HomeMy WebLinkAboutBuilding Permit # 4/14/2015 a F VtORTH
BUILDING PERMIT �z,�o ,gM �•°
TOWN OF NORTH ANDOVER I. 00
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APPLICATION FOR PLAN EXAMINATION h
Date Received °q `e.
Permit NO: "'"`� p °`�,<�•`"
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Date-issued:
'IMPORTANT:Applicant must complete all items on thisage
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TYPE OF IMPROVEMENT PROPOSED USE m
Residential Non- Residential
❑ New Building ❑ One family
Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
CY'Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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Identification Please Type or Print Clearly)
OWNER: Name: &4 e. , Phone:
Address: l,te . r
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons ntracting with unregistered ontractors do not have access to the guaranty fund
Signature of AgenUOwner ” nature of contractcar �w
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SORT
Town at2 t E. ._'q ndover
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Y C'O LAKE h Ver, Mass, s
COCMIC Kl WICK
� R T
S U
BOARD OF HEALTH
Food/Kitchen
Septic System
17 E I T L �D
BUILDING INSPECTOR
THIS CERTIFIES THAT ....... .1.11..........
!. . ........... ..� ... ......................�..... ...................................... Foundation
has
has permission to erect .......................... buildings on .......... .... ........
-.........
Rough
tobe occupied as .... ....... ..........:'0'............................ ......^........................................................ chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
EXPIRESPERMIT 0 THS ELECTRICAL INSPECTOR
® UNLESS C T CTI TAR . Rough
Service
.......................... . ..... . ... .......................
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Islay in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
PAGE# of PAGES
PROPOSAL
20 Pichowicz Rd. Tim Darcey
Billerica,MA 01821 &-OTIZIMAIV License#077587
Tel:(978)262-9955 D EEQ H.I.C.#139724
Fax:(978)262-9956 GENERAL NrfNlr3
www.darceygc.com "ROOFING SPECIALIST"
Proposal Submitted to: Job Name: Job#
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Address Job Location:
Y' f
er SE
Date Date of Plans
n/1
U r d,,t ►r l Cit y /
Phone# Fax# Architect
We hereby submit specifications and estimates for:
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16 t��e r2 neo dsioGc
Icre.P QiggP c-61Icar'S
�✓ tTg Il 6" )h e d r-i`p edge fa tha
In till �` r1c¢ ice 0,j IJra fer Shi e Ic( enyfSya/Ceu S �eyt� wo,lls
Ir► f ( s6(,IAfe onde( Inament th .-Mo aL Aa, iraa.E deck—
ft,ti'iiae 630F ra
1' (a+ r oo'1 i"\S to It 1�V),5 j I of He)in iae t r �c re 1N a C>I- cL6w✓1
110sfall c)ec1 ,Cobb-er Moiln6CQP e -1PQY'(u QUO,re�
fb 1 e — m P VI`w,P f e f , Rc;s h e d ;✓►h t kz ribber w A 6" iaec ( Os'-( C.k w2m b rq n,e
L-}ovC� r 1/14 4tzuvY0 S tore?d gartflet,-4- -Prom de!atais'-
a�>"ds ed clel2.t (a YWe'o <.t)Y`'1�n wtar.rtr1-h'c 1,-60 Ms'
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All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standar practices.Any alteration or deviation from specifications below
involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.Not responsible for recalibration of satellite dishes.Customer
should cover attic space,a small amount of debris may fall into space.All agreements contingent upon strikes,accidents or delays beyond our control.We are fully insured for Workman's
Comp and Liability Coverage.
We propose hereby to furnish material and labor-complete in accordance with the above specifications for the sum of:
$ Se.ler► f�e�v� 7��9ii Sc hcl etlr., F-}wtu!rt��yc'��- -T u (4 Fid ollars
with payments to be made as follows: y- dSLE -oC l �/4 wit
Any alteration or deviation from above specifications involving Respectfully
extra costs will be executed only upon written order,and will Submitted d
become an extra charge over and above the estimate.
All agreements contingent upon strikes,accidents,or delays Note-this pro )withdrawn by us
beyond our control. if not accepted within 10 days.
Seven year workmanship guarantee gc"pW= QT osd
Final Payment due upon completion J __
The above prices,specifications and conditions are satisfactory (A
accepted.You are authorized to do the work
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and are hereby
as specified.Payments w��ill//be made as outlined above.
Date of Acceptance:_T �� Signature
SI—X The Commonwealth of Massachusetts
Department ofIndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov1dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers.
TO BE,FILED WITH THE PERMITTING AUTHORITY.
Amflicant Information Please Print Legibly
Name(Business/Organization/Individual): —1 gq [)cvLe e-'(4 �7-CA :_,J-1",-Pj
NJc.
Address:
City/State/Zip: Phone#:
Are you an em toyer?Check thea propirlate box,
Type of project(required):
a employer with .....ff" 'employees(full and/or park-time).* 7. F1 New construction
2.0 lam a sole proprietor or partnership and have no employees working for moin 8. E]Remodeling
any capacity.[No workers'comp.insurance required]
9. n Demolition
3.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ]Building addition
4.❑1 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 UnElectrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
13.FKoof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.QWe are a corporation and its officers have exercised their right of exemption per MGL 0. 14.F1 Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
Iainatiettiployei,tliatispi-oviditigivoi-Irers'conipetisailoitilisul,aileefol,nzyeiiipf6yees. Below Is the policy and job site
information.
Insurance Company Name: &I e V"Ir? C4 kA
Policy#or Self-ins.Lic,M JJA,3e9L4,63 Expiration Date: Or.), JAl /J_
Job Site Address: 3 6?�,L 9'f, City/State/Zip: JJ 1/4P 41-
7
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 cert y under the pains and penaltles ofpeijwy that the information provided above is trite and correct.
Signature: ........ Date:
Phone#:
Official use only. Do not sprite in this area,to be completed by city oi-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 M
office of Constollet.
H�OME IMPROVEMENT CONTRACTOR
egistration:
139724 Type:
'. Expiration:
817/2015 DBA
DARCEY GENERAL CONTRACTING
TIM DARCEY
20 PICHOWICZ RD
BILLERICA, MA 01821
f MassachUSC?it.; - Dei'")arrtn,Ne�,q (_)f pr.OjDgic
Board (-)F Building and 53ta,n dard':
CS-077587
TIMOTHY P.DARCEY
20 PICUIOWICZ RD.
Billerica MA 01821
C
02/1112015
1-Qf1 UGI VGI
CERTIFICATE OF LIABILITY INSURANCE DATErMM/DOn�Yvv)
TNWW.0RTIFICxrE 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 tothe
terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
DESANCTIS INS AGCY INC PHONE pAX
100 UNICORN PARK DRIVE (AIC,No,Ext):
E-MAIL
WOBURN,MA 01801 ADDRESS:
28GBS INSURER(S)AFFORDING COVERAGE NAIC k
INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY
TIMOTHY DARCEY CONTRACTING INC INSURER B:
INSURER C:
zo Plcxowlcz ROAD INSURER D:
INSURER E:
BILLERICA,MA 01821 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TOC IFY THAT THE POLICIES OF INSURANCE DSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAPA FD ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TEAM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO ViHICH 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.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MADDWYYY) (Mt&DD1YYYY) LIMITS
GENERAL LIABILITY =ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CLAIMS MADEEj OCCUR. DAMAGE TO RENTED $PREMISES(Ea occurrence)
-- -- ED EXP(Any one person) $
GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY $
ENERALAGGREGATE $
POLICY PROJECT®LOC RODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINEDSINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION ION $ $
A WORKER'S COMPENSATION AND X WC STATU-ORy OTHER
EMPLOYER'S LIABILITY YIN UB-2E41-1683-14 oa/22=14 0BJ=015 1.LIMITS
ANY PROPERITORMARTNERIEXECUTIVEy N/A E.L EACH ACCIDENT
OFFICEWMEMRER EXCLUDED? S 100,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 100,000
If yes,desMbs order '..
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $00,000
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/RESTRIGnONS/SPECIAL ITEMS
THIS REPLACES ANYPRIOR CERTIFICATE ISSUED TO THE CERTIFICATE,HOLDHR AFFECITNG WORKERS COMP COVERAGE.
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV D
IN ACCORDANCE WITH THE POLICY PROV
AUTHORIZED REPRESENTATIVE
Is of ACORD 1988-2010 ACI CORPR . f'rIghtata rre�seived,"