. rdni arvu�d.�v� wio a m�duvNro� A�rmiauavUR«rte«14�'"��«uP~,��r' �vm/rrrcrre rrhrnvdP+wrurr;` ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. I Total Project Cost: $ WOO FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ISigriature''of;A” ent/Own'er „ Signature"of coritra'ctor '%",�'%,, ;� ' '%/ � ''' t4®RT Town of Andover 0 . Z. . COCHIC HQ WICK �" l ` U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT.............%.14 j4qLr P E Knmah . BUILDING INSPECTOR .......... ........L ........................................... has permission to erect •••••••••••••............. buildings on ...3, Foundation .. ...................... Rough to be occupied as ......."ViIii .... ,,,,,,, `provided that the person acceps permit shall in every respect co m to the terms of the application FialChimney on file in this office, and to the provisions of the Codes and By-Laws rela to the Inspection,Alteration and Final 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 MO S ELECTRICAL INSPECTOR LESS CONSTRUCTION S Rough Service ......................... ................ .................. Final BUILDING INSPECTOR GAS INSPECTOR== Y ccupancv Permit Required to Occupy Buildinz Rough is lay in a Conspicuous Place on the Premises Do Not Remove Final 4 No Lathing or Dry Wall To Be Done FIRE bEPARTMENT Until Inspected and p Approvedy the Building Inspector. Burner, Street No. l Smoke Det. f` Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements ofthe state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information NaTe Company me ®(� O*- © C. treet Address(do not use a Post Office Box address) Contract /Salesperson/Ot rName 'AhCity/Town State Zip Code Busin Address(must include street address) 50 E � Daytime Phone Evening Phone City/Town Stafe Zip Code - Mailing A dress at different from above) Business Phone I Federal EmployerID or S.S.Number HomarmtuovemmtContractorReg.Number Espirationdate Iaar requires that most hame tmpmremmt contractors have a valid regbtmdon number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) i ' I Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) ��Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,famish the material and labor specified above for the total sum of: (#) Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by / / or upon completion of $ by / / or upon completion of $�upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(") $ to be paid for i NOTES:(1)Including all finance charges('r#)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 ordered in advance to meet the completion schedule. Express Warranty-Is an express warrinty being provided by the contractor? ❑No❑yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor ruder this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof ofinsuance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the'Consumer Guide to the Horne Improvement Contractor Lara You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical eopipakly contract must be completed and signed.One copy should go to the homeowner.The other copy should be kept y the contractor. Homeowner's Signs h CoActor's Signature Date Date The Commonwealth of Massachusetts F Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. AP13licant Information Please Print Legib Name (Business/Organization/Ind i(vidual): t/r� C Address: City/State/Zip: C�a• Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4-❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.(]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insrrance.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,'tliey must provide their workers_ comp.policy number.• Iain an employer that is providing workers'compensation insurance for my employees.•Below is the policy and job site information. Insurance Company Name: A0 Policy#or Self-ins.Lie.#:J_;��_90 7 S7/ �( / Expiration Date: U� F Job Site Address:__�>l _Ssi(P1 eA I' City/State/Zip: �4d J�t— Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil'penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. Signature Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r 13 15 01:45p Ann Gallsghet 6173257892 p.1 ■ CERTIFICATE OF LIABILITY INSURANCE DATE(MAyDDMYYY) 03/05/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the temts and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER THE INSURANCE STORE -F" NAME' ---- ..._. .. . ... PHONE ----- (ac,N�,Ea): (617) 325 - 8952 I FAx'-"- -`—' 106 SPRING STREET - __ Iwc,No).(617) 325 - 7892 �E-lAAIL — -— ---- TdEST ROXBUADDRESS:RY, MA 02132 -- INSURER(S)AFFORDING COVERAGENAIC$ INSURED INSURERA:WESTERN WORLD INSURANCE COMPANY PORTANOVA ROOFING INC wsURERe:TRAVLERS COMMERCIAL AUTO 50 Elm Street (NSURERc:TRAVELERS INDEMNITY COMPANY _ INSURER D: Cohasset Ma 02025 — INSURER E: INSURERF: OVERAGES 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 VVITF 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. ,TR TYPE OF INSURANCE II E, WVO - PCLICYNUMBER IMI//DONYYY) IMMMDNYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE, $ 1,000,000 COMMERCIAL GENERAL UA8!L TY -DA1Xk?7E"TO-RE. '... PREMISES(°Doeeurrence) § 100,000 L CLAIMS-MADE! �accuR NPPBiB9359 11/09/14111/04/151 MED EXP(Any meperson) S 5,000 FERSONALa ADV P•JJUR� § 1,000,000 �----- i GENERAL AGGREGATE $ 21000,000 GEVLAGGREGATE LIMIT APPLIES PER: 'PRODUCTS.COMPIOP AGG S 2,000,000 POLICY jE0. LOC - S AUTOMOBJLE LIABILITY iEa xcidn") $ 1,000,000 'AW'9UTo BODILY INJURY(Pal Terson) $ ALL OWNED SC.HED'JLED _ —_______ AUTOS X AUTOS BA2D290560 El JNJU.4Y J Per accident $ X HIRED AUTOS X AUTOS'4NED PRO J2T'1 D:A;, Autos 05/06/14 06/05/15 (Peraccident) $ 100,000 UMBRELLALIAB OCCUR EACH OCCURRENCE E EXCESS LIAR —�CIAWS NAD= — -- r• AGGREGATE _ $ DED RETENTION $ S WORKERS COTAPENSATJON r C . - H- OT AND ERIPLOYERS'UABRITSTP7U Y fII X TORY L7.41TER T ANY PROPRIE'rORIPARTNERfE(ECUTIVE YJN I 6HTJB BD807841. ,10/28/14 10/28/15 E L.EACH ACCIDENT OF.FICERIMEMBEA EXCLUDED7 N I A $ (Mandatory in NHI - Ilyes,descnternder E.L.DISEASE-EAEMPLOYEE $ DESCR.PTION OFOPERATIC{IS helot 1 E.L.DISEASE•PO,.CY:,IMi S 3CRIPTION OF OPERATIONS)LOCATIONS)VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space in roqufred) )OFING & CARPENTRY RTIFICATE HOLDER CANCELLATION Iilding Department .ty of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN :00 Osgood streety Bldg 20 Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS- �rth Andover Ma 01845 AUTHORIZED REPRESENTATIVE � +� 1988-2010 ACORD CORPORATION. All rights reserved. 1RD 25(2010/05) The ACORD name and logo are registered marks of ACORO �/e�pa��zauoriiaealf/o����ce ccc�aset/r \ Office of Consumer Affairs&Business Regulation ( ME IMPROVEMENT CONTRACTOR registration: 178521 Type: expiration: .4/23/2016 Private Corporatio':. j PORTANOVXROOFING INC. KENNETH PORTANOVA 148 MINOT STREET DORCHESTER,MA 02122 Undersecretary I� t i _r CS 10718 a "NNURPORiKNOVA OT ST 148 MII'f APT Dorchester NMA 62.122 77i,4 �1/r " r 0912112017 I - I 1 i