HomeMy WebLinkAboutBuilding Permit # 5/11/2015 TOWN OF NORTH ANDOVER
9 APPLICATION FOR PLAN EXAMINATION
Permit NO: `�UU "�'� Date Received-
,.,.issued:
eceivedDateIssued:
IMPORTANT:Applicant must complete all items on this page
LOCATION
• ..c,„„� Pit; '
PROPERTY OWNER 1
��,,..,,' Pf�ril 100 Year Old Structure yes no
NO PARCEL pZONING DISTRICT. Historic District: ye Dno
Machine Shop Village ye` no
TYPE OF IMPROVEMENT PROPOSED USE
_ Residential Non-Residential
n New Building n One family
I I Addition ❑Two or more family ❑Industrial
❑Alteration No.of units: n Commercial
,'Repair,replacement ❑Assessory Bldg ❑Others:
❑Demolition _ U Other
❑Septic ❑Well fJ Floodplain ❑Wetlands ❑Watershed.District
❑Water/Sewer _
DESCRIPTION OF WORK TO 7 PERFO�7r'ED: `•.�
{S h Sl Y i.9?t
-,,,_Identification Please Type or Print Clearly)
OWNER: Name: -)r).�1,,-^` —17 ee Phone' ZD-60.`, 7o%l---
Address: %� C-1-2) f'�iPyri 12d
CONTRACTOR Name: Phone 9/'Y- 5// 171FXr
Address./C '_ . i 91/��� c c, iE s d�/y . C�/yS---
Supervisor's Construction License 10(oO,3/ Exp. Date. C " ,241-/
Home Improvement License /;7/4(;7 L Exp Date " !Pl-%Z
ARCHITECT/ENGINEER_ Phone:
Address: / Reg.No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F.
�/-�- , el
Total Project Cost:$ ZFEE:$ 6- ,-&D
Check No.: Receipt No.:
NOTE: Persons contracting ith 1 is re 6nLrnetors do not have access�gq &7
�Signature ofAgen Owner ignature of contractoi
Plans Submitted❑ Plans Waived Certified Plot Plan❑ Stamped Plans J
MOYNIHAN-NORTH READING LUMBER, INC.
"QUALITY BACKED BYA DESIRE TO PLEASE"
164 Chestnut Street FEIN:04-2261995
North Reading,MA 01861 AMA Contractor Reg No.:
978-864-3370/78 B Exp.Date:
Salesperson(s):
' HOMEOWNER INFORMATION
N'µm,1e y r "A M Daytime Phone
Street Addret p(N t(P/ Rox) Evening Phone
A) F
City/rown State Zip Code Mailing Address of diverent from Street Address)
WORK TO SE PERFORMSAND MATERIALS TO�BE USED .>
Moynihan-North Reading Lumber,Inc.agrees to perform the work set forth in Exhibit Afor Homeowner and to
use such materials in connection therewith as set forth also in Exhibit A{attached hereto and made',a pad
re `
heof. -
The following schedule shall be adhered to unless circumstances arise-beyond Moynihan-Nprth Reading
Lumber,Inc.'s control:Work scheduled to begin: //— Expected date of completion:_J—/
May be based upon arrival o1 special ordermaterial
(� TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
p Moynihan-North Reading Lumber,Inc gr W to perform tlwork,and furnish the material and labor set forth in
P Exhibit A for the Total Contract Price of:$ I:,4 -L+ (which amount Includes all finance charges).
Pay jg,Shall b made by Homeowner according to the follow ng payment schedule:
$ Initial deposit upon signing thls'Contract(the Initial deposit shall not exceed the greater of
f one-third(1/3)of the Total Contract Price as set forth above;OR the Total Cost of Special/Custom
f Orders as$t forth below).,
r' $ r^3 �'y by—/—/—or upon completion of delivery of materials
$ °C.�>C� frk>by_/ / or upon completion of Install
completion of the Contract
In order to meet the completion schedule set forth above,the following materials/equipment must be special
ordered before the Contract work begins,for a Total Cost of Special/Custom Orders of$
$ to be pard for ponding permit ®) rr;7
$ . ?"f to be aidfor 6m1:"troeMC"6 r0:.4k
.tmbe-paid for Ck..l4
9T IGN HIS CONTRACT IF THERE ARE ANY BLANK SPACES
� N rr,i
{ v7.'<`1
e ) Moynihan-North Reading Lumber,Inc.
Hom oSg w er' atuggre Date Contractor Date
5 � `9"'d "^"" sv:Dale Fuller
Homeowner's Name(Printed) Installed Sales Coordinator
You may cancel this Contract if it has been signed by a party thereto at a place other than an address of
Contractor,which may be its main office or branch thereof,provided you notify Contractor in writing at
its main office or branchby ordinary mail posted,by telegram sent or by delivery,no later than midnight
of the third business day following the signing of this Contract.See attached notice of cancellation for
an explanation of this right
2
- See reverse side for additional Homeowner Terms and Conditions
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Th,Cnrrunol Ith gf.Kasruufuuetts
Department of Industr ld Accidents
�) Otj`eee of lavestiglttion.s
600 Washington Street
..- Boston,!111 02111
ivnay.rnasa•.govldia
Workers'Compensation InUnrasice Affidavit;Lsuilders/Cone actors/tlecic iciuns/174rmbe:s
Applicant Informado. PleaseP-ut1:L-ihly
Mame fBuslnesJO ennizsf, n.d;vidueq__5h- n.Arse ],t_& crit Arsenault _
d/b/a Arsenault Brot:lrers Construction
Address- 105 Hamile ,_Streer-
City/Slate/Zip. Lootnins ren MA 01453 Phone tk: 978-514-4848_- _. 7
1 e yo n e pl}er s ch"',the approp t 1 0': T}p t p olect 1,
equ rA).
L®I r r employer". 3 4 ❑l am a ge e n ontrectot and I G ❑New const
employe"(full and/or pa C--),1 1 e ifle t the"sh-contractors
2.❑1 am a sole Pretoria.,o Perin— hied on tho emldled sheet. 7.❑Remodeling
scup and 1—ore empjoyees These snb—Iain is have g,❑Demofidon
working tonne in any capacity. employees o-md have workers9.❑L;uilding addition
[No wo Iters'comp_nvsnnn— comp lrsumrcu,t
required 5,❑We tie a cornomdon and its 10, clecnlral opairsor"lipor s
3.❑I azo a homeowner dousg all work officers have exercised[heir 11. Phnnhing repairs eradditions
myself.[No workers'cmnpright of exemption per MGL 12❑Boot repairs
insurance required]r c.152.S1(4),andwe have no
employees.(No wolf— 3j,-] _
comj,insurance required.]
-.a J'Wn L.mr NvIces—'A rill nIit' lelow_ehoa 5U eruakc a'un p eo yalivy-in n
"H ,� vh t n,ide �.he�r-Jo,y ill vo,kmAtl,en l,re„uido o :�1 n aft,d. luui,y,,_
vt�henc lisao�n tchei ,,i4J'ru,I:IwG:Fo �h I,e�,bo :nd.,m..vle,l,er nr aux.n,,..e1
. .u,sr sit....... /ur »pC�lcu' {3 5-1 tc
ildfurneu2iolz-
Jontrance COorp ,N.—:_
Paltcy#or Self-ins.Lia#: IHUB6B908757 3 Exphratimr Date: 04/02/16,__
Job Site Address:--_ ,..,. _City/Stato/Zip:
Att!LCll a copy of the workers'compensation policy declaration page(showing fie policy number and nxpirelion date).
Failure to secure el,,erage as required under Secflon 25A ofblGL c_152 rest Icod to the imposefon oferimin:il penuldes of o
Pill,up to'51,500 00 and/or one-year hnpror-menti as well as civil penallies in the form of a STOP WORK ORDER mda fine
of up to 6250.00 a day against the violates,Be advised that a copy of tins statement may be forwarded io the Office of
Investigations of the DIA for rn,u ce coverage verdcatien.
I do herebl,cereiJy,order rhepai. art peneUles f perjury drat the irrfnnnnnmr provided,dove istrue and correct.
us n
Si tx�n _a-" ".GVv____ _ _ Date:
Phone if: 978-514-4848
Olf"i't only D,"t-,,,in des,re,,ro ne eo„rpla d b,city or foo.ff�iaf
City or'I'o.vn: Permit/License#
Issuing Authority(circle one):
].Board of Health 2.Building Departioent J.City/Town Cleric 4.electrical inspector 5.Plumbing lnspe.ctor
6.Other
Contact Person; phone#:
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MUNIHAN
LUMBER
BEVERLY NORTH READING PLAISTOW
V River Street 164 chestnut Street
P.O.Bnx 0.0.Box HsO
P.O.Box 509 12e
Beverly.NA 01915 Narlh R6aCing,MA 010640128 PlalsYow,NH o386fi
(918)92>-0032 (9I6)6643310•(/81)9AM1-6fi00 FAX 0(603)302-1935
FAX:(916)921-62oi FAX:(978)664-0612
Subcontractor�JorBcers'Cornoensation U+6aiver
I Shawn A>...-1t hereby acknowledge that I, as an
independent contractor, have been asked by Moynihan Lumber
Company to provide it with a certificate of Worker's Compensation
Insurance coverage for myself. Based on the exemption provided by
the Worker's Compensation Insurance coverage for myself because I
am a sole proprietor without employees.Therefore, I hold Moynihan
Lumber Company and it's related organizations and the Arcadia
Insurance and or Self Insured Lumber Business Association, Inc.
totally harmless for any injuries or cost of injuries incurred by myself
because I have voluntarily chosen to exclude myself from coverage
by engaging the exemption provided under the Worker's
Compensation Laws.
I have taken this option of my own free will
Witness
Date: Al-Z
"QUALIT`!BACKED BY DESIRE TO PLEASE"
/ l
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116 --
1-101re Improvement Contractor Registration
Reglsiration: 136660
Type: Private Corporation
Explrafion: 916/2016 Trtl 215814
MOYNIHAN NORTH READING LUMBER,IN
DALE FULLER
PO BOX 128
N.READING,MA 01864 -- --- -- --
n,n„1�
_! (.
015-----A ff,,ifisll,g-ti-
P9E IMPROVEMENT CONTRACTOR
f fio 1TYPe:
3121/201612016. Ind Vdt al
SHAWN ARSENAULT
SHAWN ARSENAULT
24 GRAHAM ST
LEOMINSTER,MA 01453 UnJe�s�wrotnry
;'90 M
3-1 9_,n_ 3v��.tom. n'
CSFA-106031 •A '. — --
SHAWN ARSENAULT
10>fIANIMTON STREET
f Lcomtoster NIA I'll 3
4 i 1201
0812412016