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HomeMy WebLinkAboutBuilding Permit # 4/27/2015 .......... %400TH 0 BUILDING PERMIT 0 0 TOWN OF NORTH ANDOVER 00 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 0 ATED Date Issued: L CH IMPORTANT:Applicant must complete all items on this page l IM ogo P///N // � I �>/ /, / rr TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R/One family 11 Addition 11 Two or more family 11 Industrial 11 Alteration No. of units: 11 Commercial EfRepair, replacement 11 Assessory Bldg 11 Others: 11 Demolition 11 Other 0 1rir Identification Please Type or Print Clearly) OWNER: Name: U 0 r Phone: U11- A I Address: wlllob� a pe, /\J�r,. rr ,r r r /f / � / / r f r /. ARCHITECT/ENGINEER. Phone: Address: Req. 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: 01 S7, k4 FEE: Check No.: 2- 2_ Receipt No.: Q'i-166 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund -..... ...... t%O R T" 1C), WH 0"k IAn 4 E . .-r. ctover ® ® c+► No. t _ O - IAKF Il ti ver, Mass, 4PIO-l"I l�® COC KIC Hf WKK 1' IJ BOARD OF HEALTH Food/Kitchen Pl;; �R� MIT T D Septic System THIS CERTIFIES THATe e,_,¢ , BUILDING INSPECTOR .............................. ..... .. .......... ". Foundation has permission to erect .......................... buildings on ..... 2.. �...�dg.4&........................... �r � Rough tobe occupied as ............... .....%....�.........�.......1...5�..........5.,................................I.................... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION RT� � , Rough Service ��. ... ....... .............� ..................�...: . ...... ....... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. This form satisfies all basic requirements of the 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 Name Company Name rn Street A ress(do not e a Post Office address) Contractor/Salesperson/O er Name r/O dled City/Town State Zip Ude Business Add (must include a tr ad re ) 0V`el- O� 35 7 \J• ro Daytime Phone Evening Phone C���� � , /$tate Zip Mailing Address(It different from above) Business Phone /Y/`/1 Federal Employer ID or S.S.Number -Q 7 Home Improvement Contractor Reg.Number Expiration date Law requires that most home impro roost ationcontrumb have a valid regstration number, The Contractor agrees to do the following work for the Homeowner: (Describe in detail theiork to c pleted,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) w(a QHS O n c/ llloeurs 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,furnish the material and labor specified above for the total sum of: M Payments will be made according to the following schedule: $ / �J 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 $ 411pon 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 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 ordered in advance to meet the completion schedule. Express warranty-Is an express warranty 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 under 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. Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded 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 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 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 as provided In Massachusetts General Laws, chapter 142A. Homeowner's SighNure 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 legal 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 added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate 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 be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments ,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. However, in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the 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 or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at ZoyLo.c,kktr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-037603 KENNETH W PERIGNY ;. 5 MCGRATH ST— SALEM NH 03079 ` 912-� t Expiration Commissioner 04/17/2016 �ie tPanr��za�rcaeall�,o��ua;rac�aJe� Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Type: egistration: 100286 private Corporatio xpiration 6/15/2016.. PELLERIN VINYL SIDING- Kenneth Perigny 354 N.Broadway g Salem,NH 03079 Undersecretary The Commonwealth of Massach usetts Department of IndustrialAccidents a I 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. Avylicaut Information Iq Please Print Le ibl Name (Business/Organizationftdividun al): / j n Address: 354 N . tBroaj ujaz 1 City/State/Zip: r, � �lo� /V ��(� Phone#: (oL//_3 6 0 Are yruamployer7 Check the appropriate box: Type of project(required): 1. employer with employees(ful[and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 E]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. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ g [] Those sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs �fJ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14. O"th�erl-rig 152,§1(4),and we have no employees.[No workers'comp.insurance required.] }-v /ice *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 biro outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees, If the sub-contractors have employees,they must provide their workers'comp.policy number. I atn art employer t/tat is providing ivorlters'compensation insuratice for my employees. Below is the policy andjob site information. Insurance Company Name: Acodfa- Policy#or Self-ins.Lic.#: Expiration Date: I Q� Q Job Site Address: I 16 e— City/State/Zip: Attach a copy of the workers'compensation policy de4haiion 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. Ido hereby cert' ,under thepa' and penaIdes of perjury that the infortnationprovided 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): i 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information 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 Iicensing agency shall withhold the issuance or renewal of a license or permit to 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,by 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 cityor town 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-insured 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"fob 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia From:Nicole Boudreau FaxID:Santo Insruance Page 4 of 4 Date:4/23/2015 10:19 AM Page:4 of 4 PELLE-3 OP ID: NB CERTIFICATE OF LIABILITY INSURANCE D04123/22312IY015 045 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(ies) 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 endorsement(s). PRODUCER CONNAME CT James A Santo Planright Insurance-Salem PHONE FA 224 Main Street Suite 3C AIC No El:603-890-6439 (AIC,No): 603-890-6521 Salem,NH 03079 A DRESS:'am ie@santoinsurance.com James A Santo INSURER(S)AFFORDING COVERAGE NAIC/ INSURERA:Acadia Insurance 31325 INSURED Pellerin Vinyl Siding INSURER B: 354 North Broadway Salem,NH 03079 INSURER C: INSURER D: INSURER E: INSURER 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE SD POLICY NUMBER POLICY EFF MMILDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE FIOCCUR BOA5122764-10 10128/2014 10/28/2015 DAMAGE TO RE T D $00,00 PREMISES Ea occurrence $ MED EXP(Any one person) $ 3,00 PERSONAL&ADV INJURY S 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,00 P ❑PRO- POLICY JECT F—] ',.... LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,00 AANY AUTO BOA5122764 10/28/2014 10/28/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED — AUTOS AUTOS BODILY INJURY(Pet accident) S X HIRED AUTOS r NON-OWNED PROPERTYDAMAGE S AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S O03 1 1 RCTCNTION 3 Q WOMIER3 COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY _.._ A ANY PROPRIErORfPARTNERIEXECUTIVE YIN N WCA5122768.11 10/28/2014 10/28/2015 E.L.EACH ACCIDENT S 500,00 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) 3A NH E.L.DISEASE-EA EMPLOYEE S 500,00 If yes,describe under -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Ken Perigny&Paul Pellerin have elected to be excluded from Workers Compensation coverage RE: Cathy Greene,62 Willow Ridge Road, North Andover, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover,MA ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD